With primary care medicine facing ever increasing pressures—fewer doctors to treat more patients and a continual maze of restrictions on reimbursement—primary care practitioners are trying to diagnose and treat obesity with one hand tied behind their backs. The result, unfortunately, is that for what is likely the nation’s costliest disease, strains on coverage have been yet another needless hurdle to getting patients diagnosed and treated in a clinical environment.
A comprehensive approach to diagnosing and treating obesity is just good medicine, and physicians need good reimbursement policies to make this practice practical. Fortunately, a recent ruling out from the Centers for Medicare and Medicaid Services (CMS) is one bright spot in beginning to change this trend. CMS has ruled that it will cover services for high intensity obesity counseling.
Specifically, the federal agency has said it will pay for obese Medicare beneficiaries to undergo behavior modification and weight-loss counseling in the primary care setting. These counseling sessions could be administered outside of the context of any associated chronic conditions, such as diabetes, allowing physicians to treat the problem from its root rather than as a reaction.
The intensive behavioral therapy for obesity consists of screening for obesity in adults (using measurements of body mass index, or BMI); dietary assessment; and behavioral counseling and therapy to promote sustained weight loss through high intensity interventions concerning diet and exercise. Counseling will involve one office visit every week for a month; one office visit every other week for months two to six; and one office visit for every remaining month through one year.
Further, patients must show incremental weight loss totaling at least 6.6 lbs by the six month mark in order to complete treatment that year. While this benchmark may not seem remarkable to a culture that embraces a “Biggest Loser” mentality of weight loss, we must keep in mind that such measurable progress can make a meaningful difference in an overweight patient’s long term health, and it can reduce the risk of more than 60 related chronic conditions, including heart disease, cancer and diabetes.
Coverage For Obesity Counseling Promises Significant Benefits
Enabling more primary care practitioners to treat more patients for this $168 billion per year—and growing— epidemic is a step that may, in part, help turn the tide on the obesity epidemic in the U.S. At present, less than half of primary care physicians report regularly providing nutrition and weight-control advice to adult patients with weight-related disease, and less than a quarter track their weight-control behaviors over time.
However, a study released last month in the New England Journal of Medicine found that obese patients lose more weight when they’re part of a primary care-based program that incorporates lifestyle coaching, plus weight loss medication or meal replacement, compared with doctor visits alone. After two years, those in an enhanced counseling group lost the most weight, about 10.1 pounds on average, than those in a group that had only brief coaching sessions and a group that underwent only quarterly visits; these groups lost about 6.4 pounds and 3.7 pounds respectively. As there is no single weight loss approach that is proven to be successful across the population, the new ruling is promising in its intent to cover multiple consultations with obese patients in order to monitor progress as well as discuss alternative treatment options.
Private Payers Should Follow Medicare’s Lead In Covering Obesity Counseling
As Medicare’s new approach is a step in the right direction, it is one that private payers may also do well to adopt. While it is important to catch and treat obesity in elder populations, Americans would be well served to do the same across the age spectrum, particularly at the youngest ages when clinicians have a real shot at making a difference throughout the private sector. As we know that overweight adolescents have a 70 percent chance of becoming overweight or obese adults, such policies would be to the benefit of patients and taxpayers alike.
Indeed, the decision presents some good news for taxpayers who have been footing the bill for the obesity epidemic. Last year, the Congressional Budget Office reported that per capita health care spending for obese adults (as of 2007) is 38 percent greater than for adults of a “normal weight” — defined as a person with a BMI between 18.5 and 25. This constitutes a more than four-fold increase in obesity-related spending over a mere twenty-year span. And according to researchers at Emory University, obesity may account for 21 percent of all health care spending by 2018.
Obesity Costs Extend Beyond The Health Care System
Further, obesity is not only costly in the health care setting. Employers alone experience a more than $73 billion loss each year due to losses in productivity, absenteeism and medical costs attributed to obesity, according to researchers at Duke University. The impact on business can total $1,000 to $6,000 in added cost per year for each obese employee, with the figure rising along with a worker’s body mass index. Additionally, costs extend to our military where more than 1,200 first-term enlistees are discharged every year because they cannot maintain a healthy weight. Beyond the staggering health concerns this presents to our young men and women, the military must also recruit and train a replacement at a cost of $50,000 for each discharged enlistee.
CMS Should Cover Obesity Treatment By Specialists
With these figures in mind, the decision presents itself as an investment in both our physical and fiscal health. However some work remains to be done. While the coverage provides payment for services provided in the primary care setting, this is not the only area in which obesity treatment services are provided.
Primary care physicians often lack the essential training in nutrition and exercise therapy to provide comprehensive treatment services for their patients. These patients may be better served by seeing not only a primary care physician, but also a specialist in an area relevant to their clinical needs, such as a registered dietitian, exercise therapist or an obesity medicine specialist. As CMS continues to consider coverage of preventive services for obesity, an appropriate next step would be to provide coverage for these specialized services and other appropriate clinical visits for patients with obesity.