G-BA is commissioned with DMP Obesity
03.11.2020 18:28
In a recent statement, the Federal Ministry of Health (BMG) describes the statutory mandate of the Federal Joint Committee (G-BA) to develop a structured treatment program (Disease Management Program = DMP) as "sensible and effective ... for the care of insured persons with morbid obesity" (obesity). It is intended to "fundamentally address the project promptly in a suitable legislative procedure [GVWG]2." The German Obesity Society (DAG) welcomes this long-overdue step as a "quantum leap," because "guideline-compliant and needs-based" standard care for people with obesity through statutory health insurance is now within reach.
„A DMP Obesity has the potential to sustainably improve the inadequate care situation of people with obesity in Germany and, in the long term, reduce their quality of life, the burden of disease and premature deaths,“ said DAG President Professor Martina de Zwaan.
As further explained in the BMG statement, DMPs aim to "improve the treatment process and quality of medical care for chronically ill people." In a DMP for obesity, those affected could receive "permanent, structured, quality-assured, multimodal, and cross-sectoral care"; this includes "in particular, qualified multimodal and multi-professional conservative and surgical therapies, including modular training programs.". 1
„"As a leading medical association in the field of obesity, we warmly welcome this new development," said Professor Dr. Martina de Zwaan, President of the DAG. "Following the Bundestag, the Federal Ministry of Health (BMG) has now also, for the first time, recognized obesity as a chronic disease requiring treatment in a written statement."“
„"Today, we have a broad spectrum of therapeutic options and treatment algorithms at our disposal to provide each patient with individually appropriate treatment. The call for a 'multimodal program' includes the recognition of evidence-based, recommended, conservative basic therapy, consisting of nutrition, exercise, and behavioral therapy. Recent developments in the field of drug-based obesity therapy must also be taken into account. There is now also legitimate hope for patients that indicated surgical therapies for obesity will no longer be arbitrarily denied. We cannot emphasize enough the need for lifelong disease management," explains de Zwaan.
„"The DAG is happy to offer its support and expertise here. We are currently revising the scientific guidelines, so we are up to date with the latest empirical evidence. We hope for the swiftest possible implementation," de Zwaan continued.
„"Our years of efforts to establish a DMP for obesity are finally bearing fruit! We submitted a proposal for a DMP for obesity to the Federal Joint Committee (G-BA) back in 2015; however, the political signal has been lacking so far. The decisive impetus for this current, very positive development is the Bundestag resolution on July 3, 2020, to launch a National Diabetes Strategy – this is the first proposal to provide standard care for the chronic disease obesity to prevent type 2 diabetes," explains this year's DAG conference president, Professor Dr. Matthias Blüher.
The BMG's statement states that, according to Section 137f of the Fifth Book of the Social Code, the G-BA is responsible for "defining in guidelines suitable chronic diseases for which structured treatment programs are to be developed and for determining their specific content."„
The Federal Ministry of Health's draft bill for the Act on the Further Development of Health Care (Health Care Development Act - GVWG) of 23 October 2020 contains the following significant addition on the topic of obesity: "39. Section 137f paragraph 1 sentence 3 is worded as follows: "By [insert: date of the last day of the twenty-fourth month following promulgation], the Federal Joint Committee shall issue corresponding guidelines pursuant to paragraph 2, in particular also for the treatment of obesity."„
Cost-benefit analysis of standard obesity care 3
In 2014, around 66.5 million people aged 20 or over lived in Germany. 3 Based on the DEGS-1 study/RKI, it was determined that 16 million (24.3% of the population) were affected by obesity (BMI greater than 30 kg/m2) (8.45 million women, 7.6 million men). 3
The DAK Obesity Care Report (2016) calculated the disease burden caused by obesity (age 20 and older) based on data from 2014 (years of life lost due to premature death = years of life lost (YLL), plus years of life with reduced quality of life, measured in DALYS = disability adjusted life years and years of life lost due to disease-associated disability = years of life lost due to disability (YLD) based on the consideration of seven diseases (breast cancer, colorectal cancer, osteoarthritis, ischemic heart disease, hypertensive heart disease, stroke, diabetes mellitus).
