Posts Tagged ‘physicians’

Insurance Coverage for Intensive Behavioral Counseling

September 21st, 2010

September 21, 2010

RE: Interim Final Rules for Groups Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act, FR 75:41726, July 19, 2010 I would like to express support for the inclusions of coverage of preventive services, particularly that relating to obesity, for group health plans and health insurance issuers. Specifically, the interim final regulations incorporate the level B recommendation of the United States Preventive Services Task Force requiring intensive behavioral counseling of adults for obesity. The background information makes clear that coverage of obesity prevention and reduction services can have extremely positive effects both for individuals and the country as a whole. The background information finds that even modest weight loss produces meaningful improvements in health and reductions in health care spending. The USPSTF recommended high intensity counseling and found insufficient evidence for low or moderate counseling. Their recommendation states, It is advisable to refer obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss. The USPSTF defined intensity of counseling by the frequency of the intervention. A high-intensity intervention is more than 1 person-to-person (individual or group) session per month for at least the first 3 months of the intervention. A medium-intensity intervention is a monthly intervention, and anything less frequent is a low-intensity intervention. There are limited data on the best place for these interventions to occur and on the composition of the multidisciplinary team that should deliver high-intensity interventions This is the only specification of the minimum level of frequency, intensity and duration of services. The Overview Section of the regulations state that ?These interim final regulations provide that if a recommendation or guideline for a recommended preventive service does not specify the frequency, method, treatment or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations.? (At p.41828) Unfortunately, there is not an optimum medical management paradigm for the diverse population which will be covered by this recommendation. This may mean that many health plans will not have guidance on the level of frequency, intensity or duration of behavioral counseling adequate to meet the requirement for ?intensive? and not moderate levels of counseling. The National Institutes of Health funded multicenter clinical trial, LOOK AHEAD, is in the process of identifying optimal intensity and duration of treatment. Their research protocol provides: For the first 6 months, one individual and three group session per month with a recommendation to replace two meals and one snack a day wit liquid shakes and meal bars For months 7-12, one individual and two group meetings per month and continue meal replacements Starting at month 7, more intensive behavioral interventions as well as weight loss medications Year 2-4, treatment on a monthly basis, including at least one on-site visit per month and a second contact by phone, email or mail. Short term-refresher groups and motivational campaigns are also offered three times yearly. After year 4, participants are offered monthly individual visits, as well as one refresher group and one campaign a year. (see The Look AHEAD Study: a Description of the Lifestyle Intervention and the Evidence Supporting it, Obesity 2006 May;14(5):737-752) This ongoing trial is producing significant reductions in weigh loss and associated lipid and cardiovascular risk factors. (Waddent TA, et al, One Year Weight Losses in the Look AHEAD Study: Factors Associated with Success, Obesity (2009)17:713-722) The final regulations direct group health plans and health insurance issurers to the ongoing results of the Look AHEAD trial to identify the optimal level of frequency, intensity and duration of intensive behavioral counseling. In the alternative, the USPSTF could be charged with updating their recommendation based on current clinical studies. Thank you for this opportunity to comment.

How the AMA got it Wrong

September 27th, 2009

June 18, 2009 :: By Morgan Downey

The Associated Press reported on June 17, 2009 that the American Medical Association has adopted a new policy to oppose defining obesity as a disability. According to the report, “Doctors fear using that definition makes them vulnerable under disability laws to lawsuits from obese patients who don’t want their doctors to discuss their weight.”

What’s wrong with this? Well, nearly everything.

First, doctors do not discuss weight with their patients now. A new study confirms previous papers on physician visits found that BMI and obesity status could not be computed in half of office visits because of missing height or weight data. 70% of persons with obesity did not receive a diagnosis of obesity from the physician and 63% of those with obesity received no counseling for diet, exercise or weight reduction. Rates were even low for obesity patients with related co morbid conditions.1

Second, disability statutes don’t just list diseases and call them disabilities. Disability status is decided on a case by case basis depending on a combination of the medical factors and the applicant’s ability to carry on their normal work activities. At the federal level, the Social Security Administration has extensive procedures which basically require morbid or severe obesity and cardiovascular, respiratory or musculoskeletal problems. 2 Few would assert that obesity as a Body Mass Index level of 30 in itself is a disability. But higher BMI levels, with accompanying functional limitations, certainly do or should qualify.

