Rep Lucio Obesity PPT

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Addressing the Obesity Crisis in Texas

State Representative Eddie Lucio III

November 20, 2009

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AgendaAgenda

Obesity Statistics

– Prevalence• Nationally and in the Hispanic Population

• Health and State Implications

– Causes

– State of Texas

Legislation Addressing Obesity in Texas

– Texas SB 2577

Ideas for your state

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Prevalence and TrendsPrevalence and Trends

Nearly one-third of US adults are obese (BMI > 30 kg/m2)1

– Prevalence has more than doubled in 46 years (13.3% to 30.9%)1

Nearly 5% of US adults are morbidly obese (BMI 40)1

– Prevalence of morbid obesity has doubled in 12 years (2.9% to 4.7%)1

17% of children 6-19 years of age are overweight4

– Overweight adolescents have a 70% chance of becoming overweight or obese adults5

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Severely Obese(BMI 35 to 39.9 )

Morbidly Obese(BMI 40 or more)

Normal Weight (BMI 18.5 to 24.9)

Obese(BMI 30 to 34.9)

Overweight(BMI 25 to 29.9)2 1 1 1 1,3

1. Bannerman. CDHC Solutions. 2006.2. Department of Health and Human Services. 2007.3. American Obesity Association. 2007.

4. Ogden, et al. Gastroenterology 2007.5. Department of Health and Human Services. 2007.

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1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2008

2008

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Ref: CDC U.S. Obesity Trends 1985–2008 http://www.cdc.gov/NCCDPHP/dnpa/obesity/trend/maps/index.htm

**BRFSS= CDC’s Behavioral Risk Factor Surveillance System

2000

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

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Medical Complications of ObesityMedical Complications of Obesity

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Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate

Phlebitisvenous stasis

Gout

Idiopathic intracranial hypertension

Stroke

Cataracts

Severe pancreatitis

www.obesityonline.org

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Why? Obesity Rates Trends Why? Obesity Rates Trends

• Americans consume an average of 300 more calories per day than they did 25 years ago and eat less nutritious foods;

• Nutritious foods are significantly more expensive than calorie-dense, less nutritious foods;

• Americans walk less and drive more -- even for trips of less than one mile;

• Parks and recreation spaces are not considered safe or well maintained in many communities;

• Many school lunches do not meet nutrition standards and children engage in less physical activity in school;

• Increased screen time (TV, computers, video games) contributes to decreased activity, particularly for children

• Adults often work longer hours and commute farther.

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Self Magazine, August 2001

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STATE-BY-STATE ADULT OBESITY RANKINGSSTATE-BY-STATE ADULT OBESITY RANKINGS

–from the “F as in Fat” 2008 issue report–from the “F as in Fat” 2008 issue report

STATES with Highest Obesity Rankings– 1: Mississippi;2: West Virginia; 3: Alabama; 4: Louisiana; 5: South Carolina;

6:Tennessee; 7: Kentucky; 8 (tie): Arkansas; Oklahoma; 10: Michigan Honorable Mention States: Glass Half Empty- Higher Obesity Rank

– 11: (tie) Georgia; Indiana; 13:Missouri; 14: Alaska; 15 Texas 16: North Carolina 17: Ohio;18. Nebraska; 19. Iowa 20: South Dakota;

Middle of the Pack: Glass Half Full/Half Empty– 21: (tie) Delaware, North Dakota; 23: Kansas; 24:Pennsylvania; 25:Wisconsin;

26: Illinois; 27 (tie) Maryland, Virginia; 29: Oregon; 30:Minnesota; Honorable Mention States: Glass Half Full- Lower Obesity Rank

– : 31: Idaho; 32: Washington; 33: Wyoming; 34: Maine; 35: (tie) Nevada, New Hampshire, 37: New York; 38 (tie) Arizona, Florida, New Mexico

STATES with Lowest Obesity Rankings– 41: California; 42 New Jersey; 43: District of Columbia; 44: Utah

45:Montana; 46: Rhode Island; 47:Vermont: 48: Massachusetts; 49:Connecticut; 50: Hawaii; 51: Colorado

11Trust for America's Health 2007 report www.HEALTHYAMERICANS.org

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Direct Cost of Chronic Diseases Direct Cost of Chronic Diseases in the United Statesin the United States1,21,2

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0

10

20

30

40

50

60

Dir

ect

Cost

($ B

illion

s)

Type 2Diabetes

*Adjusted to 1995 dollars.

