Why Is Obesity Help Often Excluded By Health Insurers?
October 20, 2008 7:26 PM   Subscribe

Why do medical insurers treat obesity different than other vices? Not a GYOB (I've got one); I literally don't understand the facts of the situation.

What do I mean? A moment's thought yields thousands of examples every day where medical insurers cover medical treatment that helps people recover from the aftereffects of their own choices. Childbirth. Smoking. Heart attacks. Lacerations incurred while drunk. (And accidents caused by drunk driving.) Alcohol and/or drug rehabilitation programs. And so on. We make mistakes with our body every single day, and they incur a medical cost to our body's well-being. Most of those medical costs are alleviated by insurance.

But medical services available to help people recover from the aftereffects of obesity seem to be almost specifically excluded. Nutritionists? Nearly always excluded in every plan I've seen. Physiatrists or sports medicine for medically safe exercise? Ditto. Removal of large amounts of loose skin post weight-loss? Some people have navigated their way through appeal processes into coverage, but it's not covered without great effort and trial.

What puzzles me is that preventative and "repair" treatments has got to be more cost-conscious than paying for heart bypasses, etc., so it makes from the ultimate viewpoint that means the most to these companies, the Almighty Buck.

So what's up? Where am I making the mistake in thinking this through? The pattern seems to have boundaries that are clearly enough defined -- it seems highly, highly improbable to me that this wasn't a purposeful policy decision.
posted by WCityMike to Health & Fitness (20 answers total) 4 users marked this as a favorite
They cover diabetes treatment.
posted by smackfu at 7:38 PM on October 20, 2008

My best guess is that the aftereffects of obesity once you are no longer obese are not strictly speaking costly medical issues. I'm not saying I agree with this viewpoint but if you look at insurance as a numbers game, it's like this.

- They'll help you quit smoking because it's more expensive to them if you smoke than if you don't smoke. They will not pay to whiten your stained teeth.
- They'll help you have a baby because it's more expensive to them if you have a sick baby than if you have a well baby and received decent pre-natal care. They will not pay for you to get back in shape after you've delivered.
- They'll pay for your bypass surgery because they can't find a way to punish you for eating badly and failing to exercise (yet) and the meat and smoking lobbies are strong in the US.

In most cases, health insurance companies will pay for the treatment of obesity because a patient who weighs less has fewer future health risks. Extra skin is not a health risk and not a medical necessity [I know there are extreme instances where this is not the case, I'm speaking in generalities] and so they leave it up to the individual to deal with. Similarly exercise is supposed to be something you do on your own. I'm sure if you were someone who was injured doing bad exercises with a different weight configuration, you could get insurance to pay for visits to a physical therapist.

Basically, the general conception seems ot be that once you are no longer obese, you are no longer in a risk situation that requires cash outlay on the insurer's part -- the same may not be true for people who have given birth or who have gotten treatment for heart disease. Again I'm not saying this is my perspective, but I think that's the rationale.
posted by jessamyn at 7:39 PM on October 20, 2008

Response by poster: Jessamyn -- thanks, but you make my point. In the above examples, why wouldn't the nutritionist and sports medicine people be covered? It decreases future health risks. Yet with many, many insurers they're not. Especially nutritionists ...
posted by WCityMike at 7:41 PM on October 20, 2008

Why wouldn't the nutritionist and sports medicine people be covered? It decreases future health risks.

Well I think the question is "Is having been formerly obese and now no longer obese a precursor to future health risks?" which I personally don't know the answer to. Other than the extra skin argument you make, once a person is no longer obese, they have the same access to physical therapists and nutritionists as someone of average weight. What's the argument that a formerly obese 250 pound man should get different health care treatment than a 250 pound man who has never been obese? Health insurance is all about averages and to the insurance company, these two people are treated the same.
posted by jessamyn at 7:46 PM on October 20, 2008

Maybe meetings with a nutritionist or sports medicine person haven't been shown to effectively treat obesity as well as other treatments or cheaper treatments? (I'm not saying I know one way or another, it's just a possibility.) Insurers generally do cover some treatments for obesity, such as bariatric surgery and certain weight-loss drugs, and they often provide some kind of discount on gym membership.
posted by phoenixy at 7:55 PM on October 20, 2008

