American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, January 20, 2012

Reimbursement for obesity counseling: So what?

Medicare recently announced new regulations that authorize reimbursement for obesity management counseling by physicians. That's good, assuming the counseling is good. We are a long way from being able to count on that, however.

With a nod to my many colleagues who are genuinely expert in weight management counseling, and have long addressed it well, and especially to those who taught me to do so, I must acknowledge that the track record for the large majority of our clan is not pretty. Historically, there have been two ways physicians have mucked up weight management counseling: by providing it, and by not providing it.

The problem with not providing it is pretty self-evident. If a patient presents who is clearly severely overweight--perhaps even huffing and puffing just to settle into the exam room--not to address it is both ludicrous and an abdication of clinical responsibility. It would be as if a patient walked into the office with a spear sticking out of their chest, and left in the same condition with no mention of it in between.

But bad counseling can be worse than none at all. When the best a doctor can do is blame the victim--"Don't you know that being so fat is bad for you?"--the net effect can range from an erosion of the patient's self-esteem, to outright estrangement of the patient from the medical system. The former is bad enough--making a patient feel about an inch tall (note that if height goes down while weight remains constant, BMI actually goes up; talk about counter-productive!). The latter, however, can actually be life-threatening, when patients eschew vital preventive services, such as Pap smears or mammograms, or neglect essential care to avoid the associated denigration. This may sound like melodrama, but I have firsthand knowledge of cases in which bad obesity counseling ultimately proved lethal, and other cases in which it was nearly so.

It is in this context that the new Medicare regulations must be assessed. The change is good in that lack of reimbursement has long been cited as one of the impediments to weight management counseling. Extending this line of reasoning, the case can be made that lack of reimbursement means lack of counseling; lack of counseling means lack of experience with, or dedication to, counseling; and lack of experience and dedication in turn mean that such counseling as does occur will tend to be poor. If this were the whole story, then reimbursement might fix everything.

But it's not the whole story. Docs don't tend to get much training in nutrition, and while this has been oft lamented, it is difficult to fix due in part to the intense competition for real estate in the crowded landscape of medical education. There is, it seems, ever more to cram into those four years.

Even if time for robust nutrition education were claimed, it would only be a start. Training in behavior modification also tends to be limited, and would need to be upgraded considerably. Perhaps less daunting than these, additional training would be required for effective promotion of physical activity as well, along with the proper ways to measure and monitor not just weight but body composition.

And because in unity there is strength, approaches to weight control that engage the whole family are best. One person on a diet is weak; a family seeking health together is strong. So good counseling should address all household members, another area in which physician training (with the possible exception of family practitioners) is limited.

Were all such upgrades to occur in medical education, formidable challenges would still remain. The first is obvious: those notorious "15 minute encounters," which are in fact often less, don't allow time for conventional behavior modification counseling even by those who know how to provide it.

The second, obvious to those of us in the medical trenches, is apt to be less so for others. The time-honored adage to describe medical education is "see one, do one, teach one." If trainees don't see their mentors practicing weight management counseling, they will be dissuaded from doing so. Getting beyond the impasse requires concurrent incentives for docs in practice, which the new reimbursement scheme may provide, and improvements in training so that the next generation of practitioners can do this job better.

There are ways to address these issues. One is to enhance medical school and medical residency curricula in these areas. That struggle is underway all around the country. Another is to deliver relevant material in time-honored ways, such as textbooks. Yet another is interactive on-line training specific to weight management in clinical practice, and incentivized with continuing medical education credits. CME credits are required to maintain medical licensure, and thus serve as a potent goad.

But even if all of this were to move forward in tandem, physicians would still be struggling to allocate time to weight management counseling and away from other matters. The solution to this is for physicians to initiate the counseling, and then defer to others better suited to address the details. Dietitians are the obvious choice. In some cases, health coaches could play this role as well. But for this strategy to work, there would need to be reimbursement for that counseling as well.

Another, and perhaps even better option, is for clinicians to be able to direct patients into well-established weight management programs. There is a lot to a comprehensive weight management program, and it's unlikely that even a highly skilled and motivated physician could address all of this on his or her own. Two very compelling recent studies here and here suggest that Weight Watchers does a far better job at this than primary care, so linking the two is attractive. But again, the reimbursement model does not yet correspond.

