1. © Solving the Overweight/Obesity Management Puzzle 10/22/04 Rosemary Burke, RN, MS Robin F. Foust, BS, PAHM

2. © BACKGROUND MediCorp Health System –28 facility healthcare system headquartered in Virginia Mary Washington Hospital –Benefits Department –Associate Wellness Program Data/Experience –MedPar: 22 cases in 2001 to 147 cases in 2002 for 3 hospitals reviewed in MediCorp’s region –MediCorp: 16 cases many with poor outcomes Process for Change. –Zoe Consulting, Inc. –Associate/Member Wellness Program

3. © BACKGROUND MediCorp is not alone but a pioneer in Solving the Puzzle/Problem One of the chief medical officers for the Division of Health Care Financing in the Department of Health and Family Services in Wisconsin also approached Zoe Consulting for help… “We revamped our guidelines in 1999 using the recommendations of the Am Bariatric Soc., NIH National Heart, Lung, and Blood Institute clinical guidelines and the Clinical guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults (Arch. Int. Med/Vol 158 Sept 28, 1998). “We went from 77 approvals in 1997 to more than 300 in 2004, which will likely rise. We need to find the middle ground to support weight loss through conventional means and provide surgery when appropriate; i.e., the patient can cooperate, is psychiatrically able to participate in pre and post surgery programs, and has acceptable surgical risks”…

4. © BACKGROUND OVERWEIGHT AND OBESE MEMBERS Based on National statistics and MediCorp Associates’/Members’ research, MediCorp determined the need for work site nutrition and weight management programs in order to educate Associates on health risks and costs associated with obesity. There is a connection with: CVD: Heart disease, Hypertension, Diabetes Certain Cancers; Breast, Endometrial, Prostate Infertility, complex pregnancies, gestational diabetes, toxemia Fibroid tumors Sleep apnea or Pickwickian syndrome Pulmonary embolus Distress, anxiety, & depression Arthritis

5. © BACKGROUND OVERWEIGHT AND OBESITY Leading causes of morbidity and mortality –Sedentary Lifestyles –Unhealthy Weights (diets/overweight) –Tobacco Use –Risky drinking (alcohol) Consistent evidence that that behavioral risk factors cluster in individuals and populations More than ½ of U.S. adults report two or more of the four primary behavioral risk factors Progress in effective interventions for modifying these primary risks Source: Michael Goldstein, MD, and Susan Curry; Addressing Multiple Behavioral Risk Factors in Primary Care; American Journal of Preventive Medicine; August, 2004

6. © BACKGROUND Surgeon General Satcher, MD states: “Overweight and obesity may soon cause as much preventable disease and death as cigarette smoking. People tend to think of overweight and obesity is strictly a personal matter, but there is much that communities and employers can and should do to address these problems.”

7. © BACKGROUND PROGRAM TYPES (choices) Weight Management, Obesity with request for Gastric Bypass Surgery Overweight & Obesity Related Disease Treatment

8. © YEARLY COST PER PERSON BY PROGRAM TYPE

9. © BACKGROUND OBSTACLES FOR ASSOCIATES A survey of 235 Associates determined what obstacles they face in maintaining a healthy lifestyle. 47 77 26 14 10 42 19

10. © POLICY REVISION PREMISE Carrier’s policy was not effective, Something had to change

11. © POLICY REVISION OBJECTIVES Help achieve optimal outcomes for patients who have gastric bypass surgery –Improve Associate Satisfaction –Improve Human Performance (Productivity) –Improve Health Status Outcomes Reduce the number of inappropriate surgeries by applying prudent criteria for coverage as indicated in the scientific literature Ensure optimal quality of care is afforded gastric bypass surgery candidates Achieve optimal health status, health care, and financial outcomes

12. © POLICY REVISION Total document is over 50 – 500 pages (with or w/o guidelines) Actual Policy is 2 pages front & back Twenty (20) criteria for approving coverage –Procedures –CPT, ICD-9, DRG, –BMI –Other Unique criteria not in standard policies –Mandatory 6 month participation in Associate Wellness Weight Management Program pre and post surgically – if approved and/or proceed with surgery –Psychological assessment –Sleep Apnea lab Backed by research & published guidelines (20 referenced sources) Periodically review and update

13. © COVERAGE Coverage differential for use of Center of Excellence Coverage for abdominoplasty or panniculectomy 100% covered for AW Weight Management and other policy required services If proceed with surgery; coverage follows benefit plan based on 3 levels If Associate/Patient does not comply with requirements then all costs will be payroll deducted and associate is responsible for all charges – Weight Loss Program and/or Surgery

14. © THE POLICY IN SUMMARY: Patient must file for approval through the Benefits/Associate Wellness Program (AWP) Patient must meet clinical guidelines for approval Patient must comply with all procedures outlined by the policy and the Associate Wellness’ Weight Management program before approved for surgery Once the appropriate forms are filed and coverage approved, the AW – Weight Management program will work with the patient’s physician to refer the patient to a designated COE AWP continues working with the patient for at least 6 months post surgery both by phone and in person

15. © Options for Program Delivery to Support Employer Policy Revision -- and -- Policy and Program Implementation –Internal monitoring and program delivery like the MediCorp program design through AW -- which is presented next -- or, –External contracting through various program providers, or –Combination, and/or custom program design

16. © MEDICORP’S PROGRAM PROGRAM DESIGN: –Basic: Weight Loss –Monitoring and Support through Associate Wellness (AW) –Weight Watchers for group support ongoing & in addition to AW counselor meetings –Counselors apply behavioral change communication techniques to support lasting change Obesity Management – Gastric Bypass Surgery –Compliance with Policy –Monitoring and Support through Associate Wellness (AW) –Weight Watchers for group support ongoing & outside AW –Approval For Coverage »Yes: Surgery with 6 months post surgical program »No: Coverage for surgery denied –Goal: To educate participants to manage their weight through: –Improved nutrition and increased activity, –Develop positive lifestyle behaviors, and –Meet their individual weight loss goals.