Response by poster: I'm sorry, I imagine by putting in the loose skin thing, I've clouded things a bit. I don't understand why, while someone is obese, access to nutritionists or physiatrists/sports medicine for the mentioned purposes would not be covered ...
posted by WCityMike at 7:56 PM on October 20, 2008

Insurance companies do nothing by accident. If most insurers don't pay for nutritionists, it's likely because they've looked at studies and enormous amounts of aggregate data and found that it isn't in their interests (because most people who consult with nutritionists don't actually follow through on the plans, or don't lose weight, or that the typical amount of weight loss doesn't offset weight-related illness rates, or whatever).
posted by moxiedoll at 7:57 PM on October 20, 2008

Insurance companies almost never cover someone for a long enough period to make it worth their time to help people slim down. Being overweight at 25 isn't going to kill you by the time you're 35, but the insurance company can take a pretty good bet that they're not going to be the ones covering you in 10 years. And by the time you're 45 and have been overweight for 20 years, the company knows that the odds of you losing the weight are too low to bother with.
posted by 0xFCAF at 7:57 PM on October 20, 2008

This is anecdotal, but I've worked in places that did a lot of work with morbidly obese people, including gastric bypass surgery, etc.

Nearly every patient that I'm aware of ended up... after losing a great deal of weight.... with gallstones and/or kidney stones.

That (seemingly) direct consequence of weight loss is covered by your insurance companies, I think. (disclaimer: I'm a Canadian who works sometimes in the US. I'm often not really up on what is paid for and what's not.)

Those folks get nutritional "counseling" in-house before discharge after treatment.
posted by reflecked at 7:58 PM on October 20, 2008

I had an employer-provided/sponsored health plan that was very big into weight loss and fitness, so I'm not sure this is true across the board. They had a pretty broad set of incentives and rebates available for people who didn't smoke or who quit smoking, and for people who participated in a weight-loss/fitness regimen, and I think another for lowering your cholesterol. I never participated in the cholesterol one but I did the weight-loss one, and it involved keeping a fitness diary and doing some online counseling sessions with a trainer, creating and working towards fitness goals, etc. I thought it was a pretty good program. (At the end I got like $100 or $200, I forget.)

They didn't pay for my time with a personal trainer at the gym, though, and I expect this is because the ROI just isn't there. It's worth it to them to provide online/distance counseling and access to nutritionists, but they wouldn't have paid for me to see one, 1 on 1. It's just too expensive, I'd expect. (There was a period of time when I was really trying hard to get in shape, where I was literally paying more in personal training than in rent. I doubt that the money I saved the insurance company, even the infinite-horizon value, would be worth that expense. And truthfully I wasn't doing it for the health benefit for the most part, it was probably 90/10 vanity/health.)

I also think there's a perception on the part of insurance companies — and this comes from family members who work in healthcare professions — that the further a practitioner is from an actual, Board-certified MD, the more likely they are to be a quack. Physical therapists have been fighting this fight for a long time, and there's decades of hard data showing the effectiveness of PT in terms of outcomes and decreased morbidity and costs.

But as my (admittedly pretty forward-thinking) employer's plan shows, some insurance companies are open to the idea of, or at least pay lip-service to, including nutrition and fitness as part of a health insurance plan's purview. I suspect that such things will become more common, as long as there continues to be consistent data showing that they're worthwhile from a financial perspective.
posted by Kadin2048 at 8:31 PM on October 20, 2008

I think the insurance companies are slowly coming around to your way of thinking, because it is more cost effective to pay for preventative care. In my city it's only within the last 10 years or so that insurance companies have started paying for smoking-cessation treatment, and withing maybe the last 5 years they've started covering a portion of gym membership fees (provided you visit the gym a certain number of times each month - all the major gyms around here have reporting systems with the insurance companies to track this).

The last two insurance companies I've been covered by have also had significant resources available online to help people lose weight, including low-fat and low-calorie recipes, exercise activities, nutrition and activity trackers, and motivational tips. I've even seen programs where you can earn points towards gift certificates to stores like Best Buy by tracking your food and activity online through the insurance company's website.

