December 21, 2011

Obesity Counseling by Primary Care Providers: Wise Move by Medicare or Not So?

A few facts are crystal clear:

  • Medicare CardMyriad adults would improve their health status and potential longevity by losing a few pounds. Five percent seems to be the magic number to reap health benfits.
  • Two thirds of adult Americans are overweight or obese, including many Medicare beneficiaries.
  • Losing weight, even a few pounds, and keeping those pounds off is tough work which requires tenacity.
  • Primary care providers (PCPs), including general and family practice physicians, nurse practitioners, physicians assistants and others; aren’t known for addressing or spending the time it takes with clients to counsel them on weight control. (In all fairness, they haven’t been allotted the time until now.)
  • Susan Yanovski, MD, in her 11/24/11 New England Journal of Medicine editorial Obesity Treatment in Primary Care – Are We There Yet? (abstract), stated: “less than 50% of PCPs report consistently providing weight-control advice to adults and less than 25% report regularly referring people to other providers who may help them with weight control.”
  • It’s well known that PCPs receive a minimumof nutritional science in training and it’s highly unlikely that many have obtained the skills known to be effective in weight management counseling from studies on long term weight management.

Yet despite these facts, on November 29th, Medicare (Centers for Medicare and Medicaid Services) announced in their Decision on Intensive Behavioral Counseling for Obesity that it will start to cover obesity counseling services when provided by PCPs (as defined by CMS).

Left in the dust to be directly reimbursed for these obesity counseling services to Medicare beneficiaries are registered dietitians, behavioral counselors and weight management programs with proven track records.

What’s Covered for Obesity Counseling? 
These services can be provided for people who have a BMI ≥ 30 (defined as obese), which is pretty much the only criteria to qualify for counseling. The services include one face-to-face counseling visit a week for a month and one face-to-face counseling visit every other week for an additional five months in a primary care setting (this can include an outpatient hospital setting). At the end of six months, beneficiaries may be eligible for six more months of counseling if they’ve achieved at least three kg (6.6 pounds) of weight loss in the preceding six months.

Medicare’s Rationale?
"While CMS is providing coverage for additional preventive services, we believe it is important that these preventive services should be furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient’s total health care.  Primary care practitioners are characterized by their coordination of a patient’s comprehensive healthcare needs. Primary care practitioners are generalists who are specifically trained to provide primary care services. Other provider specialties may provide patient care in other settings but do not offer care in the context of being the coordinator of the patient’s healthcare needs, not limited by problem origin or diagnosis. Coordination of health services is especially important in the presence of the coexisting health issues of our Medicare beneficiaries.

…We believe that providing for coverage under these conditions will permit appropriate staff to furnish intensive behavioral therapy for obesity while ensuring that services are delivered within the primary care setting in order to provide a coordinated approach as part of each patient’s comprehensive prevention plan."

Medicare’s BIG PUSH in this decision seems to follow THE BIG PUSH in healthcare reform, let primary care be the central hub of care and push PCPs towards providing comprehensive care within their primary care settings.

No doubt, Medicare has to tightly control the numbers (thus types) of providers who can deliver these services. This helps control the number of beneficiaries who utilize the services and the dollars spent on it.

Did Medicare choose the right providers? 

Did Medicare choose the right venue to deliver this service:  face-to-face in primary care?

NEJMThe timing of this Medicare decision and NEJM editorial (abstract) were published just days apart. While the Medicare decision is based in a plethora of research, it’s interesting to juxtapose it with the Yanovski editorial written to debrief on two weight loss studies published in the same 11/24/11 NEJM issue. A few conclusions gleaned from these and other studies fly, to an extent, in the face of this Medicare decision.

One, a study by Wadden et al, assigned nearly 400 people in six PCP practices to one of three interventions: usual care (quarterly PCP visits), brief lifestyle counseling (quarterly PCP visits, plus monthly in person meetings with lifestyle coaches), and  the same intervention as group 2 with the addition of meal replacements or weight loss medication. About the Wadden, et al, study Yanovski writes, “A well-recognized issue that affects the sustainability of behavioral intervention is that attendance at face-to-face counseling sessions decreases substantially over time.” Even when participants in the Wadden study were provided counseling at no charge [because this was a study], participants attended fewer than half the scheduled counseling visits during year 2.

The second study by Appel et al. looked at two behavioral interventions in a group of about 400 people recruited from six PCP practices. One intervention provided remote support – through the telephone, a study specific website and e-mail. The other intervention provided in-person support along with the three remote means of support. A control group used self-directed weight loss. Worth noting is that the in-person group participated in only 2 of 24 recommended face-to-face individual and group sessions between months 7 and the end of the study.

What makes Medicare think that once initiated people will show up for their obesity counseling sessions?

Why did Medicare insist on face-to-face? Is this a way to control costs and usage? Or is it based on good science?

Obesity studies are showing that it’s important to choose and use a variety of venues. With the use of today's technologies remote venues can be time- and cost-efficient and conducive to the realities of most people’s lives today. A growing number of studies, some noted in the Medicare decision, show the effectiveness of internet-based, telephone-based counseling, and others, as the sole or as supplemental to face-to-face counseling. Back to Yanovski’s editorial, she states: “Given that remotely delivered coaching resulted in weight-loss outcomes similar to those of in-person visits, the use of mobile technologies to deliver behavioral weight-loss treatment in primary care appears to be promising.”

Research clearly shows that it’s easier to lose weight than it is to keep it off. Research also shows that people need continual and consistent support to have a snowball’s chance of keeping any of the weight off for good. It’s less about knowledge and more about finding a supportive, motivating environment.

If in the New Year you’re looking for a weight loss program that works because it’s been developed by experts and is based on research, here are a couple I can vouch for:, BMIQ and, of course, tried and true Weight Watchers. Read more about vtrimonline in a past blog in which I captured my first experience as a vtrimonline facilitator.

I’m hoping the New Year provides me an opportunity to help more people lose weight and keep it off. Best of luck to you in 2012 with your weight management efforts!