State of the Industry: Obesity

In July, the American Medical Association (AMA) announced the recommendation to reclassify obesity from a disorder to a disease.

“For some, the question might be characterized as whether obesity is a disease that requires a treatment or is it due to personal behavior-overeating, lack of exercise and physical activity,” says Joel Brill, MD, MHE editorial advisor and chief medical officer of Predictive Health LLC. “If patients assume a sick role-‘I am obese, I have a disease’-how does that impact personal responsibility?”

About 60% of Americans are overweight or obese. Research has shown that by 2022, 81 million Americans are estimated to be overweight and 113 million obese.

The AMA’s Council on Science and Public Health says, “Given the existing limitations of BMI [body mass index] to diagnose obesity in clinical practice, it is unclear that recognizing obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in improved health outcomes.”

Obesity alone causes 200,000 deaths annually and is more prevalent than tobacco use. It also accounts for $147 billion to $210 billion in costs annually, according to the Trust for America’s Health. Combined with overweight, it is the second leading cause of preventable death in the United States.

“Obviously, this is a complex issue from a coverage perspective with impact on purchasers, payers, providers and of course patients that could take time to address what types of services-drugs and devices-are medically necessary and should be covered,” says Dr. Brill.

He also says the designation might make payers and Medicare reassess coverage positions toward drugs, surgery, dietician counseling and/or minimally invasive trans-oral devices for obesity. Whether or not the designation will have an effect on these devices for people who are overweight but not morbidly obese is a big question.

“Will plans pay for obesity devices in a patient who is 50, 70, 90 pounds overweight?” he asks. “What if the patient loses 50 to 80 pounds and wants the device removed-would that [procedure] be a covered benefit? And if the patient needs a device years later, would that be covered?”  

Plans are required under health reform to cover certain preventive services recommended by the United States Preventative Task Force (USPTF) without imposing a copayment, including programs for adults needing assistance with smoking cessation and substance abuse. USPTF also has coverage recommendations for obesity in adults and children.

All adults and children, age six and older, are recommended for obesity screening. USPTF says clinicians should offer or refer patients with a body mass index of 30 or higher to intensive, multicomponent behavioral interventions. It is recommended that obese children be referred to comprehensive, intensive behavioral interventions to promote improvement in weight status.

When it comes to coverage, Dr. Brill recommends that plans take it a step further.

“Pay for nutritional counseling and follow-up,” he says. “Teach people how to shop and purchase food in a responsible manner.”

He also recommends covering kinesiologist and trainer visits so members can be assessed and participate in home exercise programs.