AMA Declaration May Influence Insurers
Public Health Feature — January 2014
Tex Med. 2014;110(1):45-48.
By Crystal Zuzek
The American Medical Association House of Delegates' vote in June to classify obesity as a "disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention" sparked national debate. Critics worry calling obesity a disease will take focus off prevention and remove personal responsibility from the equation. Supporters say the classification is bound to spur innovative policy, research, and treatment approaches to obesity. Physicians by and large hope that the new label will persuade private health plans and Medicaid to pay for treatment of obese patients.
At TexMed 2013, the Texas Medical Association House of Delegates approved a resolution introduced by the Travis County Medical Society strongly advocating that insurance plans "include obesity as a covered outpatient medical condition." TMA took the resolution to the AMA Annual Meeting and, upon realizing the momentum of support for the American Association of Clinical Endocrinologists' (AACE's) resolution calling for the recognition of obesity as a disease, TMA cosponsored AACE's resolution.
Dallas endocrinologist Jonathan Leffert, MD, secretary of AACE and an AMA alternate delegate, was instrumental in achieving passage of the resolution. "The scientific evidence is overwhelming," he told fellow delegates. "Obesity is a disease."
"Obesity has become distinguished as a multihormonal, multidimensional, pathophysiological process with effects on the body. By treating obesity we can obviate those effects," he said. "Obesity is a multifactorial issue that goes beyond lifestyle choices, and the AACE felt it should be classified as a disease."
Before the meeting, the AMA Council on Science and Public Health issued a 14-page report titled Is Obesity a Disease? During the meeting, Council Chair Russell Kridel, MD, of Houston, told Texas Medicine the council stopped short of answering yes to that question due to the uncertain definitions of "obesity" and "disease," coupled with the inability to link a high body mass index (BMI) to consistent morbidity. He said the council could not conclude that obesity is a disease "in the classic, commonly accepted way of looking at a disease."
Dr. Kridel said his council worried proclaiming obesity a disease might dissuade some people from eating right or exercising more to stay healthy or lose weight.
"We don't want people to think now that obesity is a disease, we're just going to treat it with medicine or surgery," he said. "If we call it a disease, we don't want to remove personal responsibility."
The AMA house adopted the council's report and a new policy to classify obesity as a disease.
AMA President Ardis D. Hoven, MD, said the delegates considered all the information presented to them, "including the council report and testimony presented by various physicians, state, and specialty societies. The council supports the view that the most important task moving forward is for the nation to do a better job of addressing the obesity epidemic." She said recognizing obesity as a disease will help change the way the medical community tackles the obesity epidemic and will heighten the importance of developing new approaches to prevent and manage obesity.
Stephen Pont, MD, medical director of the Texas Center for the Prevention and Treatment of Childhood Obesity in Austin, says the majority of private insurance plans in Texas, as well as Medicaid, generally don't pay for treatment related to obesity. He adds Medicaid may pay for obesity counseling when it's part of a patient's annual exam.
"I don't know of any private health plans in Texas that recognize obesity as a reason to go to the doctor. It's one of the most common diseases affecting adults and children, but the plans don't recognize the need to pay for medical intervention until the patient is suffering a condition resulting from obesity," said Dr. Pont, a member of the TMA Committee on Child and Adolescent Health.
Dr. Pont says he hopes the classification of obesity as a disease will eventually prompt Medicaid and private health plans to pay physicians for treatment related to the disease.
"I think health plans exclude outpatient care for obesity as a covered service because they fear it might cost money in the short term. But in the long term, these overweight and obese patients are developing health complications that are costly to treat," Dr. Pont said.
Last year, Medicare began reimbursing physicians for administering in-person behavioral counseling to obese patients. (Read "Federal Fat Fighters," May 2012 Texas Medicine, pages 55-58.)
Dr. Pont encourages physicians to broach the subject of payment for medical interventions for obese patients now.
"The health plans are starting to have internal conversations about this, so I'm hoping the more physicians ask questions, the more likely we'll see positive change. I talk to the health plans about reimbursement for outpatient care for obese patients whenever I can," he said.
As a pediatrician practicing in the trenches, Texas Pediatric Society (TPS) President Kimberly Avila Edwards, MD, has always considered obesity a disease and is "super excited" about the AMA's determination.
She says insurance coverage barriers restrict her ability to effectively care for obese patients. For example, she examined a 12-year-old patient who had an elevated liver function test and high cholesterol. She listed both as the primary diagnoses along with obesity and submitted the claim to the insurance company. The child's parents got stuck with an expensive lab bill.
"Obesity often gets carved out by insurance companies, and they'll use it as the basis to deny payment and coverage. I think the AMA's recognition of obesity as a disease will eventually lead to improved insurance coverage for patients and payment for physicians. And it will allow physicians to intervene with obese patients earlier," said Dr. Avila Edwards, a member of the TMA Council on Science and Public Health.
