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Will Obesity Treatment Reimbursement Benefit Those at Highest Risk?

Published:February 16, 2015DOI:https://doi.org/10.1016/j.amjmed.2015.01.026
      Historically, providers have lacked reimbursement for obesity management in the primary care setting. In 2011, the Centers for Medicare and Medicaid Services released the decision to reimburse qualified primary care providers for obesity counseling.

      Centers for Medicaid and Medicare Services. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Available at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive Behavioral Therapy for Obesity&bc=ACAAAAAAIAAA&NCAId=253. Accessed June 10, 2012.

      Currently, providers can bill for intensive behavioral therapy during weekly face-to-face visits in the first month of treatment, followed by bi-weekly face-to-face visits in months 2-6. The provider can be reimbursed for monthly face-to-face visits in months 7-12, but only when the patient loses at least 3 kg by the 6-month visit. Despite representing an important step in improving the treatment of obesity in primary care practice, some have expressed concern that the plan does not reflect fully the extant scientific literature.
      • Pagoto S.
      • Lemon S.C.
      • Pbert L.
      • Van Dornsten B.
      • Whiteley J.
      Evidence for community-based approaches to weight loss: a case for revising the Centers for Medicaid and Medicare Services reimbursement structures.
      We are concerned particularly about how the policy might adversely impact high-risk groups, namely racial/ethnic minority and socioeconomically disadvantaged populations. Not only does obesity continue to exact a disproportionate toll among high-risk groups,
      • Ogden C.L.
      • Carroll M.D.
      • Kit B.K.
      • Flegal K.M.
      Prevalence of childhood and adult obesity in the United States, 2011-2012.
      there is limited empirical evidence that we can produce at least a 3-kg weight loss in these populations. For example, across a large number of trials, Blacks demonstrate smaller absolute weight losses and poorer weight loss outcomes relative to Whites.
      • Osei-Assibey G.
      • Kyrou I.
      • Adi Y.
      • Kumar S.
      • Matyka K.
      Dietary and lifestyle interventions for weight management in adults from minority ethnic/non-White groups: a systematic review.
      This challenge is especially evident in the primary care setting. In one of the only pragmatic primary care-based trials for weight loss among socioeconomically disadvantaged patients, Bennett et al
      • Bennett G.G.
      • Warner E.T.
      • Glasgow R.E.
      • et al.
      Obesity treatment for socioeconomically disadvantaged patients in primary care practice.
      reported 24-month weight loss outcomes of −1.03 kg. Only 16% of Medicare-eligible patients in the study would have met the threshold of 3-kg weight loss at 6 months.
      What does it take to produce 6-month weight loss of 3 kg in high-risk populations? In the voluminous body of weight loss trial evidence, outcomes of this magnitude have only been reported less than a handful of times, all from high-intensity multicomponent interventions tested in highly controlled, multisite efficacy trials.
      • Osei-Assibey G.
      • Kyrou I.
      • Adi Y.
      • Kumar S.
      • Matyka K.
      Dietary and lifestyle interventions for weight management in adults from minority ethnic/non-White groups: a systematic review.
      Participants in these trials were younger, more socioeconomically advantaged, and more motivated than the average Medicare recipient. None of the trials was implemented in the primary care setting and none included physicians as interventionists.
      The field's inability to reliably produce weight losses in excess of 3 kg for high-risk patients strongly suggests that these populations may be excluded systematically from opportunities to receive a full year of obesity treatment. If so, this policy has potential to do harm, namely by widening the already pressing disparities in obesity. We recognize that the policy's planners were faced with a challenging and unenviable task, but likely few would argue that its design has demonstrated efficacy for those in high-risk populations. Providing inadequate coverage for the populations most affected by obesity would seem to be a recipe for greater future chronic disease burden and health care costs.
      We have several suggestions to improve the Centers for Medicare and Medicaid Services reimbursement policy and diminish the likelihood of increasing obesity disparities.
      First, the weight loss threshold should be removed. At least 2 trials have demonstrated that patients in high-risk groups achieve clinical benefit from treatment, even if they do not exhibit a 3-kg weight loss at 6 months.
      • Bennett G.G.
      • Warner E.T.
      • Glasgow R.E.
      • et al.
      Obesity treatment for socioeconomically disadvantaged patients in primary care practice.
      • Ockene I.S.
      • Tellez T.L.
      • Rosal M.C.
      • et al.
      Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project.
      This suggests that use of the threshold may mean that high-risk populations will receive less treatment than their lower-risk counterparts. Given the ever-widening health care disparities observed in the past several decades, policies that have great potential for introducing systematic biases in care provision should be avoided. Instead, we should reimburse providers based on the most reliable predictor of weight loss outcomes–patient engagement. In study after study, patients who show up to treatment simply do better. Turning willing and interested patients away because they haven't lost 3 kg should not constitute best practice.
      Second, expand reimbursement to nonphysician providers. Little evidence supports the efficacy of exclusively physician-delivered obesity treatment in high-risk patients. Instead, the overwhelming majority of trials have utilized registered dietitians and psychologists or other behavioral health professionals as interventionists.
      • Carvajal R.
      • Wadden T.A.
      • Tsai A.G.
      • Peck K.
      • Moran C.H.
      Managing obesity in primary care practice: a narrative review.
      These nonphysician providers have the requisite training and experience to deliver behavioral counseling and to address challenges unique to high-risk populations, including barriers to care, health literacy, socioeconomic challenges (eg, difficulty purchasing healthy food options), cultural variations in lifestyle and diet, and psychosocial issues (eg, greater depression among high-risk populations). Medical training has not generally included robust coursework in these areas. The current reimbursement structure only includes ancillary care providers who are billed under the supervision of a qualified provider, which excludes these key providers from billing independently. The Treat and Reduce Obesity Act of 2013 would do as we suggest, expanding coverage to a number of nonphysician providers, including registered dietitians and diabetes prevention lifestyle coaches. Importantly, these providers would be permitted to deliver and bill for treatment outside of the primary care setting. We would argue for the addition of a formal process to qualify additional providers, based on evidence of their effectiveness as interventionists.
      Third, expand coverage for evidence-based community programs. We have extensive evidence that high-risk populations, particularly those in rural settings, experience myriad barriers accessing medical treatment. These barriers limit their ability to engage at the reimbursed frequency. Extending coverage to evidence-based community programs would extend the reach of obesity treatment, while mitigating access to barriers in a potentially cost-efficient manner.
      • Bennett G.G.
      • Warner E.T.
      • Glasgow R.E.
      • et al.
      Obesity treatment for socioeconomically disadvantaged patients in primary care practice.
      Also, consideration for treatment delivered outside the primary care setting is included in the Treat and Reduce Obesity Act of 2013.
      Provider reimbursement represents an important shift in our approach to delivering the best care for the tens of millions of obese Americans who need treatment. While no reimbursement policy can be fully comprehensive, these strategies should be weighted toward those with greatest need. The current reimbursement policy does not appear to meet that test. Will the plan fail our highest-risk populations? Only time will tell. Unfortunately, we have little time to waste.

      References

      1. Centers for Medicaid and Medicare Services. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Available at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive Behavioral Therapy for Obesity&bc=ACAAAAAAIAAA&NCAId=253. Accessed June 10, 2012.

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        Dietary and lifestyle interventions for weight management in adults from minority ethnic/non-White groups: a systematic review.
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        Obesity treatment for socioeconomically disadvantaged patients in primary care practice.
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        • Ockene I.S.
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        Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project.
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        • Wadden T.A.
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