On July 15, Health and Human Services Secretary Tommy Thompson and Medicare administrator Mark McClellan announced, with great fanfare, what Thompson called Medicare’s “new policy” on obesity.
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Medicare said it would throw away language in its Coverage Issues Manual, the bible that guides what the agency will pay for, stating, “Obesity itself cannot be considered an illness.”
The move was widely hailed as a crucial cracking open of the door that would eventually allow Medicare to pay for some obesity treatments. “Medicare to cover anti-obesity care,” offered one headline. “Obesity deemed an illness,” blared another.
Neither statement is true. And some doctors, including one obesity expert whose patients have begun asking when the government will start paying their medical bills, believe the change hardly qualifies as a new policy — merely a hint at changes that could be years away.
“I don’t think it’s a change in policy at all. It’s the possibility that you’ve set the stage for a change in policy,” said Dr. Peter Pressman of the University of Southern California, who has counseled some 3,000 morbidly obese patients in the past four years. “It sure doesn’t mean anything to the people who need help right now and who need help in the next couple years.”
Pressman’s colleague Roger Clemens, a nutrition researcher and laboratory director at USC’s School of Pharmacy, was equally blunt: “There isn’t any policy change.”
Medicare officials demurred, though they acknowledged they had closed a three-year review of obesity without deciding whether it is, in fact, a disease.
"I think it’s a policy change," Dr. Sean Tunis, Medicare's chief medical officer, told MSNBC.com, "in the sense that we have shifted the focus of Medicare obesity-related treatments to whether or not they can be shown to improve health outcomes, rather than whether or not obesity can be considered an illness."
Illness or not?
The old Medicare policy, still listed Wednesday evening in the coverage manual on the Web site of the Centers for Medicare and Medicaid Services, said obesity's "immediate cause is a caloric intake which is persistently higher than caloric output,” though it acknowledges a connection to such covered diseases as diabetes and hypothyroidism. The old policy provided for some specific treatment in extreme cases. (Medicare officials said they were not aware the old policy was still listed until contacted by MSNBC.com.)
The deleted text amounted to one sentence. While administration officials portrayed it as a major change in Medicare's stance, short-term impacts are modest.
The revised manual will not authorize coverage for any new treatments. Its only loophole is possible coverage for gastric bypass surgery, often considered a last resort for patients who have tried, and failed, to lose weight through dieting and exercise.
The surgery, which can easily cost $25,000 or more, segregates or removes from the digestive tract a large portion of the stomach. It may be covered only if doctors successfully argue it will help treat an illness currently covered by Medicare, such as diabetes.
"We are not making some broad public health pronouncement," Tunis said, though he noted the obesity revision "kind of implicitly assumes that it could be considered an illness."
If anything, the change brings Medicare on par with other government agencies’ views about the scope of the nation's obesity problem.
As early as 2001, Surgeon General David Satcher said obesity had reached “nationwide epidemic proportions.” In March, the Food and Drug Administration’s obesity task force called it “a pervasive public health problem,” recommended better education about calories and eating habits, and suggested further study into anti-obesity drugs. In April, the Centers for Disease Control and Prevention said obesity was the fastest-growing cause of preventable death in the nation, and would soon overtake tobacco as the leading cause.
While no one familiar with the Medicare system felt the recent change shouldn't have been made, some felt its significance was overplayed and overhyped, both by Bush administration officials and by the media.
“Gee, I’m shocked, shocked,” Marilyn Moon, director of the Health Program at the American Institutes for Research and a former Medicare trustee. “I do think it’s a little bit more ado about nothing.”
'People may not know at all'
Tunis said the change offers the potential for coverage of obesity treatments in the future, pending Medicare's usual review process. It also signals to drug companies and others that they should collect data on the efficacy of proposed treatments, he added.
Tricia Neuman, vice president of the Kaiser Family Foundation, doubted that media coverage of the obesity change had an undue impact on the Medicare population. “There’s ample expectation to believe … that people may not know about it at all,” she said, citing her organization's findings that many recipients are still unaware of discount drug cards.
