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PHYSICIAN'S PERSPECTIVE: Obesity--Challenges of the “Disease”

Posted on Wed, Aug 21, 2013

By Dr. Jeff Slepin, MDobesity.jpg

Since 1980, the prevalence of obesity among children and adolescents has almost tripled. According to the Centers for Disease Control, as of the end of 2010, 35.7 percent of adult Americans were obese.  Approximately 17 percent (or 12.5 million) of children and adolescents aged 2—19 years are obese.

Health care providers have long been aware of the risks of obesity as significant factors in various chronic diseases, particularly type 2 diabetes mellitus and cardiovascular illness.  For many years, physicians have generally lacked comprehensive knowledge, resources and desire, partially due to the lack of reimbursement, to attack the problem. With the classification of obesity as a disease by various organizations including the World Health Organization, NIH and the AMA, an alarm is now being sounded that will hopefully enable patients, physicians and third party payers to increase their focus on early identification, prevention and treatment of the problem.

Obesity is a multifactorial problem that transcends behavioral, socioeconomic, clinical, political, geographic, ethnic, racial and other realms.  A significant challenge arises from a clinician’s ability to impact one aspect of obesity (such as education on proper nutrition) while another aspect (such as economics) may adversely impact the ability of a patient or family to comply with the clinician’s recommendations.  For example, a patient may understand the importance of avoiding “fast food” (such as the so-called “value menus” at various national restaurant chains), but the deterioration of economic circumstances may adversely impact the ability to obtain and consume healthier foods (i.e. fresh fruits, vegetables and non-processed foods).  Most importantly, obesity often results from personal choice and behavioral patterns that are very challenging to modify.

Under most current reimbursement models, providers (including physicians and hospitals) are generally and more favorably reimbursed for the evaluation and management of disease processes that require readily identifiable (and generally more expensive) resources.  The effects of obesity develop over years, and the treatment of obesity as a disease is a long-term and continuous process that primarily involves cognitive and interpersonal, as opposed to technical, skills and equipment. Thus, the ability of third party payers to develop a methodology and adequately reimburse providers for treating obesity has been and continues to be a significant challenge.

In late 2011, despite the fact that CMS decided to reimburse primary care physicians for behavioral counseling for obesity, the long-term nature of therapy (a minimum of 6-12 months of dietary counseling, exercise and behavioral modification – services that may be required to continue indefinitely), physicians do not have the time nor expertise to effectively treat obesity by themselves.  A more effective approach involves a coordinated team approach including the services of dietitians, behavioral health and exercise professionals; these professionals were excluded from proposed reimbursement changes.  In order to be reimbursed for services, a serious condition (i.e. a disease such as diabetes, hypertension or coronary artery disease) must develop, be identified and be managed by these health care professionals.

The consideration of obesity as a disease recognizes its potentially devastating impact on overall health. While some may interpret a “disease” as a condition that an individual has little or no control over, the long-term nature of the development, and the ebb and flow, of obesity actually affords people the opportunity to control it more than most other chronic diseases through dietary, exercise and other behavioral choices.  While these choices are not always easy to control, they can be influenced, to greater and lesser degrees among individuals and at different times in the cycle of life.  This affords humanity a greater degree of influence (and control) over obesity more than traditional disease processes, and the results, if successful, can reduce the development of other diseases, improve self-image, enhance well-being and reduce global health care costs.

Combating the growing challenge of obesity will require a continuous and more focused approach by patients, providers and payers alike. The benefits are obvious, but will only result from influencing all parties, not just the patient, to make choices in the best interest of reversing the growing number of Americans who are approaching or who have developed the condition of obesity which is truly a disease in and of itself.

slepin_jeffrey_5451.jpgAbout Dr. Slepin:  M. Jeffrey Slepin, MD, MBA, is a residency-trained, ABEM certified emergency physician who has been a Regional Medical Director for EmCare since 2003.  He attended Emory University and completed his medical education at the Medical College of Virginia. Following his residency at the University of Florida Health Sciences Campus in Jacksonville, he practiced in Virginia and Florida. He obtained his MBA at the College of William and Mary Graduate School of Business prior to joining EmCare.

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