Third, when I look at a statement like the AMA’s I find a quick test helpful: When I see “obesity”, substitute another disease such as “cancer,” “diabetes,” “arthritis,” or “sexually transmitted diseases” and see how it reads. It is impossible to imagine the AMA, which after all submitted an amicus brief to the Supreme Court in a 1998 to uphold the Americans with Disabilities Act against a dentist who would not treat a patient with HIV-positive patient3, as making such a statement about any other disease or condition.

All the AMA policy will do is to likely turn more physicians away from counseling patients with obesity, adding to the stigmatizing views of persons with obesity not only as ‘lacking self control’ but, now, ‘litigious’. It will support administrative judges deciding cases of who qualifies for disability in making negative decisions about an obese persons disability, cutting them off from perhaps their last economic support.

Too bad. On the gravest health issue of our time the AMA is AWOL. Whatever happended to ‘first, do no harm?’

1. Ma J et al Adult Obesity and office-based quality of care in the United States Obesity 2009, 17; 1077-1085

2. Social Security Administration policy on obesity as a disability



September 27th, 2009

5-10% is a realistic and achievable goal for weight loss Weight-loss outcomes: a systematic review and meta…[J Am Diet Assoc. 2007] – PubMed Result

What interventions should we add to weight reducin…[J Hum Nutr Diet. 2004] – PubMed Result

The weight stability approach Obesity in primary care: evidence for advising wei…[Br J Gen Pract. 2008] – PubMed Result

Do physicians support 5-10% reduction? What do physicians recommend to their overweight a…[J Am Board Fam Med. 2009 Mar-Apr] – PubMed Result

Look Ahead trial shows promising results from intensive weight loss counseling One-year weight losses in the Look AHEAD study: fa…[Obesity (Silver Spring). 2009] – PubMed Result

5% reduction needed to improve metabolic parameters Degree of weight loss required to improve adipokin…[Metabolism. 2009] – PubMed Result

Primary Care

September 27th, 2009

Primary care practice in medicine does a very poor job of treating obesity. In a 2009 paper, researchers analyzed 696 million physician office visits of adults over 18 years old. In only 50% of these were both height and weight taken (so Body Mass Index could be determined) This was usually due to not taking the height measurement. Where a BMI was determined 27% of patients had normal weight, 31% were overweight and 37% were obese. Of the patients with obesity, a diagnosis of obesity was made in only 1/3 of the visits. In the patients with obesity, only 37% received counseling for diet, exercise or weight reduction. This percentage went up to 55% in patients who received a diagnosis of obesity. The researchers found the same pattern even when the patient with obesity had co-morbid conditions related to obesity. Adult obesity and office-based quality of care in …[Obesity (Silver Spring). 2009] – PubMed Result

Physician attitudes toward patients with obesity appear to be influenced by competency to treat, specialty and years since postgraduate training. Studies have shown that doctors can have stigmatizing attitudes to patients with obesity, believing such patients to not being able to benefit from counseling and have reported less desire to help obese patients. Implicit fat-bias has been found among health professionals treating obese patients. (See Fact Sheet on Stigma ) In a survey of School of Medicine faculty members, internal medicine faculty reported having the highest rate of obesity in their patients. Overall, physicians felt “fairly” competent in providing obesity counseling and reported an average of 14% of patient lost weight. 45% of physicians agreed that they have a negative reaction to the appearance of obese individuals which did not differ among specialties. Only about half felt qualified to treat obese patients; psychiatrists had the lowest sense of competency. More than half did not feel successful at treating obese patients with no difference between specialty. Physician success/efficacy was most strongly related to competency and patient weight loss. Pediatricians had a high expectation of a positive outcome but poorest weight loss in practice. Younger physicians had better expectations and outcomes than older physicians. Physicians’ attitudes about obesity and their asso…[BMC Health Serv Res. 2009] – PubMed Result

