A recent landmark decision by the Centers for Medicare and Medicaid Services (CMS) represents an important first step toward addressing one of the great ironies of American health care.
Insurers have been willing to foot the bill for managing the complications of chronic diseases such as diabetes and heart disease, but most have not been willing to reimburse practitioners for their work in treating obesity, which is often the major risk factor contributing to chronic diseases. Insurers have been willing to pay for costly gastric bypass surgery, but not for intensive medical nutrition therapy that could produce similar results.
Now, Medicare will begin reimbursing primary care physicians and other qualified practitioners for administering face-to-face behavioral counseling to patients with a body mass index of 30 or more.
Some view CMS’ willingness to cover intensive weight loss counseling as an acknowledgment that traditional medicine has been limited in its ability to tackle heart disease and obesity, which account for $550 billion in annual U.S. health spending, according to the federal Centers for Disease Control and Prevention.
There are some reservations, but for the most part the health care community has welcomed this development as long overdue recognition of the medical and behavioral factors underlying costly chronic diseases, and of the need for less traditional preventive measures. It is anticipated that Medicare’s decisions will encourage more private insurers to follow suit, giving physicians and patients the moral and financial boost to do their parts.
“We as a country and certainly as a health care industry have had a fascination with technology, and yet we know from very good research that some of the most significant impact on patients’ health and wellness has to do with lifestyle issues,” said American Academy of Family Physicians President Glen Stream. “Medicare’s recognition of that and willingness to pay for it is also a message to physicians that we need to refocus on the importance of including this in the care of our patients.”
Neither the AAFP nor the American Medical Association have taken positions on the specific coverage initiatives.
A team approach to treatment, often with a physician as team leader, has been shown to work best for the management of chronic diseases. The team usually consists of a registered dietitian, nurse case manager, exercise physiologist and a mental health professional.
“It’s almost impossible for physicians to take care of everything. They don’t have the expertise or the time,” said Shanthi Manivannan, medical director of the Ornish heart disease program at West Virginia University Healthcare’s Ruby Memorial Hospital. She coordinates with patients’ primary care doctors who supervise progress by, for example, setting limits on exercise protocols or adjusting medications.
Similarly, many of the newly covered obesity counseling sessions will not be provided entirely by physicians. Supervised nurse practitioners, clinical nurse specialists or physician assistants also can provide this primary care.
Beneficiaries are entitled to receive one visit every week for the first month and then one visit every other week for months two through seven. If the patient loses at least 6.6 pounds during the first six months, the patient will be covered for months seven to 12.
Whether physicians counsel patients on weight loss themselves or serve in supervisory roles, they must engage patients in prevention and be their cheerleaders, said Steven F. Horowitz, director of cardiology at Stamford Hospital in Connecticut.
“I hear physicians say it’s impossible to change patients’ behavior, but they don’t have to,” he said. “Patients look up to their doctors, and our role is to enthusiastically support the concept,” and refer them to other professionals who can help if necessary.
Physicians also may lack the in-depth training to administer obesity counseling. Seventy-two percent of primary care physicians surveyed by the STOP Obesity Alliance in 2010 said nobody in their practices had been trained to deal with weight-loss issues, though 89 percent agreed it was their job.
Unfortunately, those best prepared to provide obesity counseling will not be able to bill directly to do so. CMS has limited who is able to bill for those services to primary care physicians and practitioners, including nurse practitioners, clinical nurse specialists and physician assistants. Those with expertise in the field, such as registered dietitians, are not eligible to bill directly. Medicare will cover services from “auxiliary” providers only if the service is provided in a physician’s office suite and the physician is immediately available to provide assistance and direction.
Jean Harvey-Berino of the University of Vermont says she doesn’t understand the concerns that pushed CMS to make that requirement.
“The reality is it’s not going to be physicians” who deliver obesity counseling to patients, she added.
Furthermore, she has stated that there is a great deal of evidence that shows physicians do not have time and do not feel comfortable providing weight loss counseling to patients. Additionally, there is not much evidence that physician involvement in the counseling process is effective.
The Academy of Nutrition and Dietetics (previously the American Dietetic Association) has voiced concern about this aspect of the Medicare coverage plan. Marsha Schofield, director of nutrition services coverage for the academy, said CMS’ decision “overall was a first good step” and that she was “happy to see that CMS is recognizing obesity as a disease that is worthy of a benefit in and of itself,” but she said that the reimbursement falls short of what needs to be achieved to improve patient health outcomes.
Georgia Clark-Albert is a registered dietitian and adjunct nutrition instructor at Eastern Maine Community College who lives in Athens. Read more of her columns and post questions at bangordailynews.com or email her at GeorgiaMaineMSRDCDE@gmail.com.