(USA TODAY) There's new hope for heavy people desperate to lose weight. Many insurers are stepping up their coverage of obesity.
Some insurance companies have helped obese patients fight fat for years. They've offered weight-loss and wellness programs at businesses, schools and in communities. Some have paid for prescription obesity medications and even covered expensive bariatric surgeries, including gastric bypass.
But now most insurance plans are required to help obese patients try to lose weight under President Obama's health care law. Exactly how they do it is up to the individual plans.
Screening and counseling for obesity has to be covered with no patient cost-sharing (co-payments, co-insurance or deductibles) by most insurers under the preventive services benefit of the Affordable Care Act, says Susan Pisano, a spokeswoman for America's Health Insurance Plans, the national trade association representing the health insurance industry. Medicare is already covering this service.
It's a part of the law that many plans have put into action already and more will continue to add by January of 2014. Under a provision of the law, some grandfathered plans don't have to cover obesity screening and treatment if they haven't changed their overall coverage since 2010 when the law was passed.
So, for the plans that have to cover obesity, if a health care provider screens a patient's BMI (body mass index, a number that takes into account height and weight) and determines that the patient is obese, then the provider may offer initial weight-loss guidance and refer the patient to a professional service.
Plans vary widely in what they will do. Some insurers are offering telephone counseling; others cover visits with a health coach, and some cover group sessions that offer lifestyle advice. Some are even referring patients to Weight Watchers.
Insurance coverage for the treatment of obesity was back in the headlines recently when the American Medical Association, the nation's largest physician organization, decided to recognize obesity as a disease that requires a range of medical interventions for treatment and prevention. Previously it referred to obesity as "a major public health problem."
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The medical group has no official say on what insurance companies cover, but the group's announcement put the spotlight back on the debate on how insurance companies can help fight the obesity epidemic that's taking a huge toll on this country.
About a third of adults in this country are obese, which is roughly 35 or more pounds over a healthy weight. That's a BMI of 30 and above. Obesity increases the risk of many other diseases, including type 2 diabetes, heart disease and some types of cancer.
Those extra pounds rack up billions of dollars in weight-related medical bills. It costs about $1,400 more a year to treat an obese patient compared with a person at a healthy weight, research shows.
Obesity insurance coverage decisions for clinical preventive services under the Affordable Care Act are based on recommendations from the U.S. Preventive Services Task Force. It recommended screening for obesity and offering intensive counseling help at the doctor's office or referring patients out for weight-loss help, says pediatrician David Grossman, a task force member. "We found 12 counseling sessions was the minimal amount needed for significant weight loss, but we didn't see any benefits to going for over 26 sessions," he says.
The task force does not address what insurance companies should specifically cover.
Under the health care law, plans can have doctors do the weight-loss counseling or "use medically appropriate" alternatives to meet the requirement, says Karen Miller-Kovach, chief scientific officer for Weight Watchers.
She says some insurers are using Weight Watchers for patient referrals. Insurance companies are paying for memberships or offering discounts or reimbursements, she says. "We've had relationships with insurance companies for years, but they are looking to start or expand their relationship with us to meet the requirement."
Julie Kessel, senior medical director for coverage policy at Cigna, a health service company that works primarily with employers that are self-insured, says the company has been offering weight-management programs for years. Under the new health care law, employers offer a variety of different options to patients, from working with registered dietitians and health coaches to group sessions with a professional teaching lifestyle changes to a hotline with a nurse who answers questions, she says.
When it comes to coverage, insurers frequently follow the example set by the federal government's Centers for Medicare & Medicaid Services (CMS), says obesity researcher Donna Ryan, professor emeritus at the Pennington Biomedical Research Center in Baton Rouge.
Currently, Medicare pays for screenings and preventive services for obesity. Those appointments have to be with a primary care physician, nurse practitioner or a physician's assistant. For counseling to be reimbursed, patients have to show progress with weight loss, she says. Unfortunately CMS does not reimburse if the weight loss counseling is with a registered dietitian or trained health coach, Ryan says.
Although she applauds Medicare's efforts, she says several major research studies show that patients lose a significant amount of weight when they work in a comprehensive lifestyle program of skill-building in dietary and exercise habits under the guidance of a registered dietitian, a trained health coach, exercise specialist or psychologist.
"We can get a 5% or more weight loss in about half the people who enter a behavior intervention comprehensive lifestyle program led by a nutrition professional. If we add weight-loss medications, we can produce a 5% weight loss in two-thirds of the people."
Studies show that people who lose 5% to 10% of their starting weight have improvements in their health, lowering their blood pressure, cholesterol and risk of developing type 2 diabetes.
Having someone like a doctor just advise people to eat less and exercise more usually produces a weight loss of 1% to 2% on average, Ryan says.
Ryan is concerned that some health plans may just cover telephone counseling and not more effective programs such as comprehensive lifestyle interventions, prescription weight-loss medications and bariatric surgery, such as gastric bypass and gastric banding.
"It's like all of medicine - you should give your most intensive therapies to your sickest patients," she says. "In order to understand treatment choices in obesity, you need to factor in health risk. For low-risk patients, telephone counseling is fine. But for high-risk patients, you want a more intensive course of action. It's not one-size-fits all."
ONE DOCTOR'S SUCCESS STORY
When it comes to treating obesity, some doctors are ahead of the curve.
Internist William Bestermann Jr., 66, director of chronic condition management for the Holston Medical Group in Kingsport, Tenn., has spent 10 years helping patients lose weight.
"I'm in Appalachia, and I'd say 90% of the people we see have a weight issue, and it's all related to food," he says. Many of his patients have type 2 diabetes or prediabetes, he says.
Bestermann decided he wanted to help patients trim down and get healthier after spending the first half of his career signing death certificates and putting people in the hospital because they had had heart attacks and strokes.
He gives heavy patients nutrition information and recommends they read books written by cardiologist Arthur Agatston, author of The South Beach Diet. At every visit, Bestermann reviews patients' weight and talks about their diets. Sometimes fine-tuning prescriptions for diabetes medications or other prescriptions that they might have can help patients lose weight.
"We don't talk about calories or amounts. I tell them to cut back on rolls, biscuits, breads and corn bread, sugar, white potatoes and fat. I recommend they eat lean meat, eggs, low-fat dairy, seafood, beans, fruits and vegetables."
Physical activity is also key. "Every step they take, every move they make is tremendously helpful."
He has gotten results. He did a survey of 500 of his patients, average age 65, and found they had lost an average of 25 pounds. He recently had a patient who lost 108 pounds in 10 months.
Nanci Hellmich, USA TODAY