Another challenging issue is the linkage of reimbursement to outcomes. On the one hand, it is quite appropriate to ensure that we are "getting what we are paying for." And of course, we are paying, since ultimately, Medicare and Medicaid resources derive from taxpayers. We should all want to know that counseling is actually working.

The danger in this is that weight change is the obvious measure of success, but not the right one. A physician might counsel well, and yet a patient with many other challenges in their life might not comply. Should a physician who takes care of especially challenging patients be financially penalized?

Even more compelling is the fact that two patients might be equally diligent about improving diet and activity, but one might lose weight and the other not due to genetic factors and other causes of relative weight loss resistance. Should that good faith effort by physician and patient alike, an effort likely to improve health even if weight does not change, be dubbed a failure? Pay-for-performance might more reasonably focus on behaviors individuals do control directly, such as dietary choices and activity pattern, than on weight, which they do not.

While good quality counseling may help with weight management, we should not get carried away with that idea. The metabolic complications of obesity are bona fide clinical problems, but weight gain over time is quite another matter.

Weight gain is a result of more calories in than out, and that in turn is largely the result of a modern, obesigenic environment and the ways in which a majority of us interact with that environment. It is about daily use of feet and forks. It is about food marketing and food processing; suburban sprawl and drive-throughs; vending machines and video games; long days and labor-saving technology. Medical school does not provide a fix for any of these! The origins of prevailing weight gain and obesity are not clinical--they are not about physiology run amok--they are societal.

Fixing obesity will thus require a societal response. It will require solutions populating the settings where people spend most of their time, and make relevant decisions about the use of feet and forks--home, school, and work; supermarkets and shopping malls; online, in church, and so on. Empowering programming can be devised to populate all such settings--and physicians can guide patients to its use. One national physician organization has endorsed a supermarket-based nutrition guidance system to that end. Many more such linkages between enlightened clinicians and empowered patients will help us get to the prize.

So what, exactly, does reimbursement for obesity counseling give us? It can help make physicians a part of a comprehensive solution. Being a part of the solution is far better than being a part of the problem. So reimbursement for counseling is a good start, assuming we can make sure the counseling is consistently good.

But we clinicians, at our best, can never be more than a modest part of the comprehensive solution epidemic obesity requires. We will see the toxic tide of epidemic obesity turn when, and only when, we fix the problem at its many sources in our society, and make eating well and being active the norm, rather than the exception, when health is found along the path of lesser resistance, rather than the road less traveled.

The promise of that day is great. We have miles to go to get there from here.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blogger Nicholas Pennings, DO said...

Thank you Dr. Katz for you excellent insights into the dilemma that many physicians face. We tell our patients to lose weight but we don't have anything concrete to offer them. That was my predicament 4 years ago until I found a program to help my patients lose weight, make lifestyle changes and actually start to reduce rather than increase medications. There is a way and I would be happy to share it with anyone that is interested.

January 24, 2012 at 5:39 PM  
Blogger apleaforsanity said...

Nearly 15 million obese Medicare patients can now see their primary care doctor for "free" up to 20 times in one year for face to face obesity counseling.

That's potentially 300 million doctor visits which is 100 million more office visits then Medicare patients see their primary care doctor now for all reasons. (There are nearly 50 million Medicare patients who see their primary care physician an average four times a year).
The goal of reducing obesity is admirable, but it’s not clear that the 3 kilogram loss requirement in six months is a good return on investment.

Before CMS issued this ruling, they did no actual cost benefit analysis; no estimate of the total cost of the program or whether this new service can even be delivered. (There is a well known projected shortage of primary care doctors? Have we forgotten the 33 million uninsured who are scheduled to enter the system in 2014?)

The Affordable Care Act gave CMS the power to do this which rivals anything Soviet era central planning ever tried to accomplish.
How is this new CMS benefit any different than when the Central Committee set wheat production goals by fiat and then set the price of bread without any concern if the wheat could be grown or the price of bread could cover the cost of production?
Meanwhile, the looming cuts of SGR still loom and Medicare is running out of money.

January 25, 2012 at 12:56 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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