The thing is, insurance companies place the responsibility on the individual to take advantage of these resources. Unlike bypass surgery, or stitches for your drunken lacerations, or sterilized rooms in which to give birth, simply showing up at the doctor's office and having someone look after you for an hour isn't going to fix the problem of obesity. No matter how many nutritionists or sports-medicine professionals you get recommendations from, in the end you the individual have to make the choices day to day and hour to hour that will lead to weight loss. And with all the weight-loss information available, I think anyone would be hard-pressed to argue that a lack of good information is what's causing people to be obese. It's much more likely a lack of will-power and commitment, neither of which can be solved by medical professionals. So I think the insurance companies might feel justified in arguing that paying for medical help is not likely to help someone be less obese, and thus it is not effective in preventing future costs.
posted by vytae at 8:33 PM on October 20, 2008

I think Kadin is on with that response. But I would like to point out that it's not just the health insurer, it's the plan sponsor (your employer in most cases) who is responsible for choosing what coverage you get. All the major health insurance companies do have incentives and disease management programs available for obesity, where you can work with nurses and nutritionists, get gym discounts or money for participating in things like Weight Watchers. BUT your employer has to buy access to them, in the same manner as the smoking cessation programs.

As an aside, I have seen some crazy stuff by way of these types of incentives, and if your plan sponsor wants to have their employees get full gym memberships paid for and nutritionist visits reimbursed, then the insurance company does it.
posted by smalls at 9:05 PM on October 20, 2008

I don't live under quite the same health insurance regime as the OP, but I know that when I bought health insurance, I'd be paying extra if were I a smoker, wanted cover for obstetrics, or had had heart attacks. Not sure about alcohol, but I suspect that's a fair bit harder to screen for.

I think you just need to shop around insurers a bit more.
posted by pompomtom at 9:13 PM on October 20, 2008

"if I were" , "were I" pick one...
posted by pompomtom at 9:14 PM on October 20, 2008

Regarding your specific question addressed treating post-obesity conditions, and the deal there is that once you're not obese anymore, you are not posing as great a cost risk as someone who needs a double-bypass. You've lost the weight, so presumably you know a bit about nutrition and exercise. And the extra skin is (usually) a cosmetic issue. Furthermore, it is worth noting that in some particularly bastardly insurance plans, damage to your body that's is determined to be purely caused by your own stupidity--like breaking a leg while driving drunk--isn't covered.

Regarding pre-obesity preventative care, as another poster noted, often insurers do offer programs for the things you list. But your plan has to include those. When employers are determining plans, they have to figure out what services to cover that will both make the plan worth it to their employees while not sending premiums so high it is cost-prohibitive.

Also, the whole "preventative" health care scheme has only slowly been coming into play. For one thing, medical costs have risen a LOT so it's only now that it is becoming more cost-effective to start instituting these programs. For another thing, obesity has only become a problem in the national consciousness in the past decade or two, so again, it's only now that insurers are beginning to seriously consider ways to mitigate the health care costs of the obese. I'm sure in the future we will see more active pay schemes that involve rewards for participation in exercise and nutrition programs, or at least "well-body" programs the way we have well-baby programs.
posted by schroedinger at 9:27 PM on October 20, 2008

Best answer: There is no evidence that losing significant amounts of weight, on its own, lowers people's risk of diseases that cost health insurers money.

Health insurers would prefer that everyone, regardless of their weight, exercise regularly and eat healthfully. But is there evidence that providing free gym memberships and nutritionist visits will cause to do so? In fact, most economists will tell you that people are more likely to use something like a gym membership if they're paying for a monthly membership, because they subscribe to the sunk cost fallacy. And programs such as providing nutrition advice to the families of low income public school children have been shown to have almost zero effect.

There is little reason to believe that such interventions are effective, so insurers have little reason to offer plans that cover them. However, if customers (individuals or employers) are willing to foot the bill for them, insurers will offer them, which is what seems to be happening of late.
posted by decathecting at 10:34 PM on October 20, 2008 [1 favorite]

In South Africa, our health plan included gym membership and fabulous incentives for preventative care. We earned points for going to the gym as well as for check-ups. Points converted to magazine subscriptions and heavily discounted travel to posh hotels and resorts.

