Posts Tagged ‘Medicare’

Privacy or Neglect?

May 17th, 2014

An article by Sheri Fink in the New York Times on May 16, 2014 will raise many questions. The article describes a program of data-mining of Medicare records for use in emergencies, such as hurricanes like Katrina and Sandy. Under the program, vulnerable people are identified who may need help in evacuations or need to help to get to shelters. However, the data are also used to identify those who take frequent ambulance trips or alert primary care physicians when their patients are admitted to hospitals. In emergencies, ‘authorized individuals’ are allowed to access medical records even though they have not been given permission. In an effort to protect privacy, federal officials have decided not to identify “stigmatized groups” including those with mental illnesses, intellectual disabilities and those with obesity. The system is being tested by looking at those on ventilators or using other medical devices who may lose power and have batteries run out of power.

But the issue of not including persons with obesity and those with mental and intellectual disabilities is a challenging one. Are they being left without this safety net? Obviously, not every person with obesity would need this level of attention but those with morbid obesity, in wheelchairs, on insulin surely would. Ask the obesity specialists at Pennington about trying to get insulin to patients after Hurricane Katrina if you want a picture of what a natural disaster can mean. So, is this protection of privacy or leaving the most vulnerable to fare for themselves while others are saved? The debate has only begun.


Time Sensitive: AHRQ Requests Comments on Obesity Tx in Medicare

March 10th, 2014

The federal Agency for Healthcare Research and Quality (AHRQ) has issued a draft topic refinement document on therapeutic options for obesity in the Medicare population. The Medicare population includes those over 65 years of age and are ruled disabled by the Social Security Administration.

The draft lists key questions such as “what is the comparative effectiveness of interventions that are intended to improve outcomes by reducing obesity?” “How well does treatment-induced reduction in BMI predict obesity-related outcomes?” Comments are open until March 20, 2014.

Click here for more information.


CMS Reviews Centers of Excellence for Bariatric Surgery

July 8th, 2013

The Centers for Medicare and Medicaid Services have announced they are considering doing away with the requirement that, for Medicare coverage, bariatric surgery must be performed in Centers of Excellence. No other substantive changes to Medicare coverage are being made. Comments are being received until July 26, 2013. Click here for the CMS Proposed Decision.


Obesity and Essential Health Benefits

December 26th, 2012

Below are my comments  about the lack of inclusion of obesity treatments in the definition of essential health benefits under the Affordable Care Act.

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Attention: CMS-9980-P

Baltimore, Maryland                                      Re: Standards Related to Essential Health Benefits (EHB)

Thank you for the opportunity to comment on CMS-9980-P, establishing standards related to essential health benefits.

The proposed regulation is a missed opportunity to effectively address one the nation’s major health crises- obesity. There is no need to repeat the well-covered statistics on the nation’s obesity prevalence nor on the extensive impact on personal health caused or made worse by obesity. Suffice it to say that obesity is recognized as a major driver of poor health care, of high utilization of healthcare services and of high, and growing, national health care expenditures.

The proposed regulation establishing standards for essential health benefits (EHB) will have an enormous reach. Non-grandfathered plans in the individual and small group markets, both inside and outside the exchanges, multi-state plans, Medicaid benchmark and bench-mark equivalent, and Basic Health Programs must cover EHB by January 1, 2014. However, the proposed regulation is deficient in its failures to address this national health epidemic.

The proposed regulation fails the test of comprehensiveness

The Affordable Care Act establishes ten categories of ‘essential health benefits’. One of these is “Preventive and wellness services and chronic disease management.” However, the proposed regulation do not define this category in general nor address obesity specifically. Traditionally, these areas have been either ignored or underserved by health insurance programs. Yet, the structure of the EHB regulation relies entirely on already established health insurance programs for its ‘benchmark’ plan.

According to the Obesity Action Coalition, only 22 states have chosen benchmark plans that cover bariatric surgery. Only 5 states have chosen benchmark plans that cover weight loss programs. 28 states have chosen benchmark plans that cover neither bariatric surgery nor weight loss programs. (Source: Obesity Action Coalition, accessed December 26, 2012)

Few governmental or private health plans provide coverage of Food and Drug Administration approved drugs for the treatment of obesity. Many health insurance plans have explicit exclusions for weight loss. Medicaid coverage is also poor. Eight state Medicaid programs appear to cover all recommended obesity treatment modalities for adults. Only 10 states reimburse for obesity-related treatment in children. In the small group market, 35 states expressly allow obesity to be used for rate adjustments while 10 states allow it in the individual market. Only 5 states provide coverage of one or more treatments in both the small-group and individual markets. (Lee JS, Sheer JL, Lopez N, Rosenbaum S, Coverage of obesity treatment: a state-by-state analysis of Medicaid and state insurance laws, Public Health Rep. 2010 July-August;125 (4): 596-604)

The Medicare program itself is a more positive model. In 2004, Medicare eliminated language in its coverage manual that obesity was not a disease. In February 2006, CMS significantly expanded its national coverage policies to cover more bariatric surgery procedures when performed in designated centers of excellence. In 2011, CMS added intensive behavioral counseling for adult obesity (A grade B recommendation of the U.S. Preventive Services Task Force). As yet, Medicare Part D does not cover drugs for the treatment of obesity.