17. © MHS PLAN Implement Weight Loss Program for Associates with 100 pounds excess weight or have a BMI of 35 or more with co-morbidities Implement Weight Watchers at Work Program for Associates with moderate excess weight Implement an alternative weight loss program for Associates seeking Gastric Bypass Surgery Developed and implemented Program and Data Base System –Monitor patient/associate’s progress – Initial Assessment, Reassess every three months –Monitor compliance to policy approval criteria –Programs consist of: Lifestyle changes, Proper nutrition, and Physical Activity (exercise)

18. © PROGRAM ENTRY SURGICAL CANDIDATES WEIGHT MANAGEMENT SURGERY APPROVED ASSESSMENT RISK & LEVEL OF CARE GOAL SETTING SHORT TERM LONG TERM COMPLIANT 6 Month Pre- Surgical Plan YESNO YN ELECTS SURGERY 6 Month Post Surgical & Weight Management GRADUATION GOAL ACHIEVED PROGRAM REPORTING & EVALUATION EDUCATION: Carekits/other materials mailed Surgery Denied ACHIEVE HEALTHY WEIGHT COMPLIANCE PROGRAMS & ELEMENTS GROUP SUPPORT SESSIONS i. E, Weight Watchers, or other

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22. © PROGRESS REPORT Associates confirming improved overall health –More energy and stamina –Decreased medications –Decreased shortness of breath with physical activity –Decreased joint pain –Increase in confidence and “Total Quality of Life” –Decrease in time off from work and health claims

23. © ASSOCIATE PROGRESS REPORT 45 presently in Weight Management 52 enrolled in Weight Watchers at Work 235 have completed the program since 2000 MediCorp has lost a total of 5730 pounds since 9/2000 Documented 9 surgeries avoided since program began; or $360,000 saved. (average cost of $40,000/case with no complications) 3 current candidates requesting Gastric Bypass surgery: –Wt loss from 45-73 pounds per person in <1yr 1 had a gastric bypass (Self-pay) after 31# loss in 8 weeks in program. Now a spokesperson to stay in AW program -- not surgery

24. © 92 Associates Who Have Lost As Little As 15% of Their Total Body Weight Experienced Improvement in Overall Health. n=43 n=92 n=30 n=38 n=79 n=21 n=84

25. © Where Are We Now? MAINTAINED WEIGHT LOSS (6 Mo. To 3+ Yrs) n= 14 n=59 n= 24 n=36 N=135 total

26. © NEXT STEPS Increase promotion of programs: Campaign for membership – membership drives, hospital orientation, Great American Weigh-In, Wellness Fair Advertise – ICP mail, posters, Quick Takes Offer non-food incentives for joining the program Increase number of mentors Continued support upon completion of program (re-assess every 6 mo.) Implement a Weight Management Team consisting of Weight Management Staff, F&N, Dietician, Assist, PM&R, Orthopedic, Endocrinologist Increase number of Weight Watcher Meetings to 4 each week

27. © SUCCESS STORIES P60 yr old male lost 170 # over 15 months “Made me more productive at work and home. Improved my relationships with family.” P40 yr old female lost 40 # in 6 months “I can walk without being winded. I can ride amusement rides, not sit on the bench.” P30 yr old female lost 100 # in 11 months “I never missed a meeting. This has changed my life forever. I am no longer out of control.” P50 yr old female lost 75# in 12 months “I am down from 7 to 2 pills a day.”

28. © CONCLUSION Overweight/Obesity negatively impacts:  Health  Life at home and at work  92% of on the job injuries at MHS  Cost and Use of health insurance  Our management survey revealed -- & weight management Associates confirmed -- that obesity decreases productivity WORK PLACES CAN MAKE A DIFFERENCE

29. © The Surgeon General is right “… there is much that communities and employers can and should do to address these problems.”

30. © THANK YOU Rosemary Burke rosemary.burke@medicorp.org Robin F. Foust 803-324-8626 robinzoe@comporium.net www.zoeconsulting.com

31. © References: 1.Obesity Statistics, National Institute of Diabetes & Digestive & Kidney Diseases and WebMD.com 2.O’Brien PE, Dixon JB, The Extent of the Problem of Obesity, AMJ Surg. 2002 Dec; 184(6B):4S-8S 3.US Department of Health and Human Services; Centers for Disease Control and Prevention, 2002 4.Finkelstein EA, Fiebelkorn IC, Wang G, State Level Estimate of Annual Medical Expenditures Attributed to Obesity Jan 2004; 18-24 5.Centers for Disease Control and Prevention, Prevalence of Overweight and Obesity Among Adults; US 2004 6.Monahan, b, AVP, Workforce Strategies, Fighting Obesity is the Key to Health and Productivity Management Study, AON 2004 7.Palmer and Cay Consulting Group “Policy Criteria and Procedures for Gastric Bypass Surgery Approval” Aug. 2003 8.US Surgeon General, Prevent and Decease Overweight and Obesity 2001 9.US Depart. Of Health and Human Services NI Pub. No. 01-4006 Dec 2001