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Medicare May Cover Obesity Counseling

November 16, 2011
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I know this may not be of interest to a lot of our readers, since I don’t think many of you are quite ready for Medicare yet, unless you’re disabled (and if you’ve been disabled for two years and on SSI/SSDI, you qualify for Medicare no matter what your age). But most of us have parents or grandparents who are eligible for Medicare, or else use Medicare now (I have Medicare as part of my insurance coverage, as I’ve been disabled and unable to work for five years now), so if your parents or grandparents are fat, this article could be of interest to you and them.

The Centers for Medicare and Medicaid Services (CMS) has proposed paying for “high intensity” obesity counseling for seniors to help turn the tide on the obesity epidemic in the US.

According to a proposed decision memo posted on the CMS website Wednesday, the agency is proposing to pay for obese Medicare beneficiaries to undergo behavior modification and weight-loss counseling by a primary care practitioner.

“High intensity” obesity counseling? Without retraining the doctors who are going to be doing this “high intensity” obesity counseling, it sounds to me like it’s going to be more of the same old shame, blame, and disbelief that fat people have been getting all along from their doctors when told to follow the Nightmare on ELMM Street.

The counseling would involve one office visit every week for a month; one office visit every other week for months two to six; and one office visit for every remaining month through one year.

At the six-month visit, the doctor or other healthcare provider would determine how much weight the patient had lost so far. To be eligible for the next six months of treatment, the patient must have lost at least 6.6 lbs.

Just 6.6 pounds in 6 months? What fucking planet are they living on? If a person is obese, 6.6 pounds is a drop in the bucket and isn’t going to make one bit of difference in that person’s health. Hell, my weight can fluctuate by 6 lbs from month to month without me doing anything different — no change in the way I eat and no change in what I’m doing physically on a day-to-day basis. Now, if patients switched to a healthier way of eating and added exercise to their day that they didn’t have before, their health markers might improve, and they might even lose that 6.6 lbs. But you know the doctors aren’t going to attribute the improvements to the healthier habits, they’re going to say those health markers improved because the patients lost weight.

CMS is authorized to add new preventive services to the list of what Medicare Parts A and B it will pay for if the service is determined to be reasonable and necessary for the prevention or early detection of illness or disability, and is recommended by the United States Preventive Services Task Force (USPSTF).

Since 2003, the USPSTF has recommended screening for obesity in all adults and then offering intensive counseling and behavioral interventions to promote sustained weight loss.

The USPSTF has concluded that there’s “fair to good evidence” that “high-intensity counseling” on diet and/or exercise, coupled with behavioral interventions aimed at skill development, motivation, and support strategies, lead to sustained weight loss of between 6.6 lbs and 11 lbs among people who are obese.

From USPSTF:

Rationale: The USPSTF found good evidence that body mass index (BMI)…  is reliable and valid for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. There is fair to good evidence that high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese (as defined by BMI ≥ 30 kg/m2). Although the USPSTF did not find direct evidence that behavioral interventions lower mortality or morbidity from obesity, the USPSTF concluded that changes in intermediate outcomes, such as improved glucose metabolism, lipid levels, and blood pressure, from modest weight loss provide indirect evidence of health benefits. No evidence was found that addressed the harms of counseling and behavioral interventions. The USPSTF concluded that the benefits of screening and behavioral interventions outweigh potential harms. [emphasis mine]

Again, I want to know what planet the USPSTF is living on. No direct evidence was found that behavioral interventions lower mortality (death) or morbidity (disease) from obesity, but we’re going to go ahead and recommend these interventions to lower mortality and morbidity anyway? Since when has it been shown that there’s fair to good evidence that high-intensity counseling on diet and/or exercise (and all the other BS mentioned above) lead to sustained weight loss?

Another problem with this approach is what else I found on USPSTF’s website:

The data supporting the effectiveness of interventions to promote weight loss are derived mostly from women, especially white women. The effectiveness of the interventions is less well established in other populations, including the elderly. The USPSTF believes that, although the data are limited, these interventions may be used with obese men, physiologically mature older adolescents, and diverse populations, taking into account cultural and other individual factors. [emphasis mine]

So, even though the data supporting the effectiveness of these interventions isn’t well-established for senior citizens, it’s OMGOBESITYEPIPANIC, we have to do something to stop that 5.7% of total US health expenditures that’s being spent on the 34% of the population that’s “overweight” and the 27% of the population that’s “obese”!!!!1!!!!!!ELVENTY-ONE! (bet ya didn’t know we had increased to 71% of the population, did ya). Stop and think about that for a minute. They’re all in a panic about 5.7% of total US health dollars being spent to treat the so-called “diseases” of obesity, which don’t happen to just fat people — that’s money that’s spent on 71% of the population. How fucked up is that?