It is a questionable health policy which covers counseling and surgery for American adults over age 65 when, by this regulation, the same coverage could be extended to younger Americans with obesity for whom the interventions are likely to be more effective in improving health outcomes and reducing the need for expensive treatments of related comorbid conditions. Perpetuating this scattered picture of health insurance coverage makes no sense, especially in the context of implementing the Affordable Care Act.

Further, a companion proposed regulation on employer wellness program would allow overweight or obese employees to be penalized up to 1/3 of the cost of their health insurance plan if they failed to meet employer-determined biometrics, such as weight or Body Mass Index. Yet, under this proposal, their employer’s health plan (or exchange or multi-state plan) would not be providing the employees with the treatments they need to obtain that goal. This is unlike the situation for high blood pressure, high cholesterol or type 2 diabetes where treatments are almost always covered in insurance plans.

Recommendation: The regulation should define EHB to include behavioral, pharmacological and surgical interventions based on the evidence‐based recommendations of the National Institute of Health/National Heart, Lung and Blood Institute. The guidelines for treatment of adult obesity were issued 1998, and are currently being updated, see Regarding children and adolescents, the American Academy of Pediatrics and 15 national medical societies have adopted guidelines which can be incorporated into the regulation.

The proposed regulation fails the test of non-discrimination

Section 156.125 provides, “An issuer does not provide EHB if its benefit design, or the implementation of its benefit design, discriminates based on an individual’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions.”

While this is elegant language, it is doubtful that, given insurance practices, it is enough to overcome the inherent prejudice, stigma and discrimination directed at persons with obesity. The insurance industry’s current exclusion of obesity treatments is exactly because of expected length of life, present or predicted disability, degree of medical dependency, quality of life and other health conditions.

Keep in mind that overweight and obese employees already receive a wage penalty because of their weight. A recent study has confirmed that obese employees with employer-provided health insurance are paid less than their peers because of higher health care costs. Stanford University researchers analyzed data from the Bureau of Labor Statistics, the National Longitudinal Survey of Youth and the Medical Expenditure Panel survey. They found that, on average, obese employees with health insurance were paid $1.42 an hour less that non-obese workers. Women had a higher wage penalty than men. Women with obesity whose employers provided health insurance paid a wage penalty of $2.64. (Bhattacharya, J, Bundorf, MK, The incidence of the healthcare costs of obesity, Journal of Health Economics 2009: 28:649-658.)

Recommendation: Section 156.125 should make clear that a plan design which excludes bariatric surgery, FDA approved drugs to treat obesity, intensive behavioral counseling is, ipso facto, discriminating against persons with obesity.  Additionally, it is not enough to just have the states monitor and identify discriminatory designs. A federal office needs to be designated where complaints or inquiries can be addressed.

Health reform must address one of the root causes of mortality and morbidity in the country. Without fully including evidence‐based interventions for obesity, it is hard to foresee a net improvement in the health of Americans. The current situation of health insurance, in its avoidance of obesity prevention and treatment, perpetuates a focus on the conditions caused by obesity. Millions of dollars spent on heart disease or type 2 diabetes (not to mention the other ill effects) will only continue.


Comments Sought on Medicare Screening Proposal

December 14th, 2012

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research (Mathematica) to develop new measures for potential use by eligible professionals (EPs) in the EHR Incentive Program. Mathematica and its subcontractor, the National Committee for Quality Assurance (NCQA), have developed the measures under consideration based on literature reviews of the evidence and reviews by a technical expert panel that includes clinicians, quality experts, EHR vendors, consumers, and other stakeholders.

This measure involves adult obesity screening and counseling as part of the annual wellness visit for Medicare beneficiaries under the Affordable Care Act.  Comments must be received by December 17, 2012.

Click here for the proposal.


Republican Party Platform Guts Obesity Policies

August 30th, 2012

Among the provisions in the Republican Party Platform adopted this week in Tampa, Florida are these affecting obesity:

Food stamps and other nutrition programs be sent in block grants to the states.