The basis for the projection was determined (status quo 2014):
- Obesity as a cause: On average, around 15% of the cases of illness and death from the 7 diseases considered (in individual cases, e.g. diabetes: around 43%) (Table 14, p. 82)
- Obesity-related disease burden: DALY = 15.2%, YLL = 51.7%, YLD = 48.3%
For example: On average, about half of the years of life lost due to premature death from these seven diseases are caused by obesity. For both types of cancer, it is about 95%, and for diabetes mellitus, it is about 15%. However, here, obesity increases the number of years of life limited by disability by 85%. (Table 15, p. 83)
Subsequently, it was calculated how regular medical care for obesity (nutritional advice/therapy, multimodal program/surgical therapy) would affect disease burden, premature deaths and the cost situation for these seven diseases if 15 (Scenario 1) or 20 (Scenario 2) of people with obesity were treated.
Improvements through structured obesity therapy with a treatment rate of 15% or 20% of those affected (extrapolation):
→ Decline in people with obesity by 24% (-3.9 million, from 16.14 to 12.22 million) and 33% (-5.36, from 16.14 to 10.78 million)
→ Reduction in obesity-related illness and death by 34.9% and 32.2% (treatment rate 15% and 30% respectively) and 45.6% and 43.2% (treatment rate 20% and 30% respectively).
This means that obesity-related illnesses and deaths are declining more rapidly than the number of people affected by obesity. Explanation: More severe forms of obesity, with even higher disease risk, are avoided if obesity therapy begins at a young age and at low BMI levels.
Further projections (treatment rate of 151%, compared to the status quo in 2014):
→ Temporal decline in obesity prevalence:
- After 5 years: – 1 million people with obesity
- After 10 years: – 2 million people with obesity
- After 20 years: – 3 million people with obesity
→ Development of therapy costs:
- Increase from EUR 535 million to EUR 1.28 billion in the first year (+230 million)
- after 5 years: 1.15 billion, after 10 years: 1.05 billion €, i.e. the longer the optimized treatment is continued, the more the number of those affected who require obesity treatment decreases and, with a constant treatment rate, the treatment costs also decrease.
→ Decline in disease cases, disease burden and temporal development:
- Cases of illness: – 35% (Table 18, 19, pp. 88-89)
- Delayed, subsidence expected after about 5 years (Fig. 21, p. 94)
- Disease burden (DALYS) halved after about 20 years
→ Decline in deaths and temporal development:
- Deaths: – 32% (Table 18, p. 88)
- Delayed in the first 10 years
- After 10 years: – 300 obesity-related deaths/year
- After 20 years: – 2300 deaths/year
- After 30 years: – 6000 deaths/year
- Conclusion: Since the costs of improved obesity care are immediate, while the positive effects (fewer cases of illness, disease burden, and deaths) are delayed, individual health insurance funds have so far lacked incentives to finance obesity therapies on a larger scale through selective contracts. To ensure that otherwise willing "first movers" among health insurance funds do not have to fear competitive disadvantages and to finally get optimized care for people with obesity underway, it is necessary to jointly adjust the framework conditions for all health insurance funds, as will now be achieved with a planned DMP.
Figures on obesity in Germany:
- People with obesity in Germany (18-79 years): 23-24% of the population 6
- Reliable figures on conservative therapies are currently not known
- Number of surgical procedures per year: The surgical frequency for patients with morbid obesity (Grade III = BMI 40 or higher; Grade II = BMI 35 or higher + comorbidity, e.g., type 2 diabetes) is currently 10.5 per 100,000 adults. In other European countries, it is several times higher (Sweden: 114.8; France: 86.0; Switzerland: 51.9). 4
- Obesity in children and adolescents: around 6%, approximately 800,000 affected 5
- Decline in the number of treatment facilities for children and adolescents with obesity in the last 10 years from almost 150 to currently 44. 5
Sources:
1. Federal Ministry of Health: „Statement on a DMP Obesity“ (October 2020)
2. Federal Ministry of Health's draft bill for the Act on the Further Development of Health Care (GVWG) of 23 October 2020
3. Rebscher, H (ed.): DAK Obesity Care Report (2016)
https://www.dak.de/dak/download/versorgungsreport-adipositas-pdf-2073766.pdf
4. Stroh C: „Bariatric surgery: gastric bypass preferred operation“
Dtsch Arztebl 2016; 113(20): A-980 / B-826 / C-810
https://www.aerzteblatt.de/pdf.asp?id=179375
5. DAG press release: New S3 guideline for the prevention and treatment of obesity in childhood and adolescence: Early treatment initiation shows success, but care is inadequate (February 25, 2020)
6. Mensink G, Schienkiewitz A, Haftenberger M, Lampert T, Ziese T, Scheidt-Nave C:
Overweight and obesity in Germany (DEGS1)