The objective of the health care system is to generate health, and that may come at a price. Which price? That is the key question cost-effectiveness analyses aim to address.
Achieving weight loss serves a purpose: to lead a long and healthy life. In COMPAR-EU, we investigate the cost-effectiveness of self-management programs for obesity, among others. This means that we aim to compare the costs that come along with these programs to the short and long-term health effect that they realize.
Greatest longevity, according to a landmark US study, is achieved with a body mass index (BMI) between 23 and 25. High BMI (>35) is associated with a reduced life span with 9 to 13 years in men, an effect which is less pronounced in women. It goes to show, obesity is a serious and life-threatening condition and it is a risk factor for diabetes, cardiovascular diseases and cancer. Following a forecast scenario, up to 57.8% of the world population could be overweight or obese in 2030. While obese individuals consume more health care, the above-mentioned reduced longevity means that health care is consumed over a reduced period of time and as such, life-time spending may not be reduced when reducing obesity.
Anyone who has tried knows that losing weight in the short-term is more likely than maintaining this weight loss in the long term. A large study with a 10-year follow-up published in The Lancet indicated that lifestyle changes resulted in impressive short-term weight loss, but that within 10 years weight was similar to the placebo group (figure 1). Nonetheless, the incidence of diabetes was reduced in the lifestyle group compared to the placebo group with 34%, indicating that a lifestyle intervention in obesity, even when weight is regained in the long run, can prevent or delay onset of diabetes.
Figure 1: Mean BMI changes in three intervention groups (Lancet study)
Source: Supplement to: Diabetes Prevention Program Research Group. 10-year follow-up of Diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009; published online Oct 29. DOI:10.1016/S0140-6736(09)61457-4.
Increased health comes at a price
We know that patients can gain length and quality of life following increased physical activity and weight loss, through preventing chronic diseases such as Diabetes later in life. Which self-management interventions achieve the most health gain will be identified by the COMPAR-EU project. We do know, however, from some previous studies, that the increased health comes at a price. In general, despite not generating savings to a health care system, it is a good investment to buy Quality Adjusted Life Years (QALYs) through reducing obesity at about €6,000 per QALY. These values compare very favourably to what societies are willing to spend for pharmacological and technological treatments, which are often well above €50,000 per Quality Adjusted Life Years. Preventive measures such as lifestyle interventions (of which self-management is a key factor) generally generate health at low costs. Author Over et al. showed that the use of a pedometer combined with counselling increased physical activity (11,000 € per QALY). Van der Bruggen et al. showed that an intensive lifestyle intervention could improve health at between 3,100 € and 5,500 € per QALY. The efficiency with which health, in terms of QALYs, can be purchased, is relevant information: in a finite budget, you can choose to spend resources in a manner that yields a lot of health in return, or you can direct resources to interventions that are very costly at very little (health) return. Investing in effective weight loss programs, from a purely efficiency point of view, disregarding ethical concerns about responsibility and moral hazard, is a very good investment.
Dr Matthijs Versteegh
Matthijs Versteegh is the Director at the institute for Medical Technology Assessment (iMTA) of Erasmus University Rotterdam. Matthijs Versteegh worked for the consultancy firm Ecorys on projects for the European Commission, the World Health Organisation, the World Bank and on large regional variation studies for the Dutch National Health Care Institute.
All costs and benefits of reducing Obesity must be considered
We already know that the basic benefit package of health insurance rarely covers non-surgical weight loss programs, although recently, the Dutch health insurance package included life-style interventions. Nevertheless, obesity is often considered a problem of the individual and hence seeking help comes at own cost and responsibility in the form of either out-of-pocket expenditures or supplementary health insurance. Health insurers in turn have little incentive to invest, at own costs, in prevention since a) the benefit of a weight loss program will fall far into the future, when an insured may have left the health insurer for a competitor and b) the weight loss program may not necessarily reduce health care spending on the insureds, since increased longevity will result in additional years of health care consumption.
Reducing obesity will improve the healthy life expectancy of many, but contrary to popular opinion, will not reduce health care expenditures: living longer in good health is associated with other non-obesity related health care consumption later in life. Part of these additional costs are offset in wider society: a 2015 study in Germany showed that weight loss increases the chance of women to remain employed resulting in societal gains. In COMPAR-EU, we aim to take into account all costs and benefits related to reducing obesity, and in two years’ time, we hope to provide you with a list of self-management interventions that are most value for money.