Archive for September, 2013

Fall-out from Penn State Wellness Debacle

September 25th, 2013

New York Times’ Natasha Singer reports today that Rep. Louise M. Slaughter (D-NY) has asked the Equal Employment Opportunity Commission to investigate employer wellness programs that seek intimate health information, like Penn State’s program, and to issue guidelines preventing employers from using such programs to discriminate against workers.  The EEOC held a hearing on employer wellness programs in May, 2013.


Obamacare Premiums Lower Than Expected

September 25th, 2013

The Department of Health and Human Services has released data on the premiums for health plans in the state marketplaces/exchanges which come online in two weeks. The plans go into effect January 1, 2014. Premiums nationwide are around 16% lower than expected. About 95% of eligible uninsured live in states with lower than expected premiums. Click here for the full report.


CMS Drops Centers of Excellence for Bariatric Surgery

September 24th, 2013

The Centers for Medicare and Medicaid Services has announced that it is removing the requirement that covered bariatric surgery procedures must be performed in certified centers of excellences. While eliminating the requirement for centers of excellence, there is no change in coverage of bariatric surgery procedures. This comes as a setback to the Association for Metabolic and Bariatric Surgery and other professional societies which had supported continuation of the certification program.


Cancer Patients with Obesity Undertreated

September 24th, 2013

The Washington Post carries an article today on physicians under-treating cancer patients with obesity by giving lower doses of chemotherapy than appropriate for their weight. A recent paper in Nature by Lyman and  Sparreboom highlighted the problem. The American Society of Clinical Oncology has issued new guidelines urging full, weight-based doses for persons with obesity. This problem is not unique to chemotherapy by any means. An article by 10 FDA scientists in 2011 found “specific dosing recommendations for these (obese) patients are often absent in drug product labels.”


Penn State Wellness (All Stick No Carrot) Implodes

September 21st, 2013

Last week Penn State, no stranger to bad publicity, reversed course and canceled a widely-trashed employee ‘wellness’ program, according to a report in the New York Times. The report focused on concerns about the intrusive nature of the health risk assessment which asked questions about financial stress, supervisors and, of women, whether they planned on becoming pregnant in the next year.

What the media missed: HIPAA does NOT protect information in a Health Risk Assessment

The same article quotes a vice president of Highmark as saying the Health Risk Assessment information was protected from disclosure by the Health Information Portability and Accountability Act (HIPAA). However, this is not correct. Perhaps Highmark treats the information as if it were protected by HIPAA but the law does not do so. Check the Department of Health and Human Services HIPAA webpage. It clearly states, “The Privacy Rule does not prevent your supervisor, human resources worker or others from asking you for a doctor’s note or other information about your health if your employer needs the information to administer sick leave, workers’ compensation, wellness programs or health insurance.”(Emphasis added.)

Therefore, your employer can do anything with your personal information you provide in a Health Risk Assessment, including selling it to a data farm to be combined with your other personal information.

What else the media missed: Wellness programs cannot be used for cost-shifting.

The NYT article states, “Penn State instituted the wellness plan in an effort to slow double-digit annual growth in its health expenditures. The university is self-insured, which means that it directly covers the health costs of some 40,000 employees, spouses and dependents — at an estimated cost this fiscal year of $217 million.” If this is true it violates federal regulations. They state that wellness programs must be “reasonably designed to promote health or prevent disease; has a reasonable chance of improving the health of, or preventing disease in, participating individuals, is not overtly burdensome; is not a subterfuge for discriminating based on a health factor, and is not overtly suspect in the method chosen to promote health or prevent disease.” At this point it seems that the Penn State program was not designed to promote health or prevent disease or had a reasonable chance of improve the health of participating individuals.” It is or certainly seems to be just an attempt to shift cost to employees…an illegal strategy. Hopefully, this will come out in future explorations of the Penn State program and put the lie to these “wellness” programs.


