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July 30, 2004

Medicare Changes View on Obesity

School Researchers Explain the Significance of New Policy 

The federal Medicare program recently abandoned a long-standing policy and removed language that declared obesity was not a disease. As a result, Medicare will now begin to consider covering a range of treatments that might benefit many obese beneficiaries who are at increased risk of heart disease, diabetes, cancer and stroke. According to the Centers for Medicare and Medicaid Services (CMS), approximately 18 to 20 percent of the Medicare population fits the definition of obesity (a body mass index of 30 of higher) and would be eligible for treatment. As many as 8 million Americans could potentially opt for dramatic and expensive therapies, such as bariatric surgery, to help control their weight.

To sort out the implications of this policy change, Kelly Blake, communications/publications coordinator with the School’s Center for Human Nutrition (CHN) spoke with Lawrence Cheskin, MD, an associate professor with CHN and director of the Johns Hopkins Weight Management Center, and Thomas Oliver, PhD, an associate professor with the Department of Health Policy and Management and an authority on Medicare policy.

Kelly Blake: How will this Medicare policy change affect access to obesity treatment?

Lawrence Cheskin: There’s a disparity in the United States between the people who are most affected by obesity and those who can afford treatment. Obesity treatment is becoming more effective and there are now surgeries and invasive procedures that can be very helpful for those who are extremely obese. Yet insurers are not uniformly covering these things. So you tend to have wealthier people better able to afford treatment. Of course, this is not what we like to see in the United States. Ideally we would like to have treatment available to everyone who needs it.

This policy change opens up the possibility, initially only for Medicare recipients, but eventually to those in the general population, that people will have better access to treatment.

KB: How will private insurance companies respond to the Medicare change? 

Thomas Oliver: Some private insurers are already covering obesity treatment and others are not, but nobody wants to pay for something that is viewed as really experimental or costly until it’s endorsed by Medicare. This policy change is hugely important in terms of ratifying the idea that obesity is a medical condition. Even if it’s also a result of lifestyle choices, it ultimately produces a complex set of medical problems. Once Medicare decides it is important to address this, it’s very difficult for the rest of the industry not to follow suit. Medicare is the largest single insurance pool in the world – it covers 41 million people – and when it speaks, people pay attention to it.

KB: Do you see any risks involved with classifying obesity as a disease? Does it take away from the focus on prevention and the need to change the environment and behavior?

LC: Although I certainly welcome this new shift in policy, I have not been an advocate of calling obesity a disease in the past because I don’t think it really fits the strict criteria for a disease. It is a health condition that can lead to other diseases, but in and of itself I still don’t really view it as a disease.

Also, if you call something a disease and imply that it’s out of your control, it can have negative effects on people’s ability to make changes. If you call something genetic, or say “it runs in my family,” then what can you do with it? You’re stuck with it, you’re destined – so I am usually cautious about using those terms. Genetics is not destiny.

Obesity is strongly influenced by our environment, which is why we’ve had a doubling of the proportion of people in the United States who are obese in the past generation or so. That’s not genetics or destiny, that’s a result of things that we have been doing that we can, at least in theory, put back in our control.

KB: What type of treatments do you think should and will be covered and who will be eligible? 
LC: Obesity surgery is one of the first things Medicare is planning to evaluate this fall and it will likely only be available to people with a BMI of 40 or higher. The standard definition for obesity is a person with a BMI of 30 or higher, but there are many weight loss approaches to consider before surgery, especially if someone is not extremely obese.

There has been very little access to expert nutritional assessment and diet planning either from physicians or dietitians, unless you have a specific diagnosis like diabetes. If you are simply obese, up until now, it has not been covered. So the broadest, most available service people could receive would be nutritional counseling with a dietitian. This may also be expanded to going to a commercial weight control facility. 

If you go to an established weight loss program with a track record that follows certain guidelines, there’s an expectation now that eventually this will be reimbursed in the same way that going to your local private practitioner to have standard medical tests done would. There are all sorts of possibilities for what could be considered, it may even include doing supervised exercise or the cost of going to the YMCA, we just don’t know yet.

KB: What kinds of things won’t be covered and why?

TO: The Medicare program is fairly constrained in defining the kinds of treatments that it will cover. In the absence of clear instructions from Congress about the kinds of practitioners that should be reimbursed for particular services, I think that they will be very cautious about creating a whole new bundle of covered services.

But having said that, there’s been some thinking about whether Medicare should be paying attention, not just to its own beneficiaries, but to the under 65 population who are going to be beneficiaries. Thinking about Medicare as a social program rather than just as a narrowly defined medical insurance program would lead them to get involved in more education around health and wellness, but without someone inside of the bureaucratic machinery giving those kinds of instructions and giving them the resources and the tools to do that, it’s hard to imagine that CMS is going to risk taking those steps on its own.

KB: Who determines what constitutes an “effective” treatment? How will a standard of care be established? 

LC: One such guideline for effectiveness is used by the FDA when it evaluates medications for the control of appetite and body weight. The standard for efficacy is “Does the agent cause at least a 5 percent loss of body weight, at least half of which is sustained for a period of greater than one year?”

The longer the better, obviously, but very few studies are done for longer than that right now. A one-year follow-up is usually what you see in clinical trials.

To determine a standard of care, you have to initially set up some sort of arbitrary criteria about what is effective, which would start with a group of experts who are knowledgeable about what works in treatment coming up with guidelines for what components a weight control program should have. For instance, is it adequate to simply have an initial meeting with a dietitian before obesity surgery? Or should there be some follow-up or mechanism for long-term support? And there would be some criteria for establishing if a program is effective -- if nobody ever loses weight or they all regain it back, this is obviously not an effective program. There would need to be some monitoring or mechanism for ensuring that Medicare and other insurers are paying for programs that are truly effective. That would put the burden on the program to prove that it works. 

KB: How long will it take to establish what obesity treatments are covered and who will influence that process?

TO: It will take a minimum of a few years for Medicare to get a handle on how to regulate the quality and volume of its services for obesity treatment, as well as figuring out a payment schedule.
But now that the policy is established, all the stakeholders will rush in and try to shape what the policies and procedures are going to be around this. I believe you are going to see a lot of maneuvering by practitioners and weight loss programs to be recognized and covered and if they feel they are not getting their way within CMS, they will go to members of Congress and try to work through earmarking and other kinds of strategies to have influence. I would suspect this is a trigger of a whole lot of activity that is going to now take place. Every time that Medicare has done anything, because it is so big, it just can’t help but make a lot of ripples.
--Kelly Blake

Public Affairs media contacts for the Johns Hopkins Bloomberg School of Public Health: Tim Parsons or Kenna Lowe at 410-955-6878 or paffairs@jhsph.edu.

Photographs of Lawrence Cheskin and Thomas Oliver are available upon request.