Tuesday, May 8, 2012

Prevention May Be The Best Path

Did you hear the good news? Yesterday, researchers at Duke University using a new model, predicted that by 2030, only 42% of Americans will be obese. Today that number is 36%, but the apparent good news is that a previous model predicted it would be 51%.  At the same time, the researchers predict that severe obesity would rise to 11% instead of the previously predicted 9%. 

The reasons for the discrepancy were described as the researchers taking into account factors such as unemployment rates; prices for alcohol, gas, and fast food; prices of healthy versus unhealthy foods; access to the Internet; and the number of fast-food and full-service restaurants per 10,000 people.

So is this really good news? Should we break out the champagne or the tissues? I find it hard to imagine that nearly half of all Americans will be considered obese in less than twenty years. But what is even more difficult to absorb is that our government is not obsessing about this problem.

This year, the Centers for Medicare and Medicaid Services (CMS) took a big step forward and initiated coverage of Intensive Behavioral Therapy for Obesity. They define obesity as a body mass index (BMI) of 30, which is about a 5 foot 4 inch woman weighing about 170 pounds or a 5 foot 9 man weighing about 200 pounds.  The problem is that if your BMI is 29.9, you are out of luck. At that number, you are entitled to no therapy whatsoever.

I can appreciate that there needs to be a threshold at some level, but I believe it should be several BMI points lower. Why wait until someone is already obese to intervene? Studies show that many things change including our gut bacteria, metabolism, and hormonal balances as we gain weight. Basically, it gets harder to lose weight the more you gain AND it gets harder to keep it off after we gain it and try to lose it again.

The other problem with CMS's obesity initiative is that the reimbursement is approximately $27 for 15 minutes up to 16 times spread across 6 months (6 more spread across the next 6 months if you lose 6.6 pounds after the first 6 months). That extrapolates to about $108 per hour, far below what the average primary care physician, which is the only type of physician that can offer the service, earns before overhead, staff, malpractice insurance, billing costs, etc.

Multiple google searches have failed to identify a single doctor or practice in the U.S. offering this service. I can find no practice marketing it. I also asked dozens of primary care providers and they have said they do not as well.

Is it the low reimbursement? Maybe. Is it the lack of knowledge necessary to provide intensive behavioral therapy? Maybe? Is it the reluctance of doctors to tackle their patients' obesity?  I can only say maybe again because I don't really know any of these answers as to why other doctors choose as they do. But I do know we have a problem and it's not just doctor engagement.

I think the real problem is the patients.  Tackling obesity with just primary care practitioner led therapy, instead of pills and surgery, requires real commitment on the part of patients. Obese patients know they have a health problem and that their long term health prospects are at play. Most also know that obesity is not particularly attractive. Yet, whether you believe it is a disease or a choice, these same people find it difficult to tackle their issue. Few prefer to be so overweight and need help to break out of their weight captivity.

So what do we do about this problem? Some may say financial incentives. I don't think that is a long term solution and I have previously explained why. While short-term incentives may work, weight is often easily regained unless fundamental changes to lifestyle are made and such changes can most of the time only be brought about by a concerted effort.

So how do we do that? I propose an integrated and interdisciplinary approach. In other words, I think it will take a team effort of motivated, committed, and trained practitioners to support, guide and educate patients to bring about real change. About 4 months ago, MDPrevent proposed such a model to CMS. MDPrevent asked for funds, to which I and others would contribute additional funds, to tackle not only the rising epidemic of obesity, but also heart disease, diabetes, dementia, and cancer.

MDPrevent's program, which we titled, Intensive and Integrated Behavioral Therapy for Lifestyle Modification would combine the talents of a primary care provider, a registered dietitian, a health psychologist, a fitness instructor, and a health educator to work with patients on both an individual and group (group success can be contagious) basis and help them tap into their own motivation to make change.

We anticipated that it would take a full year to bring about meaningful success and expected to be able to do so at a cost of slightly above $600 per patient. For this meager amount, we believe that we can change the course of someone's health and life trajectory.

Can anyone argue that it isn't worth the effort given the obesity and other chronic disease projectories? There is no profit for MDPrevent in the amounts requested because we believe that we must first prove the success of such a program before profits can even be considered.

The goal of the program is to identify and tackle pre-obesity, pre-diabetes, pre-stroke, pre-heart attack, and pre-cancer situations and implement a series of lifestyle changes to prevent, delay or even mitigate the development of these life threatening conditions.

The decision from CMS regarding funding this initiative was originally due March 30. We are in overtime. I am told it will come shortly. This program could be a game-changer for the country at large. Wish us luck!

1 comment:

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