Obesity CoronaryHeart

Disease

Hyper-tension

Stroke

$18.1$18.4

$38.7

$51.6$53.2

1. Wolf et al. Obes Res 1998.

2. Hodgson et al. Med Care 1999.

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Prevalence Rates in the Hispanic Prevalence Rates in the Hispanic PopulationPopulation

1 out of 3 Hispanic Adults in Texas is

Classified as OBESE

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TexasTexasState Rankings for 2008State Rankings for 2008

#15 in Adult Obesity at 27.2% 64.1% overweight and obesity

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#6 in Child Obesity at 19.1%Ages 10-17

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#11 in Diabetes at 8.8%#27 in Hypertension at 26.9%

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#8 in Adult Physical Inactivity at 28.1%

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Obese High School Students15.9%

55

Overweight HS Students*15.6%

66

Trust for America’s health 2008 report www.HealthyAmericans.org 2005 – 2007 average

Percentage of state population per category

*Only 45.2% meet recommended Physical Activity Level

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The Cost of Obesity in TexasThe Cost of Obesity in Texas

According to the Texas Comptroller’s Report on Obesity (2007)

– Cost of obesity to Texas employers in 2005 was $3.331 billion

– By 2025 estimated to be $15.845 billion annually.

$1,378.2

$590.7

$1,246.5

$115.6

$2,308.6

$898.1

$1,895.3

$175.8

$3,747.9

$1,235.7

$2,067.7

$241.9

$5,839.0

$1,658.0

$3,498.9

$342.6

$8,754.7

$2,144.8

$4,526.1

$419.9

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

2005 2010 2015 2020 2025

Disability

Presenteeism

Absenteeism

Health Care

Obesity Costs to Texas Private Businesses and Insurers

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Texas Obesity LegislationTexas Obesity Legislation

SB 2577 – Coverage of bariatric surgery for state employees

SB 395 – Establishing an early childhood health and nutrition Interagency council

S.B. 870 expanded the duties of the council and TDA relating to health wellness, and prevention of obesity and the establishment of an obesity prevention pilot program.

– Creates an evidence-based public health awareness plan.

– Coordinates to establish a pilot program designed to decrease the rate of obesity in child health plan program enrollees and Medicaid recipients, improve the nutritional choices and increase physical activity levels of child health plan program enrollees and Medicaid recipients, and achieve long-term reductions in child health plan and Medicaid program costs incurred by the state as a result of obesity.

HB 4630 – Relating to state employee wellness program

– Creates an online questionnaire for state agency heads to report information, including:

• the agency policy on leave time for employees to complete a health risk assessment;

• the agency policy on leave time for employees to receive an annual physical examination;

• the agency policy on providing employees time during the workday to exercise; and

• whether the agency has a wellness coordinator or council.

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Texas Bariatric Surgery LegislationTexas Bariatric Surgery Legislation

SB 2577 Texas Bariatric Surgery Coverage for State Employees

Bill Text: relating to bariatric surgery coverage for state employees.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1.  Subchapter E, Chapter 1551, Insurance Code, is amended by adding Section 1551.225 to read as follows:

Sec. 1551.225.  BARIATRIC SURGERY COVERAGE. (a)  The board of trustees shall develop a cost-neutral or cost-positive plan for providing under the group benefits program bariatric surgery coverage for employees eligible to participate in the program under Section 1551.101.

(b)  The board of trustees may adopt rules as necessary to implement this section.

SECTION 2.  The board of trustees of the Employees Retirement System of Texas shall implement the plan required by Section 1551.225, Insurance Code, as added by this Act, as soon as practicable, but not later than September 1, 2010.

SECTION 3.  This Act takes effect September 1, 2009.