More than one expert speculated that election-year politics might have played a role in the administration's announcement of the change.
“These guys like to have some good news,” Moon said, “and this was an easy one to do.”
Said Peter Neumann, an associate professor at the Harvard School of Public Health who has closely studied the Medicare policy process: "Politics is close to the minds of the people who are making decisions."
With the nation growing older and fatter, and with 40 million Americans covered by Medicare, any policy change could have profound implications. Nearly a third of the overall U.S. population is considered obese, and aging Baby Boomers are contributing to an ever-graying population.
Among the Medicare population, 18 percent are obese and another 37 percent are overweight, according to the American Obesity Association, one group that lobbied Medicare to change its obesity policy. The association estimates that, between 1991 and 1998, obesity among those aged 60 to 69 increased 45 percent.
Small changes, big implications
Any changes in coverage of obesity would resonate far beyond Medicare since most insurance companies use the Medicare coverage manual as a template for their own coverage decisions. If certain treatments are, effectively, endorsed by the federal government, private insurers would feel pressure to add them to their own coverage offerings.
But Medicare's future coverage plans are vague at best.
The language change was the result of a three-year review begun in September 2001. A “technical assessment” of obesity in the elderly, completed in December 2003, came to few firm conclusions but said those with heart disease were “most likely to benefit” from weight loss.
Medicare concluded there was “no general agreement on the classification of obesity as an illness.” And it has no plans to further consider whether obesity is a disease.
Rather, it decided to remove the single line from its coverage manual.
While Medicare has approved treatments for health problems like smoking without determining that tobacco use is an illness, the agency clearly stated in its tracking sheet on the obesity review that the recent change in language “does not change any of the current coverage determinations.”
Even the July 15 news release acknowledged it “is not expected to have an immediate impact.”
Scrutiny for surgery
The only issue for review in the near future is whether Medicare should more broadly pay for bariatric surgery, which includes procedures like gastric bypass. A similar surgery, intestinal bypass, is specifically excluded from coverage.
Made popular by celebrities like "Today" show personality Al Roker, bariatric surgery has become a more frequent weight-loss option in recent years — though even some of its proponents describe it as a last-ditch option with many possible complications.
The American Society for Bariatric Surgery estimates over 102,000 procedures were performed last year, up from 16,200 a decade ago. At the same time, insurers have balked at the steep costs. Blue Cross, Blue Shield and Cigna have stopped paying for it in some states, including Florida.
The Medicare Coverage Advisory Committee, which recommends what the agency should pay for, may consider bariatric surgery this fall. But the agency has not scheduled discussion of other, less drastic treatments, such as nutrition counseling and structured weight-loss programs, though Tunis told MSNBC.com those treatments could be considered if the agency is asked to review them by outside petitioners.
Approval for treatment, especially the surgery options, are likely to be limited to patients demonstrating severe health problems directly tied to their weight.
"It would be very precise criteria for who gets the surgery and it might vary for other interventions," said Urban Institute senior fellow Dr. Robert Berenson, who was in charge of Medicare payment policy from 1998 to 2000.
Years to change?
In 2003's Medicare reform law, Congress generally required coverage reviews to be completed in nine months or less, but the bureaucratic process could still drag on. Neumann estimated revisions have averaged seven to 15 months, depending on whether the advisory committee is involved. (Involving the committee can take twice as long.)
Yet the decision to erase a single line about obesity took nearly three years, one of Medicare's longest decision-making efforts. Additional decisions on obesity treatment will likely be equally fraught with the same back-and-forth wrangling that has marked the national debate on obesity and health, experts said.
Pressman, who prepares patients to have bariatric surgery but often advocates against it, says he already has patients asking whether Medicare will help pay for such an operation. He clearly believes the government spoke too soon.
“It’s kind of embarrassing, and I think it’s a little cruel, because it sets people up,” Pressman said. “It’s kind of stinky. And the reason it gets me is because I have to see the patients every day.”
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