A complex set of factors may influence the physician’s decision to provide counseling, including judging the patient’s receptiveness to counseling, a ‘teachable moment,’ other medical matters, time and how many other patients are waiting to be seen. The art and complexity of primary care clinicians’…[Ann Fam Med. 2006 Jul-Aug] – PubMed Result

Another factor may be intentional neglect. In 1998 the editors of the prestigious New England of Medicine wrote an editorial in which they argued that weight loss was futile and dangerous and more so that treating obesity. They wrote, “In our view, doctors should provide advice if an overweight patient asks for phelp in planning a weight-loss program and recommend weight loss if a patient is suggering from health problems that can be ameliorated by weight loss, such as hypertension, diabetes or osteoarthritis, or it a patient is so obese that he or she is clearly in jeopardy (for example, if the patient is virtually immobilized.) In other situations, doctors should be cautious about exhorting patients to lose weight, especially when they are only mildly obese.” Losing weight–an ill-fated New Year’s resolution. [N Engl J Med. 1998] – PubMed Result The editorial produced a storm of reaction. William H. Dietz, MD, of the Centers for Disease Control and Prevention wrote prophetically, “This passive approach will not prevent weight gain in those at risk, nor will it prevent further weight gain in those who are already overweight. Furthermore, the rapid increase in body-mass index in the U.S. population who are overweight will most likely continue unabated if this passive approach is used. Because health care providers represent a trusted source of information about nutrition, we believe they should counsel all patients who are overweight to avoid further weight gain, regardless of whether their patients raise the issue of weight. Abundant data confirm that weight loss reduces obesity-associated morbidity. Delaying counseling until such a condition has developed reflects ineffective attempts at prevention and increases the likelihood that patients will rely on inappropriate or unhealthy methods of weight control.” The obesity problem. [N Engl J Med. 1998] – PubMed Result George L. Blackburn responded for the Massachusetts Medical Society Committee on Nutrition. They took issue with another statement from Dr. Angell in a February 9, 1998 Wall St. Journal that some people “just like to eat – an in that case it’s (obesity) no more a disease than bank robbery is a disease.” More on the obesity problem. [N Engl J Med. 1998] – PubMed Result

Childhood obesity is also poorly treated in primary care practices in the United States. This study reviewed many studies and found primary care physicians had negative feelings about dealing with childhood obesity. Primary care physicians’ knowledge, attitudes, bel…[Obes Rev. 2009] – PubMed Result

The Centers for Medicare and Medicaid undertook a large trial to see whether general prevention visits by Medicare beneficiaries resulted in improvements in smoking, alcohol consumption and sedentary lifestyle. There was not effect on sedentary behavior over two years. Medicare Lifestyle demonstration – PubMed Results

For more information, see

Reducing overweight and obesity: closing the gap b…[Fam Pract. 2008] – PubMed Result

Suboptimal identification of obesity by family phy…[Am J Manag Care. 2009] – PubMed Result

Health care providers perception of role Health care providers’ perceived role in changing …[Pediatrics. 2009] – PubMed Result

AHRQ Guidelines for Screening obesity in Adults Navigating the Health Care System: Ready to Lose Weight in the New Year? Experts Offer Guidance for Adults and Children

Latest News

September 27th, 2009

October 21, 2009

FDA plans revision to nutrition label. FDA seeks to improve nutrition labeling on food products –

October 20, 2009

Women with obesity at risk for in vitro fertilization failure The Press Association: Obesity cuts IVF success – study

October 19,2009

Can anyone get insurance? Now an underweight girl is excluded. Underweight Girl Denied Insurance Coverage – Denver News Story – KMGH Denver

October 18, 2009

Washington Post columnist Robin Givhan address the Fashion industry and thinness in the culture.Robin Givhan on Fashion: Size of the Model vs. Size of the Customer –

Great Idea: solve obesity by making people taller. Idea Lab – Should a War on Shortness Be One of the Goals of Health Care Reform? –

October 17, 2009

NYT reports on prospects for new drugs for obesity Arena, Orexigen and Vivus Are Chasing an Effective Diet Drug –

Why can’t CDC find obese swine flu patients? Pneumonia, Susceptibility of Young Among Traits of Swine Flu –

October 15, 2009             

Family Physicians Ink deal with Coke Family Doctors Sign Educational Deal With Coca-Cola – NPR Health Blog : NPR

