OBJECTIVES

To understand the rationale behind why payers and employers opt to cover or not cover bariatric surgery.

METHODS

Primary data was collected from interviews with payer medical directors and employer HR health benefit contractors. A secondary research payer coverage scan was also conducted to understand current coverage dynamics and future coverage demands. After review, a collaboration was formed with the National Alliance of Healthcare Purchaser Coalitions and Greater Philadelphia Business Coalition on Health (GPBCH). The joint effort included a breakout session at the National Alliance’s Annual Meeting in November 2018, as well as the development and dissemination of a clinical brief about updated evidence and recommendations for a benefit design plan that allows for bariatric surgery coverage.

RESULTS

While some employers do take a holistic approach to benefit design, it was noted that communicating indirect costs to leadership is difficult. Pre-surgical requirements were also viewed as a tool to help patients achieve the best possible outcomes following bariatric surgery and generally implemented due to a carrier's recommendation. Employee longevity, productivity, and budget impact are factored into coverage decisions, with 3-5 years being the typical timeframe for return on investment analyses. Overall, employers are open to learning more about the benefit design options available.

CONCLUSIONS

Adverse selection can be a barrier to establishing or expanding coverage. High costs associated with surgery and the large volume of potentially eligible patients influence this thought process, especially as some payers are under the misconception that obesity is a lifestyle choice rather than a disease. Lack of demand among employers may also contribute to resistance around expanding coverage. Unmet needs include identifying the correct patient population for bariatric surgery and supporting the maintenance of post-surgery compliance.