Diet plan has to really work before Medicare will pay
WASHINGTON -- The government is looking for the Holy Grail of weight loss programs: one that keeps the pounds off.
Now willing to pay for a treatment that works, Medicare is shunning fad diets to focus on one of the more radical solutions, stomach bypass surgery.
Despite the claims of various diets and surgical procedures, most researchers agree that no approach to weight reduction has been proven to be effective over the long haul. In deleting Medicare's edict that obesity is not a disease, officials said they would consider paying for something, but only something that can be shown to work.
"The key piece of data that's not there is the long-term benefit of any of these particular therapies," said Steve E. Phurrough, director of coverage and analysis at the federal Centers for Medicare and Medicaid Services. "That's what we're looking for."
A Medicare advisory commission will take the first step in November when it considers the effectiveness of stomach-bypass surgery, which has soared in popularity over the past five years.
More than 100,000 morbidly obese people had the surgery in 2003, up from 25,000 in 1998, according to the American Society for Bariatric Surgery. Costing $30,000, the surgery is intended for people who are at least 100 pounds above their ideal body weight and who have failed at other attempts at weight loss.
Many insurance carriers have started to cover the procedure, finding it cheaper to pay for the surgery than long-term treatments of obesity-related health problems such as diabetes and high blood pressure.
One major insurer, however, Blue Cross and Blue Shield of Florida, which serves 6 million people, will stop paying for it next year.
"Gastric bypass surgery is an extremely risky procedure that is of questionable benefit to the patient," said Robert Forster, Florida Blue Cross' vice president and chief medical director. "We are concerned at the growing numbers of these procedures while significant questions remain regarding quality of care, safety, efficacy and long-term consequences."
Medicare has scheduled no other weight-loss treatments for review yet, but officials said they expect to get many requests from weight-loss programs, fitness centers and doctors.
Will Weight Watchers, Jenny Craig, Atkins and other programs win Medicare approval? Atkins' medical director, Dr. Stuart Trager, said he plans to find out.
"Clinical science shows that approaches like Atkins can work," Trager said of the low-carbohydrate diet that remains a subject of great debate among medical practitioners.
Some health plans subsidize gym memberships, but it is unlikely that Medicare would, despite the undeniable benefits of exercise.
Medicare often is a pacesetter in coverage decisions, followed closely by private insurers. But in the case of obesity, the agency will be catching up to health plans that already cover a variety of treatments. Medicare also lags behind the Internal Revenue Service, which designated obesity as a disease in April 2002.
The IRS allows eligible taxpayers who spend thousands of dollars because of obesity to deduct expenses for stomach-stapling surgery, approved weight-loss drugs and nutritional counseling.
Medicare's change of heart last week on weight loss was years in the making, prompted by the alarming rise in obesity as a killer of Americans. Now ranking just behind smoking, obesity claimed 400,000 lives in 2000, according to the Centers for Disease Control and Prevention.
The issue has been a self-described obsession of Health and Human Services Secretary Tommy Thompson, who regularly hands out pedometers and is known to scold overweight aides in public. "The problem is growing as fast as our waistlines are in America," Thompson says at virtually every opportunity.
Perhaps as many as 7.4 million Medicare beneficiaries are obese, generally described as excess body fat of 30 pounds or more over ideal body weight.
Thompson and other top Medicare officials said they have no idea about the cost of any change in coverage. The amount will depend on any treatment that is accepted and how widely it is used.
Even without a new weight-loss benefit, cost pressures are building on Medicare. A new prescription drug benefit taking effect in 2006 will cost at least $400 billion and possibly much more over 10 years.
Taxpayers already foot the bill for $39 billion in medical costs related to obesity. Medicare and Medicaid programs now cover sicknesses caused by obesity, such as type 2 diabetes, cardiovascular disease, several types of cancer and gallbladder disease, according to the CDC. The government also pays for a limited array of treatments for illnesses that can lead to obesity, such as thyroid problems.
Officials have an array of questions to be answered before Medicare starts covering weight-loss programs. What is effective, and for whom? Can people 65 and older withstand the stress of stomach-reduction surgery? Just how obese must a person be to qualify for coverage?
On the Net:
Medicare coverage page: http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id57