October 14, 2009

First Lady Michelle Obama tackles childhood obesity Michelle Obama’s Weight Loss Tips: Watch TV Standing Up — Politics Daily

North Carolina Plan criticized Obesity penalty isn’t fair or effective – Columnists/Blogs – News & Observer

Ralph Lauren model fired for being too fat Photoshopped Ralph Lauren Model Filippa Hamilton Fired For Being Fat – WPIX

Dr. Bernandine Healy hits punitive steps against the obese The Obesity Epidemic Isn’t Just About Willpower – US News and World Report

October 13, 2009

Candidate’s weight becomes important issue in NJ Governor Race Is Chris Christie Too Fat to Be the Next Governor of New Jersey? – The Gaggle Blog –

October 12, 2009

Infant denied health care for  pre-existing conditions Why we need health-care reform: ‘Obese’ infant denied insurance!

Colorado Insurer caves The Associated Press: Colo. insurer changes course on fat infants

Baby denied health insurance for obesity as pre-existing condition 17-Pound, 4-Month-Old Baby Denied Health Insurance for Being Too Fat – Children’s Health –

October 9, 2009

Groups push back on premium increases in Senate Finance Bill If Your Waistline Grows, Should Your Premiums, Too? – Prescriptions Blog –

October 8, 2009

Corzine attacked as bigot Is Corzine A Bigot? | The New Republic

October 7, 2009

Physicians lead the way in treating obesity Doctors join fight against obesity –

NJ Governor Corzine accused of attacking opponents weight Corzine Points Spotlight at Christie’s Weight –

North Carolina to punish overweight state workers North Carolina state health plan to penalize smokers, obese

October 6, 2009

Study showing restaurant calorie labeling doesn’t change habits sure to add fuel to labeling debate Calorie Postings Don’t Change Habits, Study Finds –

October 2, 2009,

New York Board of Education bans bake sales Bake Sales Are Banned in New York Schools –

October 1, 2009

After 20 years USDA program for Women Infants and Children adds fruits and vegetables to its voucher program WIC nutrition program expands to cover fruits, vegetables —

September 17, 2009 NEJM publishes study on taxing sugar-sweetened beverages NEJM — The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages

September 11, 2009

Indiana Court allows workers comp coverage of bariatric surgery Indiana Appeals Court Affirms Work Comp Coverage for Obesity Surgery

September 9, 2009

STOP Obesity Alliance presents health care reform proposals Curbing Obesity Epidemic Key to Health Care Reform: Experts – US News and World Report See 16th and 17th U.S. Surgeons General, STOP Obesity Alliance Announce America has Reached Tipping Point on Obesity, Call for Direct Action – STOP Obesity Alliance

September 1, 2009

Institute of Medicine issues recommendations for combating childhood obesity Report maps out solutions to child obesity –

USDA announces child nutrition grants Release No. 0416.09

More employers trying financial incentives As Federal Healthcare Reform Debate Continues, New Survey Reveals More Companies Turn to Financial Rewards to Tackle Soaring Employee Healthcare Costs

August 31, 2009

New target for therapies identified Study may lead to new obesity therapies –

New York City targets sugar-sweetened drinks New Salvo in City’s War on Sugary Drinks – City Room Blog –

Risk of infant mortality rises with mother’s weight Mom’s obesity tied to higher infant mortality

August 30, 2009

Obesity linked to swine flu deaths Obesity linked to swine flu deaths | World news | The Observer

August 27, 2009

Extreme obesity shortens lives by 12 years Extreme obesity can shorten people’s lives by 12 years –

New drug claims ability to fight obesity and diabetes New fat-fighting drug has anti-diabetes action too | Health | Reuters

Obesity deniers come out

August 24, 2009

American Heart Association raises alarm about sugar Heart Association recommends limits on added sugars – White Coat Notes –

Interesting graph plots out contribution of obesity, age and health status on costs. A Concentration of Health Expenses – Prescriptions Blog –

GE introduces new MRI geared for larger patients GE Healthcare shows off latest MRI – The Business Review (Albany):

Obesity a risk for swine flu deaths Half of swine flu deaths in high-risk people -study | Reuters

