Managed care organizations, like almost everyone involved in the health-care delivery system, are realizing that a major threat to our country’s health and health-care costs is the American diet and the associated increased prevalence of obesity. As the articles in
this supplement illustrate, increased obesity, especially abdominal obesity, is associated with clustering of risk factors for diabetes and cardiovascular disease, now referred to as cardiometabolic risk. The articles show the high prevalence of cardiometabolic risk factors in our managed care populations, the clustering of these risk factors in individual members, and the increased relative risk of diabetes and cardiovascular events that will develop. That obesity is linked to diabetes, dyslipidemia, and cardiovascular disease is well accepted, and many managed care organizations have active disease management programs to help manage these high-risk and high-cost populations. These programs commonly target their populations through claims data, both medical and pharmacy, that identify through diagnosis codes or prescribed medications appropriate members for the disease management programs. But, these programs all intervene after the proverbial horse has left the barn. These members already have developed diabetes or cardiovascular disease and are experiencing high-cost events related to these diseases. To fully realize our potential as managed care organizations and our mission of “health maintenance,” is it possible to successfully intervene before the development of clinically recognized diabetes, coronary artery disease, or cardiovascular disease?

The articles in this supplement discuss the clustering of risk factors associated with abdominal obesity that increased a person’s relative risk for developing diabetes and cardiovascular disease. What can managed care organizations do to identify their members with cardiometabolic risk before the onset of clinical disease to facilitate early treatment in the hopes of reducing the development of diabetes, cardiovascular disease, and associated costs? Unfortunately, there are no specific diagnosis codes or medication profiles that can easily identify members with cardiometabolic risk before they actually develop diabetes or experience a cardiovascular event. As the article by Hollenbeak et al. discusses, most managed care plans do not have access to the metrics (i.e., weight circumference and lab results for blood sugar and lipids) that identify this population. Without the ability to identify these members, enrolling them in traditional disease management and case management is not possible. The recognition of patients with increased cardiometabolic risk and initiation of early interventions and treatment will mostly fall to primary care physicians. Managed care organizations can help facilitate knowledge of these risk factors and the importance of treatment through provider communications, but health plans are not normally recognized as clinical experts. The primary responsibility of the educational efforts toward primary care physicians must come from appropriate specialty organizations and key opinion leaders.

Despite managed care’s secondary role in the educational effort for primary care physicians, health plans still play a critical role. Health plans develop medical insurance products and determine benefit design, which greatly influences medical services provided. In general, health plans provide varying, but limited, coverage for weight reduction. Most plans presently do cover bariatric surgery for appropriately selected morbidly obese patients. To their credit, an increasing number of plans are presently offering nutritional counseling for weight reduction or discounts toward established commercial programs, such as Weight Watchers, Jenny Craig, etc. Nevertheless, the large majority of health plans continue to exclude weight reduction medications from coverage. There are many historical reasons for the exclusion of weight reduction medications. One important reason is that most of these medications either did not work or were dangerous, amphetamines and Fen-Phen being two well-known examples of the dangers. Another reason is the aversion to using valuable premium dollars from all members to cover treatment of “life style” decisions made by individual members. Not that long ago many health plans did not cover medications for smoking cessation or provide any coverage for substance abuse treatment, whereas coverage is currently available in most plans. It is generally accepted today that many “life style” choices may include a genetic propensity toward the habit or addiction, and discontinuing the behavior may not be simply a matter of choice. A third argument is the perception that weight reduction is most commonly done for the reason of appearance, not to treat a disease. The articles in this supplement show that for many individuals the presence of  an increased body mass index and waist circumference is a problem beyond appearance and is associated with a cluster of one or more risk factors for future diabetes and cardiovascular disease. To help physicians combat the increasing prevalence of obesity with associated increases in diabetes and cardiovascular disease, managed care organizations should reexamine their benefit designs around the treatment of obesity. Increasing coverage of wellness programs, nutritional counseling and weight reduction programs, and safe and effective medications for weight reduction should be considered. Managed care organizations have the tools to insure only the appropriate risk population receives treatment for their obesity and associated cardiometabolic risk factors. A blanket exclusion of weight reduction services and medications may no longer be in the best interest of managed care organizations or their members.