Medicare Obesity Treatment Plan a Poor Role Model for Private Insurance
There was a recent decision made regarding who Medicare and Medicaid will reimburse for providing behavioral weight loss counseling to obese individuals. This decision not only impacts me as a registered dietitian, but it impacts you as well.
Dr. Felicia Stoler is a registered dietitian, a nutrition and exercise physiologist, and journalist who runs a health consultancy in New Jersey. She is also the host of Honey, We're Killing the Kids on TLC and the author of Living Skinny in Fat Genes: The Healthy Way to Lose Weight and Feel Great.
We are both members of an American Dietitian Association discussion list and she has given me permission to share with you her take on this recent decision. What follows are the words of Dr. Stoler:
The Centers for Medicare and Medicaid Services (CMS) announced its decision to reimburse primary care physicians for Intensive Behavioral Counseling for Obesity (IBCO). It is a miracle that obesity is finally recognized as a disease. However, it is the kiss of death for interventions, because evidence-based practice has been ignored. The significance of this decision, and the ripple effect of those who have been part of the weight management care team PRIOR to CMS' decision, have been left out: Registered Dietitians (RDs), sychologists, Licensed Clinical Social Workers (LCSWs), community weight loss programs, and programs like Weight Watchers.
The current language has limited the treatment of those 65 and older with a BMI of 30 or greater with the least effective treatment option as their only "reimbursable" choice. According to CMS, "it is important that these preventative services be furnished in a coordinated approach as part of a comprehensive prevention plan within the context of a patient's comprehensive care. Primary care practitioners (PCPs) are characterized by their coordination of a patient's comprehensive healthcare needs."
We seldom see assistance from those in the primary care setting, with any "coordination of healthcare needs." Medicine has become a script pad with a drug or referral to a specialist - which is why so many people assume weight loss is as simple as taking a pill or looking for the quick fix. PCPs are supposed to be responsible for a patient's overall health care, but surely lack the training to be "one stop shopping" for their patients. This is the reason why there are specialties within healthcare. Ask any endocrinologist who is best at managing diabetes or a cardiologist about heart disease (and its precursors). In the mental health sphere, psychiatrists are the experts in pharmacological management of psychological disorders.
Here is the kicker, the PCP will be doing the billing, but who will be doing the IBCO? Will it be the physician, the nurse, or the physician's assistant? Perhaps a patient may watch a video and then Medicare is billed for it.
BMI as a measure of obesity is controversial. Technically anyone can plug their height and weight into a BMI calculator and see the results, free of charge, without a PCP billing Medicare for the same thing. As for "prevention" - by the time someone has a BMI of 30, there are a myriad of comorbidities that begin to emerge. Perhaps intervention should begin when BMIs are 26-29.99, because there is a greater chance of preventing diabetes, hypertension and high cholesterol.
As a career changing RD, this absolutely disgusts me. I have two advanced degrees in nutrition, completed a supervised practice for a year, passed a national exam (which means I hold a minimal standard of proficiency in diet, nutrition, health and food service), and must complete continuing education each year. CMS recognizes RDs as part of the multidisciplinary care team for medical nutritional therapy (MNT) for diabetes and end stage renal disease, but not obesity. Is it because we can exist in private practice outside of a physician's office without being paid by the doctor (or sharing the fee with them for the work that WE do)?
Does this seem like the floodgates are now open for billing fraud? Most PCPs complain they do NOT have the time the time to spend with their patients each day. So will they just tell their patient they need to lose weight, bill the insurance for 30 minutes and call it gravy?
Arguably, many individuals who are obese have behavioral and psychological issues. The skills to deal with these are not provided to physicians, nurses, or physician assistants during their professional training; whereas it is an integral part of professional preparation for psychiatrists, psychologists, LCSWs and RDs.
In October 2011, the Lancet published a study (doi:10.1016/S0140-6736(11)61344-5) finding the "partnership between PCPs and role-model led group weight loss programs resulted in greater weight loss in overweight and obese adults compared to primary care team counseling." This was Weight Watchers. Am I missing something?
Is it simply that PCPs can write a prescription for weight loss pills, which may, at best, illicit ten pounds of weight loss over a year, or refer patients for bariatric surgery for another band aid in the war against our waist lines? Ironically, I frequently see patients who need an evaluation from me and a letter for their bariatric surgeon, in order to prequalify for surgery. Yet, RDs and others cannot be reimbursed for IBCO.
Do not get me wrong, my best friends are doctors - not just personally, but professionally - and I get many referrals from them. Not all doctors have the God syndrome and recognize the value of referring patients to specialists. Some physicians do have advanced training in nutrition, but the majority do not even get a full semester on nutrition - let alone counseling or behavior modification techniques. I would be a wealthy woman if I had $100 for each time a patient mentioned incorrect food and nutrition information from "their doctor."
Most of my patients, who are referred by their physician, are disappointed to find out that insurance does not cover weight loss counseling. They are not my rules. Traditionally, private insurance companies have modeled reimbursement for health care services on what Medicare provides. It is absurd to base medical services for all ages upon the standard for Medicare patients. While you're never too old to change, by the age of 65, unless confronted with a significant health scare, one is pretty set in their ways. No one in a primary care setting will teach the old dog new tricks. This is still sick care, not well care, nor prevention.
If the answer were simple, overweight and obesity would not be a big problem. Wouldn't primary care offices, regardless of reimbursement, provide "intensive behavioral counseling" if a patient's health and life were at risk, regardless of reimbursement? During the course of a check up, the physician can discuss lifestyle behaviors impacting body weight - they are already billing for the exam time.
Part of the Hippocratic Oath is referral of services to those who are more qualified. We need to start using evidence based practice for weight loss. It would be nice if one day when patients call my office, and ask if I take their insurance, I might be able to say "yes."
What Can You Do?
The above message from Dr. Stoler said it well, so I won't go into more detail on my own thoughts which support what you've already read above.
There is an active petition on whitehouse.gov asking the CMS to reconsider it's decision. The petition needs 25,000 signatures before it will be reviewed. I just checked and we're currently at 9,522. If you'd like this decision to be re-evaluated, please take a moment to add your signature at http://wh.gov/DWX