We warned providers against relying too heavily on commercial diet programs to address their patients' obesity in our last post on weight management. However, if commercial diet programs are not best practice to address obesity, what is?
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To learn more about the challenges and solutions for obesity management, we spoke with primary care physician and American Board of Obesity Medicine-certified obesity and weight management expert Angela Fitch, associate director of the Massachusetts General Hospital Weight Center and secretary/treasurer of the Obesity Medicine Association.
Question: What are the main challenges getting in the way of effective obesity care?
Angela Fitch: First and foremost it's an education issue, both for patients and providers.
On the patient side, there's a fundamental misunderstanding of the treatment options for managing obesity. Patients often see obesity as a temporary, reversible condition rather than a chronic condition. They expect that if they alter their behavior—if they eat right and exercise for a few weeks or months—they'll lose their excess weight and then they can go back to their previous lifestyle. So, when the initial rate of weight loss tapers off, patients frequently disengage and think that whatever they're doing isn't working.
It is important to recognize that behavior change alone is not enough in every case. Patients are generally accepting of taking medication or having surgery if that's what it takes to manage their chronic heart condition. But when it comes to obesity, they're much more skittish. They may think that medication is unnecessary and equate bariatric surgery to a personal failure, or echo the stigma around surgery as "the easy way out" —which it definitely isn't. From a care planning perspective, it's crucial for providers to communicate the value and dispel the misconceptions of medication and surgery, so that patients may be open to incorporating them into their treatment plan when appropriate.
Unfortunately, providers themselves aren't usually well-equipped to do that, for two reasons. Many aren't comfortable speaking with their patients candidly about their obesity because of the stigma associated with it. The other reason is that many providers aren't well-versed in obesity medication therapy and bariatric surgery, so they aren't comfortable prescribing either. We're at with obesity today where we were with depression 20 years ago, and it's showing. Only 3% of people eligible for obesity medication get an effective treatment, and only 1% of patients eligible for bariatric surgery get it.
Q: What should comprehensive obesity management look like?
Fitch: The main tenets of obesity management are nutrition, physical activity, behavior change, medication, and surgery. Care absolutely needs to be multidisciplinary, and you need to match treatment intensity to disease burden. We've done that with other chronic conditions over time, but not obesity. You can only expect a certain amount of weight loss from each treatment option, so in order for patients to achieve the ideal weight loss, more often than not they'll need to combine approaches. And we're making some progress, but we need to do a better job of educating and providing medication and surgery as effective weight-management strategies rather than drastic, last-resort options.
Like other behavior change conditions, obesity management should also incorporate a team approach. PCPs don't need to be providing the nutrition counseling, drug therapy, and behavior change support themselves. Consider using a dietitian, pharmacist, health coach—or other team members who are better-trained and better-positioned to support these elements of care.
Ideally, primary care offices could screen patients for obesity and then refer appropriate patients to a weight-management center for treatment, but while these centers' presence is growing, I recognize that most providers don't have that option and should provide initial obesity treatment.
Q: What is the financial landscape around weight management/obesity care?
Fitch: Getting health systems to invest in weight management has been slow and arduous. Legacy payment models aren't set up to support it and we face ongoing challenges around getting drugs covered (especially by Medicare and Medicaid) and figuring out how to reallocate internal dollars to sustain what is ultimately a cost avoidance lever.
That said, there are more opportunities to fund obesity care than ever before. The majority of payers reimburse for preventive counseling codes—the 99401-99404s, which cover up to 15 visits per year with a physician or non-physician practitioner. There's an ICD-10 code for obesity. There's the revenue opportunity associated with surgery. And of course, value-based care contracts that promote population health management provide the incentives to help patients with weight loss and management. Like I said, then it's a matter of reinvesting at least some of those dollars back in obesity care. For example, if the Weight Center helps a patient maintain their A1c or avoid an ED visit, we should be seeing some of those P4P bonus dollars or shared savings, or some financial reward for cost avoidance. Right now most systems aren't doing that.
Q: In light of the challenges you've laid out, what makes you optimistic about obesity care in the United States?
Fitch: We still have a long way to go, but obesity care has matured considerably over the past decade, and it continues to do so. The first year providers could be board-certified in obesity medicine (2012), there were about 300 certified obesity doctors; now there are over 3,000 of us. Thankfully, payment systems are moving toward supporting chronic care management. Employers have a vested interest in reducing employee health burden, and obesity is often seen as the low-hanging fruit to go after to reduce other health risks (e.g., 5% weight loss reduces the risk of diabetes by 58%). We're seeing tons of innovation, especially in the surgical space, which means that more minimally invasive options, which present a lower barrier to entry for eligible patients, may be available soon. And finally, I do see the needle moving on physician education around obesity. It's not where it needs to be, but it's moving.
Understand the wellness spectrum—and promote healthy habits at work
Programs aimed at promoting healthy habits among employees are likely to lead to improved employee engagement and productivity—but they're unlikely to reduce the total cost of care. To do that, you'll need to take a population health approach.
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