At press time, no health insurer had indicated to TMA's Payment Advocacy Department that AMA's action would change their position on paying for obesity treatment.
Dr. Avila Edwards says finding time to address obesity in patients is difficult in the midst of an annual exam or immunization visit.
"Simply telling parents their children need to eat less and exercise more probably won't be effective. They need to be educated about specific actions and strategies that can improve their children's health," Dr. Avila Edwards said.
As more physicians and health organizations recognize obesity as a disease, Dr. Pont says he's optimistic more tools will be developed to help physicians effectively address the obesity epidemic.
"The tools we use and our approach to obese patients need to be different to effectively spark behavior change," he said.
TPS offers Pediatric Obesity: A Clinical Toolkit for Healthcare Providers to aid pediatricians in treating obese patients. The toolkit offers a diagnosis and treatment overview for physicians and includes an evaluation form; posters in English and Spanish; patient handouts in English and Spanish that provide nutrition, behavior, and lifestyle guidelines; English and Spanish healthy lifestyle "prescription" forms; and a BMI wheel designed to calculate BMI percentile by age and gender. The toolkit features information on motivational interviewing to assess and empower patients' likelihood for positive health change, as well as recommendations of the U.S. Department of Health and Human Services Health Resources and Services Administration.
The recommendations guide health care professionals on the prevention, assessment, and treatment of child and adolescent overweight and obesity. The toolkit contains a chapter on the prenatal and perinatal influences on childhood obesity.
To access the toolkit, visit the TPS website.
Changing the Conversation
Recognizing obesity as a disease will encourage patients and physicians to have candid conversations about their weight and about key health indicators like blood pressure, blood sugar, and cholesterol levels, Dr. Hoven says.
Approaching obesity as a disease may also transform the way physicians view their obese patients.
"The concept of weight bias or discriminatory attitudes in regard to obese patients is well-documented in all settings, including health care. If obese patients feel their doctors judge them to be lazy or incompetent, they're less likely to return for future care," Dr. Pont said. "Physicians need to be nonjudgmental toward their obese patients."
Resources are available to help physicians break down the bias. The Yale Rudd Center for Food Policy & Obesity works to end weight bias through research, education, and advocacy and offers continuing medical education credit for physicians who complete Weight Bias in Clinical Settings: Improving Health Care Delivery for Obese Patients, a free web-based course available online. The course helps physicians implement strategies to reduce bias and provide better care for overweight and obese patients.
Dr. Pont says effective strategies may include purchasing chairs that accommodate larger patients in the medical office waiting room, providing larger gowns, and making other modifications for obese and overweight patients.
The Yale Rudd Center's policy brief "Weight Bias: A Social Justice Issue" outlines the following health consequences of weight bias:
- Binge eating,
- Unhealthy weight-control practices,
- Refusing to diet,
- Avoiding physical activity,
- High blood pressure,
- Increased stress, and
- Overall poor quality of life.
Self-report studies indicate physicians frequently regard obese patients as "lazy, lacking in self-control, non-compliant, unintelligent, weak-willed, sloppy, and dishonest," according to the policy brief.
Declaring obesity a disease will likely benefit those who suffer from it, Dr. Leffert says.
"Anytime we increase the light we shine on a disease, it benefits those with the disease. Complications associated with obesity cost the state billions of dollars. Elevating obesity to the level of a disease allows us to move forward in researching and treating it," he said.
State officials estimate obesity costs Texas businesses $9.5 billion annually. If the obesity rate and the cost of health care continue to increase as projected, the cost to businesses could reach $32.5 billion per year by 2030, according to a 2011 report released by Comptroller Susan Combs.
The price tag for obesity is nearly three times the estimate Ms. Combs released in 2007.
In February 2011, the comptroller released a report, Gaining Costs, Losing Time: The Obesity Crisis in Texas, which calculates the cost of obesity-related health care, absenteeism, decreased productivity, and disability to Texas employers.
In addition to saving the state money, approaching obesity as a disease adds a level of urgency to the need for prevention and treatment, Dr. Avila Edwards says.
"I think obese people will see their disease as something they can control and as something that doesn't have to beat them. I believe this classification will actually stimulate behavioral change in obese patients," she said.
While Dr. Leffert acknowledges prevention is important in fighting the obesity epidemic, he says he doesn't think classifying obesity as a disease absolves obese people from responsibility for their disease.
"Some fear obese people will think they don't have to work to lose weight because they have a disease. That's far from what I see in my endocrinology practice. My patients are concerned about obesity and its association with heart disease, high cholesterol, and diabetes," he said.
Dr. Leffert says his patients are willing to make lifestyle modifications and to take effective medications, opting for surgery as a last resort.
Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
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