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Bill DetailsBill Details

SB 2577 gives the Employee Retirement System of Texas (ERS) the ability to add Bariatric Surgical Procedures to the ERS health plan.

The bill directs ERS to produce a bariatric coverage policy that would be cost neutral or cost positive to the plan.

This allows ERS the opportunity to take direction from the Legislature on the important issue of obesity in Texas by allowing state employees to have the same options that a majority of Texas employers, CMS, and Medicaid recipients in Texas and 45 other states have.

Fiscal Impact to the state: Neutral to Positive

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How to Achieve Cost-Neutral/Cost-PositiveHow to Achieve Cost-Neutral/Cost-Positive

ERS reports that in order to achieve cost-neutral or cost-positive results, some examples of potential benefits designs would include, but not be limited to:

– availability to employees who have been covered under the HealthSelect portion of the GBP continuously for 5 years prior to the surgery;

– adherence to guidelines established by the GBP's Third Party Administrator (TPA) including, but not limited to, a Body Mass Index (BMI) of 40 or more, or a BMI of 35 or more with at least 1 comorbidity, and participation in a medically supervised weight loss program and failure at least 1 year prior to the surgery;

– services would be required to be performed at a Center of Distinction, as defined by the TPA;

– benefits would be subject to a separate deductible and co-insurance rate

– expenses would not be applied against the employee's annual out-of-pocket limit;

– benefits would be limited to in-network only and no coverage would be available out-of-network or through a noncontracted facility or physician;

– surgery would only be allowed once in the lifetime of a member.

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Senate Bill 395Senate Bill 395

Little attention paid to early childhood population

SB 395 establishes the Early Childhood Health and Nutrition Interagency Council

Council will engage the 7 regulatory agencies that have a role in the regulation and management of early childhood settings in TX

Agencies will work with experts to study best practices for improving early childhood nutrition and create a plan that will provide related recommendations for implementation over a 6 year period

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Ideas for State Obesity LegislationIdeas for State Obesity Legislation

• 19 states set nutritional standards for school lunches, breakfasts, and snacks that are stricter than current USDA requirements. Five years ago, only four states had legislation requiring these stricter standards.

• 27 states have nutritional standards for competitive foods sold a la carte, in vending machines, in school stores, or in school bake sales. Five years ago, only six states had nutritional standards for competitive foods.

• Every state has some form of physical education requirement for schools, but these requirements are often limited, not enforced, or do not meet adequate quality standards.

• 20 states have passed requirements for body mass index (BMI) screenings of children and adolescents or have passed legislation requiring other forms of weight-related assessments in schools. Five years ago, only four states had passed screening requirements.

• 19 states have laws that establish programs linking local farms to schools. Five years ago, only New York had a farm to school program.

• 30 states and D.C. have some form of a snack tax.• Four states -- California, Maine, Massachusetts, and Oregon -- have

enacted menu labeling legislation.• 24 states have passed legislation to limit obesity liability

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QuestionsQuestions

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BACK UP SLIDESBACK UP SLIDES

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40

60

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Increase in Healthcare Costs of Obese versus Increase in Healthcare Costs of Obese versus Individuals with BMI < 25 kg/mIndividuals with BMI < 25 kg/m2 12 1

Incre

ase in

Cost

Com

pare

d

wit

h L

ean

Su

bje

cts

(%

)

BMI 30-34 kg/m2 BMI >35 kg/m2

1. Quesenberry et al. Arch Intern Med. 1998.

HMO Setting: Northern California Kaiser PermanenteHMO Setting: Northern California Kaiser Permanente

Healthcare visits

Pharmacy

Laboratory tests

All outpatient services

All inpatient services

Total healthcare

25

25

Comorbidity

+

-

National Institutes of Health et al. http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Accessed November 5, 2008

• Diet• Exercise• Behavior modification

Lifestyle Changes

Medications (Alli® OTC, Xenical® and Meridia®)