August 18, 2009

Sleep apnea on increase Sleep Apnea Rises With Obesity, Boosts Deaths in Middle-Aged –; PLoS Medicine: Sleep-Disordered Breathing and Mortality: A Prospective Cohort Study

Push back on doctor’s campaign against obesity Anti-Obesity Dr. Jason Newsom Chomps Down on Dunkin’ Donuts « Vitals Spotlight – We Give the Doctor an Exam

August 11, 2009

President Obama calls for health insurance reform to cover obesity treatments, stating, “All I’m saying is let’s take the example of something like diabetes, one of — a disease that’s skyrocketing, partly because of obesity, partly because it’s not treated as effectively as it could be. Right now if we paid a family — if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they’re taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed. Well, why not make sure that we’re also reimbursing the care that prevents the amputation, right? That will save us money. Text – Obama’s Health Care Town Hall in Portsmouth –

August 10, 2009

Nominee for Surgeon General attacked over body weight Does it matter what the doctor weighs? —

Arena preparing to submit new obesity drug to FDA San Diego Business Journal Online – business news for San Diego, California

August 7, 2009

Recession could worsen obesity prevalence Recession could have negative impact on obesity levels | News | Nursing Times

July 17, 2009

Minorities, blacks hardest hit by obesity reports CDC Atlanta health, diet and fitness news |

July 16, 2009

AHA: severe obesity increases risks in surgery Severe obesity increases risks of health problems during surgery

AHA: Clarity on the overweight mortality confusion Mortality, Health Outcomes, and Body Mass Index in the Overweight Range: A Science Advisory From the American Heart Association — Lewis et al. 119 (25): 3263 — Circulation

July 14, 2009

Excess weight speeds up osteoarthritis Excess Weight Speeds Up Osteoarthritis: MedlinePlus

July 14, 2009

RWJ releases report on taxes for sugar sweetened beverages Sugar-Sweetened Beverage Taxes and Public Health – RWJF

July 14, 2009 WHO addresses swine flu vaccine for persons with obesity. Swine Flu Vaccine Recommendations from World Health Organization – Health Blog – WSJ

July 10, 2009 CDC finds high prevalence of obesity in swine flu patients. Intensive-Care Patients With Severe Novel Influenza A (H1N1) Virus Infection — Michigan, June 2009

July 2009 Study finds insulin resistance in overeating lean humans for the first time. Short-term overeating induces insulin resistance i…[Mol Med. 2009 Jul-Aug] – PubMed Result

July 10,2009

The economy, stress and overeating Job Stress, Economy Weighing on Americans: MedlinePlus

June 24, 2009

Obesity: Africa’s Next Big Killer Africa’s newest silent killer: obesity | FP Passport

July 2, 2009

Connecticut Governor Vetoes Labeling Bill

Rell rejects nutritional labeling for chain restaurants – The Connecticut Post Online

July 1, 2009

Obama Address Obesity in Town HallObama Addresses Health-Care Reform at Virtual Town Hall Meeting –

July 1, 2009

Trust for America’s Health releases “F as in Fat 2009”

June 30, 2009

Institute of Medicine Issues Report on Comparative Effectiveness Research

Initial National Priorities for Comparative Effectiveness Research – Institute of Medicine

Read Morgan Downey’s Testimony


June 30, 2009

Oregon enacts restaurant labeling bill AP Wire – Oregon | | News for Portland Oregon and SW Washington

June 29, 2009

More Data on surgery for diabetes Weight-Loss Surgery May Be Beneficial for Diabetes –

June 29, 2009

Kentucky phasing out sugar sweetened beverages Congress May Look to Ky. Schools’ Healthy Example in Creating Nutritional Policy –

June 25, 2009

IOM release workshop on Food Desserts The Public Health Effects of Food Deserts. Workshop Summary – Institute of Medicine

May 28, 2009

IOM Releases report on Weight Gain in Pregnancy Report Brief. Weight Gain During Pregnancy: Reexamining the Guidelines – Institute of Medicine

May 9, 2009

Do obesity related diseases predispose to swine flu severity? Other Illness May Precede Worst Cases of Swine Flu –