We don't get any such thing now, in Switzerland. My partner's employer pays a chunk of his gym membership, but that's it. (while he's with one of the giant multi-nationals, the health plans are decided separately in each country. This must be the case, as regulations vary greatly).
posted by Goofyy at 12:40 AM on October 21, 2008

Response by poster: Thanks for the answers thus far. Just to clarify, by loose skin, I'm not talking about some loose skin around the stomach — I'm talking about — well, the specific image that bothers me is, say, this guy (on the right, obviously — and warning, not a visually pleasant picture). That obviously crosses a boundary past cosmetic, yet I have a feeling even this guy would have a hard time getting covered for removal. Or am I wrong on that?
posted by WCityMike at 7:51 AM on October 21, 2008

Best answer: WCityMike, I don't think the dividing line is obesity vs. other self-inflicted conditions (as you've framed it in your question).

If you think about it for a while, you'll realize that there are almost an infinite number of things that one could argue should be covered by health insurance because they somehow impact health. (For example, shouldn't insurance cover the cost of your daily multivitamin? It potentially impacts your health.) The insurance industry relies on certain standards that allow it to say "everything (or most things) of this type are covered, nothing else is." Specifically, with commercial health insurance, the dividing line is often medically-necessary treatments that will improve health, versus everything else which isn't covered. I would argue this is also how you end up with weird outcomes like most health insurance covering Viagra (which is meant to measurably improve ED) but not birth control pills (which don't "improve" upon your health) unless the state you're in happens to mandate equal coverage for contraceptives.

This type of informal industry standard is why certain medical treatments to improve obesity may be covered (weight loss surgery, perhaps some medications) but any treatment meant to basically maintain your current level of health isn't covered. This is probably annoying in the case of weight-related issues. It's much more problematic, I would argue, in the case of disabilities--often times commercial health insurance companies won't provide services meant to help disabled people maintain their current level of functionality, while they will cover it when the person eventually ends up in the hospital. On a related note, there's something of an interesting policy debate about the move by states to push Medicaid and SCHIP programs towards a commercial insurance model exactly for this reason--many people end up in safety-net health programs run by the state due to disability, and a move to commercial insurance will likely result in better coverage for some people (e.g., pregnant women and health children) but may well lead to a deterioration of exactly this sort of "maintaining functionality" coverage that disabled people rely on.
posted by iminurmefi at 8:06 AM on October 21, 2008

Best answer: Urgh, in case what I said above wasn't terribly clear, I think this policy brief gives a good (although somewhat jargon-y) overview of the widely-used standards for benefit design in commercial health insurance. The relevant bit starts on page 4, and she lays it out pretty clearly:

An examination of cases involving medical necessity denials by private health insurers suggests that insurers typically use a definition of “medically necessary” that permits coverage only where a service is necessary to diagnose and treat an illness or injury or restore a patient to normal functioning. The effect of such a definition would be to deny coverage for care and services otherwise included in a contract in those cases in which a patient has a “condition” rather than an illness or injury or where the patient’s condition means that treatment will not “restore normal” functioning or “cure” a condition.

Again, this isn't so much driven by "obesity is their own fault!" sort of thinking, so much as an industry standard that commercial health insurance covers curative therapy for disease or injury. Thus, Viagra = covered (restores "normal" functioning), the Pill = not covered unless mandated (does not restore normal functioning nor cure a disease). Weight loss surgery = may be covered ("cures" the condition of obesity) but sessions with a nutritionist post-weight-loss to maintain the loss = not covered (doesn't cure anything).

The focus on curing things after-the-fact rather than investing in preventative care does seem strange, but that's probably because you're thinking of health insurance as something that is intended to make or keep people healthy (as is the case with national health care programs). That is not how insurance companies think of it; they think of their product as insurance. A health care company is just about as likely to cover nutritionists and experts to help people exercise safely as your homeowners insurance is likely to pay a landscaper to come in and re-design your yard to make it more fire-proof. This issue isn't so much "does this maybe make sense from a cost-benefit standpoint" as it is, "is this what insurance does?"
posted by iminurmefi at 9:02 AM on October 21, 2008

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