Obesity and Obamacare: A Practical Guide

September 15th, 2013


By our estimates, some 65 million Americans with obesity will be impacted by Obamacare. Many provisions of the Affordable Care Act, known as ‘Obamacare’are already in place. But October 1, 2013 will be a milestone as millions of uninsured Americans can start enrolling in health marketplaces (formerly called ‘exchanges”) for coverage starting next year. The law is complex and it’s no wonder most Americans don’t understand it. We’ve tried here to distill the basic information for consumers, especially those with obesity, who had problems getting or keeping insurance or getting reimbursement for obesity treatments.

Here’s where Obamacare will make a major impact:

56 Million Americans with group or individual insurance now have new security against exclusions for pre-existing conditions, rescissions of their contracts, rights to independent review of denied claims and new protections for employer wellness program abuses. They will also be eligible for intensive counseling for adult obesity.

5 Million Americans with obesity would come into the Medicaid program under Obamacare if all the states adopted it.

3.7 Million Americans with obesity are likely to enroll in health marketplace (exchanges) where they will be entitled to intensive behavioral counseling of obesity, and at least one prescription drug for obesity treatment.2

Here some FAQs to help navigate Obamacare:

Q. Does Obamacare affect me?

A.  Effective January 1, 1014, everyone must have health insurance or else be subject to a tax. For specific information, see this IRS page.

Q. Are there exemptions?

A. Yes. See the IRS page above. In addition, if you live in a state which has not elected to expand their Medicaid program you will be exempted from the individual mandate. Federal regulations treat this situation as a ‘hardship exemption’ from the individual mandate.


Q. Does Obamacare change Medicare?

No. No one on Medicare needs to buy anything or answer any questions from callers. Because of the confusion around the law, scammers are calling folks asking for personal financial information on the basis that they are asking if they are qualifying for health insurance. Don’t believe them.

If you have Medicare the only change Obamacare makes is to shrink the prescription drug ‘donut hole.’ Supplemental insurance programs will not change.

Group or Individual Plans

Q. I have health insurance at work through a group plan. I’ve been told there will be no changes. Is that right?

A. Not really.  In the private insurance market, both group and individual plans, exclusions for pre-existing conditions will be banned, as will annual and lifetime caps on reimbursement.  All private insurance plans starting in 2014 must cover intensive behavioral counseling for obesity in adults. (That’s about 56 million people with obesity.) There are new rules giving you the right to appeal denials of claims to independent outside reviews. New rules on employer wellness plans gives employees rights to alternative avenues to benefits and puts your individual physician in charge of what is right for you. Other changes, as with the tax deduction for medical expenses and a future ‘Cadillac’ tax on expensive health plans are less positive for affected persons.

Q. I have health insurance at work through a group plan and we have been told the rates we pay for it will go through the roof because of Obamacare. Is that true?

A.  Health insurance premiums are going to vary by age, your state and what kind of plan you purchase and whether you qualify for federal subsidies. And they will vary by what strategies your firm takes. For example, some employers are moving full time workers to part time status; others are reducing family or dependent coverage. Recently, premiums have been fairly flat. A RAND study predicts small firms with under 100 employees will see a 6% reduction in 2016 health insurance premiums.

The Kaiser Family Foundation published a study of premium changes in 17 states and the District of Columbia, with and without the tax subsidies. Check it out here.

Q. What about rates if you buy individual health insurance?

A. A RAND study found little likelihood of big increases in premiums in the individual market but there are government subsidies for almost half the polulation. Forbes has published this map and information on what they project.  The Forbes’s site also has a calculator to see if you might be eligible for federal subsidy. Kaiser Health News has estimated that about 48% of adults already purchasing coverage for themselves will be eligible for subsidies next year and those subsidies will average $5,548 per family.

Kaiser Health News has provided detailed information on how the subsidies will work.


