UO > Feature > Battling Obesity

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A board-certified internist and endocrinologist, Vash says he realized during his fellowship at UCLA that diabetes was out of control in type 2 patients, largely because of a lack of exercise and maladaptive eating. He says research has shown that a diabetes type 2 patient’s symptoms could be dramatically reduced or resolved if the patient reduced weight and increased activity.

He says physicians need to look at treating obesity not as a hopeless experience, but a professional challenge with economic opportunities - for the patient as well as the physician.

“There’s a tremendous opportunity for physicians to seize upon and dramatically help patients reduce or eliminate their number of medications,” he says. “When you look at the care costs of obesity and the rising number of obese children, you see that there is the potential to bankrupt the health-care system as we know it,” he warns.

That dire outlook is shared by Craig Keebler, MD, the medical director of the Center for Medical Weight Management at Swedish Medical Center in Seattle and the chairman of the American Board of Bariatric Medicine.

“The traditional model of insurance not paying for obesity treatment is going to change,” Keebler says. “Everybody knows there’s this iceberg under the surface. The number of obese kids means open heart surgery and kidney dialysis may be happening to people in their 30s. The nation is going to have to do something.”

But, at least right now, that message doesn’t seem to be resonating loud and clear with insurers. Currently, insurers are paying for bariatric treatment in “limited markets and in limited fashion,” according to the ASBP’s Little. “Right now, insurance companies are looking for balance,” she says. “It is a chronic disease and they need to see that patients have some accountability, some success.” She believes Medicare’s change in its long-standing policy in 2004 has opened the door for more coverage by insurers.

The American Obesity Association hailed the Medicare decision, saying it will encourage employers and managed care companies to cover appropriate treatments. “It marks a new chapter in the fight against obesity,” according to the association’s vice president, Judy Stern.

Keebler says self-insured corporations are more likely than HMOs to offer benefits for obesity treatment. “Insurance companies in general need to hold down costs, so they’re less likely to look at obesity treatment, which is preventative,” he says. “But corporations are paying out of their own pockets, and they see an expensive problem down the road that they want to avoid.”

LuAnn Heinen is the director of the Institute on the Costs and Health Effects of Obesity, part of the Washington, DC-based Business Group on Health, a nonprofit coalition of large companies that provide health coverage to more than 45 million workers, retirees, and their families. Heinen says employers are interested in supporting evidence-based medicine, so where there is evidence of positive outcomes, employers will be more interested in providing coverage.

The Business Group on Health launched its obesity institute in 2003, calling obesity one of the nation’s most serious, yet most preventable, health problems. It is working to estimate the cost of obesity to employers, initiate employee communication on healthy weight, and design employer-sponsored wellness programs that meet HIPAA requirements.

Heinen says employers are doing a lot for the prevention of obesity with people who have BMIs of 25 and lower by promoting nutrition and exercise. For obese people with BMIs of 35 or greater, she says employers would like to learn about alternatives to bariatric surgery, which is very costly.

Bariatric surgery typically costs tens of thousands of dollars, most of which is paid by private insurance. It carries serious risks, such as bowel obstructions and malnutrition.

Vash sees great potential for bariatric physicians to lower health-care costs by reducing the need for bariatric surgery. “There are about 10 million Americans who have class III obesity—the most severe—with BMIs over 40,” he says. “As such, they qualify for bariatric surgery. Each bariatric surgery costs an average of $20,000. If we can help people not become obese, we can reduce the need for bariatric surgeries.”

He says insurance companies are beginning to be more cooperative, noting that in a few states, Blue Cross/Blue Shield allows patients four visits a year to a bariatrician. “Insurance companies are beginning to see if patients go to doctors who know what they are doing, health-care costs for these patients are greatly reduced.”

The lack of universal coverage for bariatric treatment apparently hasn’t been a huge obstacle for bariatricians, says Little, and some don’t even want insurance reimbursement, “Because then they are told how to practice.”

Little says insurers sometimes will pay when a co-morbid condition, such as diabetes, is the primary reason for the patient’s visit. Otherwise, she says, “Patients who come to a bariatrician understand that it is fee for service.” She says people have become used to paying for self-improvement services and “feel safer” under the care of a physician than with some other form of weight-loss program.

Keebler believes now is a “very exciting time” to go into bariatric medicine. He cites several reasons: “Changes are happening in the whole science of understanding of what causes obesity, plus there are 140 obesity drugs currently in development—the first of which is to be out in about a year. And the insurance piece will ultimately turn around.”

Little, understandably, is equally enthused about bariatric medicine. “Bariatric physicians get an enormous amount of satisfaction,” she says. “They are in a position to join a patient on a journey and serve as a coach, as well as a medical adviser.” g