On Medicare and Medicaid, the platform states,  “The problem (with these programs) goes beyond finances. Poor quality healthcare is the most expensive type of care because it prolongs afflictions and leads to ever more complications. Even expensive prevention is preferable to more costly treatment later on. When approximately 80 percent of healthcare costs are related to lifestyle – smoking, obesity, substance abuse – far greater emphasis has to be put upon personal responsibility for health maintenance. Our goal for both Medicare and Medicaid must be to assure that every participant receives the amount of care they need at the time they need it, whether for the expectant mother and her baby or for someone in the last moments of life.”

Editor’s note: This paragraph is rather hard to discern. On the one hand, it seems to be an blank check for prevention programs which are, overwhelmingly, governmental programs. Yet, then it shifts to personal responsibility. Then, a neck-whipsawing shift to Medicare and Medicaid participants getting every service they need when they need it. So, what exactly does this mean? Do you get bariatric surgery, for example, when you need it? Or is it denied because you did not take “personal responsibility?”

Regarding Medicare, the platform calls for making the program into a “premium support” program for those age 55 and younger. For these individuals, Medicare would provide a voucher to go out and purchase private health insurance coverage. Currently, Medicare covers bariatric surgery and intensive behavioral counseling for both those over age 65 and those disabled and receiving Social Security disability. Frankly, I am skeptical that private insurance companies (which did not insure elderly persons before Medicare was enacted) would cover such persons and such services without prohibitively high premiums.

For Medicaid, the platform proposes “alternatives to hospitalization for chronic health problems. Patients should be rewarded for participating in disease prevention activities. Excessive mandates on coverage should be eliminated. Patients with long-term care needs might fare better in a separately designed program.”

Editor’s note: The platform does not describe what an “alternative to hospitalization” would be. The reference to “patients with long-term care needs” refers to millions of elderly Americans whose nursing home costs are paid for by Medicaid, after their own assets are exhausted. It has been a politically charged issue to make the spouse’s assets at risk for the patient’s nursing home costs. This was proposed in the Ryan Budget. What a “separately-designed” program would be was not specified.

Of course, the platform calls for  the repeal Obamacare or the Affordable Care Act “in its entirety.” This would include free intensive behavioral  counseling for adults with obesity under plans which were not grandfathered, grants for healthier communities, access to breastfeeding sites at work, access to health insurance by persons whose obesity has prevented them from getting insurance due to a “pre-existing condition, and greater rights for individuals to fight denials of claims.

Of course, also repealed would be the regressive provisions for “workplace wellness” programs which penalize overweight workers for not meeting weight targets set by their employers.

In 2008, The Republican Party Platform, adopted in St. Paul, Minnesota, provided:

“Prevent Disease and End the “Sick Care” System. Chronic diseases – in many cases, preventable conditions – are driving health care costs, consuming three of every four health care dollars. We can reduce demand for medical care by fostering personal responsibility within a culture of wellness, while increasing access to preventive services, including improved nutrition and breakthrough medications that keep people healthy and out of the hospital.  To reduce the incidence of diabetes, cancer, heart disease and stroke we call for a national grassroots campaign against obesity, especially among children”.


Older Americans Showing Greater Obesity

August 17th, 2012

It had been generally assumed that older Americans were not experiencing the higher rates of obesity seen in children, adolescents and younger adults. Not so, according to a new federal report. The report, covering many demographic features of older Americans, finds that in 2009-10, 38% of people age 65 and over were obese, compared with 22% in 1988-1994. In 2009-2010, 44% of people age 65-74 were obese, as were nearly 30% of those 75 and over. The report is available at

This report would indicate that Medicare should do more to address obesity in the over 65 population. Bariatric surgery is already covered as is intensive behavioral counseling. What is excluded are drugs to treat obesity under Part D. This report would indicate it is time to re-examine this exclusion.


Texas Grapples with Costs of Bariatric Surgery

June 24th, 2012

The New York Times reports on the issue of Texas, which has one of the highest rates of obesity in the country, grappling with the costs of bariatric surgery in Medicare and Medicaid. NYT:Spending for Weigh Loss Surgery Increases in Texas

No doubt this scenario will be played out in many states in the coming years. I’ve always said, “Obesity is too expensive to treat and it is too expensive not to treat.” This article bears this out. The tipping point for me is that at least with treating, we are reducing suffering for some humans. Predictably, at the end of the article a professor is cited as saying that the state could reach many more people with less expensive lifestyle interventions and improve their health enough to save far more dollars than bariatric surgeries do. This would be true if any lifestyle intervention was shown to achieve bariatric surgery’s long term, significant weight loss, with a reduction in co-morbidities, such as type 2 diabetes. But the professor’s statement is still, after millions of dollars of research on lifestyle changes, only a hypothesis, yet to be established.