Q. I’m uninsured because it costs too much. What does Obamacare do to help?

A. If you make 133% of the federal poverty level or less,  you may qualify for Medicaid. If your income is 4 times the federal poverty level or less, you qualify for federal subsidies to make purchasing a private plan affordable. When you apply on a health marketplace (exchange) the system will automatically determine if you qualify for Medicaid in your state.

Q. My state won’t expand Medicaid so I won’t be eligible? Can I still get insurance through ObamaCare?

A. There seems to be a way but it’s a little tricky.

Q. When can I enroll in ObamaCare?

We’ll assume by ‘Obamacare’ you mean the state health marketplaces. You can start the paperwork now. October 1, 2013 the open enrollment starts. Sign up here.

Q. Am I eligible?

A. Nearly everyone is eligible. Go to this site.

Q. I need health insurance but don’t make much money. I am very healthy and active. Can’t I just wait until I’m sick and then get insurance from a health exchange?

A. That’s a risk. You can only enroll during open enrollment periods. If you need health insurance after one period closes, you will have to wait until the next open enrollment period to enroll. Any costs you incur then will be your responsibility. In addition, there is a (modest) tax for not having health insurance.

Q. What kind of health plans will be available?

A. There will four types of plans: bronze, silver, gold and platinum. Basically, with bronze, the premiums will be the least expensive but your out-of-pocket costs will be the highest. With platinum, it’s reversed: they will be the most expensive but your out-of-pocket costs are the lowest. They all have to provide “essential health benefits” but who provides and where will vary. More information is available here.

Q. What will be the premiums in the health marketplaces (exchanges)?

A. The Kaiser Family Foundation published a study of premium changes in 17 states and the District of Columbia, with and without the tax subsidies. Check it out here.  A similar analysis is available from Avalere Health here.

This site compares premiums inside and outside the marketplaces (exchanges),

Q. What are ‘essential health benefits’?

A. ‘Essential Health Benefits’ are specific types of health care services. Preventive services are one of the ten types and include intensive behavioral counseling for adult obesity. Plans will also have to have at least one drug from every therapeutic category. So one of the current FDA approved drugs for obesity should be available. Bariatric surgery may vary. However, the law contains very strong language that plans cannot discriminate in “benefit design” Read the federal regulations. This language should provide the legal justification for coverage of bariatric surgery.

Q. I’m still confused. Is there anyone in my state to help me?

A. For information on consumer assistance, see Families USA;

A State-by-State Map of consumer assistance resources is also available.

Q. I have family member who is not just obese but has some mental and other physical problems as well. She finds it hard to find services in her area and needs care across her problems. Any help?

A. One change to Medicaid in the ACA may be especially useful to persons in her situation. It creates an optional Medicaid benefit (Social Security Act §1945) for states to establish “Health Homes” to coordinate care for people with Medicaid who have chronic conditions. Health Homes are for people on Medicaid who have 2 or more chronic conditions, have one chronic condition and are at risk for a second, have one serious and persistent mental health condition. Chronic conditions include mental health, substance abuse, asthma, diabetes, heart disease and being overweight (BMI >25). Health Homes are intended to integrate and coordinate all primary, acute, behavioral health and long-term services in support of the whole person. More.

There is more information on these two government sites and CMS.


1. Decker, SL, Kostova D, Kenney GM, Long SK, Health Status, Risk Factors, and Medical Conditions Among Persons Enrolled in Medicaid vs Uninsured Low-Income Adults Potentially Eligible for Medicaid under the Affordable Care Act. JAMA, 2013; 309(24):2579-2586., accessed Sept. 13, 2013.

2. The Urban Institute, Health Status of Exchange Enrolees: Putting Rate Shock in Perspective




98th Cause (that was fast)

September 1st, 2013

The 98th putative cause of obesity is (drummroll please): proximity to a home in foreclosure. Click here. For the other 97 chick here.