BMI (kg/m

²)Surgery*

27-29.9

≥ 30

25-26.9

≥27

35-39.9

≥ 40

Ineffective over time (5% to 10% EWL, on average)1,2,3

Short-term use not effective (5% to 10% EWL, on average)1,2,3,4

Effective over time (≥50% EWL sustained for 10 years)2,3

Treatment OptionsTreatment Options

*Malabsorptive procedures: Jejunoileal bypass Restrictive procedures: Gastric banding, Sleeve Gastrectomy Combination procedures: Roux-en Y gastric bypass (RYGB),

Biliopancreatic Diversion/Duodenal Switch

1. Dixon et al. Diabetes Care. 2002. 3. Fisher, et al. Amer J Surgery, 2002. Xenical ® is owned by Hoffmann-La Roche Inc.2. O’Brien et al. Obes Surg. 2006. 4. Wierzbicki, A. Int J Clin Pract. 2006 Meridia® is owned by Abbott Laboratories, Inc.

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Weight-Loss SurgeryWeight-Loss Surgery

Laparoscopic Adjustable Gastric Banding* vs Gastric Bypass Surgery—Safety

CategoriesCategories LAGBLAGBGastric Gastric BypassBypass

Total Complications†1 9%(n = 480)

23%(n = 235)

Major Complications†1

(Grades III and IV)0.2%

(n = 480)2.1%

(n = 235)

Postsurgical Mortality Rate2

(Short-term)

0.05%(n = 5780)

0.5%(n = 9258)

* Includes LAP-BAND® System and other adjustable gastric banding systems.† Published complication rates vary depending upon the institution and how the surgeon diagnoses and defines a particular complication.1. Parikh et al. J Am Coll Surg. 2006.2. Chapman et al. Surgery. 2004.

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Impact of Bariatric Surgery on Impact of Bariatric Surgery on MortalityMortality

Within the past several years, studies evaluating the effect of bariatric surgery on mortality have found:1-6

Overall mortality appears to be reduced by approximately 50%

– Mortality reduction is seen with deaths related to myocardial infarction, cancer, and diabetes

– Dramatic decreases in mortality was observed in obese patients (hazard ratios 0.11-0.76)

– Substantial mortality reductions relative to controls were observed in two studies evaluating only LAP-BAND® System patients (hazard ratios 0.28 and 0.36)5,6

Studies do not allow for conclusions to be drawn about the relationship between the extent of weight loss and mortality

1.Christou et al. Ann Surg 20042.Flum et al. J Am Coll Surg 2004 3. Sjöström et al. NEJM. 2007

4.Adams et al. NEJM 20075. Peeters et al. Ann Surg 2007

6.Busetto et al. Surg Obes Relat Dis 2007

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Cost Savings in Surgically Treated Cost Savings in Surgically Treated vs Conventional Therapy at 5 yrs vs Conventional Therapy at 5 yrs

N=1118. 5-yr follow-up (1986-2002). McGill University Heath Center, Montreal.

Sampalis JS. Obes Surg. 2004;14:939-947

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

Cardio Endocrine Cancer Infection Respiratory

Bariatric

Control

Ave

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e C

ost

Per

1,0

00 P

atie

nts

for

Ho

spit

aliz

atio

n$

(Mill

ion

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Economic Impact of Bariatric SurgeryEconomic Impact of Bariatric Surgery

Objective: evaluated private, third-party payer return on investment for bariatric surgery in the U.S using a large, insurance claims database

N=3651 bariatric surgery patients and matched morbidly obese controls, based on patient demographics, selected co-morbidities and costs

Analyzed 6 months pre-surgical evaluation and care, surgery, and ~18 months post surgical care

– Included costs incurred from surgical complications– Some patients’ post surgical claims tracked for up to 5 years– Costs included payments for prescription drugs, physician visits and

hospital services– Monitored claims for obese patients without surgery over the same period

Results: insurers fully recovered costs of laparoscopic surgery after 2 years, and within 4 years for open surgery patients

– Between 2003 and 2005, break-even point was reached in 49 months for traditional bariatric surgery, which carries an average cost of $26,000.

– Laparoscopic surgery is a less-invasive version of gastric bypass, with an average cost of $17,000

*The study did not address gastric banding

Cremieux et al. Am J Manag Care. 2008;14(9):589-596