The agency analyzed a number of studies to make its proposal, including a 2009 literature review of randomized, controlled studies on behavioral interventions for weight loss that found eleven of 39 interventions produced significant improvement in weight after two years or longer, compared to groups who didn’t have any intervention. That study concluded that diet with exercise and/or behavior therapy also reduced hypertension and lowered a person’s risk of metabolic syndrome and diabetes.

CMS also relied on the results of a 2006 review that concluded healthy older adults who are at increased risk for cardiovascular disorders or arthritis-related functional impairment are likely to benefit from being diagnosed as obese and starting intensive lifestyle interventions, including diet and exercise and “behavioral components.”

“We conclude that the evidence is sufficient to determine that screening for obesity in adults, along with high-intensity behavioral interventions, is reasonable and necessary for the prevention or early detection of illness or disability,” CMS said.

I noticed that there aren’t any details on what those 11 interventions (out of 39) were that produced significant improvement in weight after two or more years. If I read the above correctly, the study to which they are referring (the one that says diet with exercise and/or behavior therapy also reduced hypertension and lowered a person’s risk of metabolic syndrome and diabetes) is actually just an analysis of a number of other studies and a literature review of randomized, controlled studies. So, they took a lot of studies and a review of some studies, and created another study. So, did they pick and choose what data they wanted to justify their program? I’m guessing yes.

One such behavioral intervention called the “five A’s approach” is adapted from smoking cessation programs.

  • Assess the patient’s risk for obesity
  • Ask if the patient is ready to try losing weight
  • Advise in developing a dietary program
  • Assist in establishing the intervention
  • Arrange for appropriate follow-up

This “5 A’s approach” has at least one drawback that I can see, right off the bat: Assess the patient’s risk for obesity. Give me a break. Is this really necessary? You’re planning on doing interventions with fat people, FFS. I’d say that they’re beyond being at risk for being fat; they’re already fat, that’s why you’re working with them, dipshits.

And what are you going to do if the patient says they aren’t ready to try losing weight or don’t want to try losing weight ever? Are you going to advise them on how to devise a dietary program that doesn’t involve cutting calories? (I’m betting no on that one). And if there’s not going to be a weight loss diet, you’re kind of up a creek when it comes to establishing an intervention, now aren’t you? About the only follow-up you’re going to be able to do is to see if they need further help tweaking that healthy eating plan, and checking on their health markers. Kind of kills that little intervention plan you had going, doesn’t it?

And I’m betting more people will go the route I’ve outlined than will opt for the Nightmare on ELMM Street that you want them to take. After all, that Nightmare is doomed to fail — it has, time after time after time to the tune of 60 billion dollars a year in the diet industry’s pockets. You haven’t learned anything from that, have you, CMS?

Massive FAIL, all the way around.

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2 Comments leave one →
  1. November 16, 2011 11:56 am

    Great find, vesta. And we wonder why obesity costs more for medical services… we keep paying for and promoting programs that have NO CLINICAL PROOF OF EFFICACY!!! So, Medicare pays for this program that they know doesn’t work, then when it fails, they promote some other program that they know doesn’t work, and so on and so on and so on.

    In the end, the fat person is still fat, but they’ve been accused of burdening the healthcare system with costs they were told would help them “cure” their “disease.” It’s such bullshit!

    Ugh.

    Peace,
    Shannon

  2. vesta44 permalink
    November 17, 2011 11:21 am

    I think the most maddening thing about this is that Congress is trying to find ways to cut funding for Social Security, Medicaid, and Medicare, yet Medicare is willing to spend what little money they’re going to have in their budget on bullshit like this. Instead of spending their budget on actually improving the health of senior citizens, they’re going to take that money and spend it on high intensity interventions for weight loss that don’t fucking work. Talk about pounding sand down a rathole – they’re certainly doing that well.

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