UPDATE: 97 putative causes of obesity

September 1st, 2013

UPDATE: 97 Putative Causes of Obesity

An earlier post I listed 82 putative causes of obesity. Now, the list has been updated. Two of the previous categories have been combined (chemical toxins and endocrine disruptors; global food system and international trade policies). 17 new putative causes have been added. As I mentioned in the earlier post, “The links will not take you to a definitive study but only to an example of the debate going on in that area. So, the questions are: 1. If a disease has 82 (now 99) possible causes, can anyone say we know what THE CAUSE is? 2. Can all these putative causes be correct? In other words, can a diverse collection of events trigger a perturbation in the system to cause obesity? Alternatively, since each putative cause has some individuals with exposure who do not develop obesity, is there some kind of “master switch” which has to be tripped to cause excess adipose tissue accumulation? 3. What possible prevention strategy could account for all these variables?

There was an interesting essay recently in Forbes critical of a study showing a co-relation of BPA and obesity. It’s worth reading.

Nikhil Dhurandhar commented to ABC News on whether obesity may be several diseases. The story referenced the large number of putative causes.

1. agricultural policies

2. air conditioning,

3. air pollution,

4. antibiotic usage at early age

5. arcea nut chewing,

NEW 6. artificial sweeteners,

NEW 7.  Asian tiger mosquitos,

8. assortative mating,

9. being a single mother,

10. birth by C-section,

11. built environment,

New 12. celebrity chefs,

13. chemical toxins, (endocrine disruptors)

14. child maltreatment,

NEW 15. compulsive buying,

16. competitive food sales in schools,

NEW 17. consuming skim milk in preschool children,

18. consumption of pastries and chocolate (in Burkina Faso),

19. decline in occupational physical activity,

20. delayed prenatal care,

21. delayed satiety,

22. depression

23. driving children to school

24. eating away from home

25. economic development (nutrition transition)

26.entering into a romantic relationship,

27. epigenetic factors,

NEW 28. eradication of Helicobacter pylori,

29. family conflict,

NEW 30. family divorce,

31. first-born in family

32. food addiction

33. food deserts

34. food insecurity,

35. food marketing to  children

36. food overproduction

37. friends

38. genetics,

39. gestational diabetes,

40. global food system,(international trade policies)

41. grilled foods

42. gut microbioata,

43. having children, for women,

44.  heavy alcohol consumption,

45.  home labor saving devices,

NEW 46. hormones (insulin,glucagon,ghrelin),

47. hunger-response to food cues,

48. high fructose corn syrup,

NEW 49. interpersonal violence,

50.  lack of family meals,

51. lack of nutritional education,

52. lack of self-control,

53. large portion sizes,

54. living in the suburbs,

55. living in crime-prone areas,

NEW 56. low educational levels for women,

57. low levels of physical activity,

NEW 58. low Vitamin D levels,

59.  low socioeconomic status,

60. market economy,

61. marrying in later life

62. maternal employment,

63. maternal obesity,

64. maternal over-nutrition during pregnancy,

65. maternal smoking,

66. meat consumption,

67. menopause,

68.  mental disabilities,

NEW 69. neuro-endocrine stress response,

70. no or short term breastfeeding,

71. non-parental childcare

NEW 72. outdoor advertising,

73. overeating,

74. participation in Supplemental Nutrition Assistance Program (formerly Food Stamp Program)

NEW 75. perceived weight discrimination,

76. perception of neighborhood safety,

77. physical disabilities,

78. prenatal  maternal exposure to natural disasters,

79. poor emotional coping

80. sleep deficits,

81. skipping breakfast,

82. snacking,

83. smoking cessation,

NEW 84. spanking children,

85. stair design

86. stress

87.  sugar-sweetened beverages,

NEW 88. taste for fat

89.  trans fats,

90. transportation by car,

91. television set in bedrooms

92. television viewing,

93. thyroid dysfunction

94. vending machines,

95. virus

96. weight gain inducing drugs,

New 97. working long hours,