Medicare recently announced new regulations that authorize reimbursement for obesity management counseling by physicians. That's good, assuming the counseling is good. We are a long way from being able to count on that, however.
With a nod to my many colleagues who are genuinely expert in weight management counseling, and have long addressed it well -- and especially to those who taught me to do so -- I must acknowledge that the track record for the large majority of our clan is not pretty. Historically, there have been two ways physicians have mucked up weight management counseling: by providing it, and by not providing it.
The problem with not providing it is pretty self-evident. If a patient presents who is clearly severely overweight -- perhaps even huffing and puffing just to settle into the exam room -- not to address it is both ludicrous and an abdication of clinical responsibility. It would be as if a patient walked into the office with a spear sticking out of their chest, and left in the same condition with no mention of it in between.
But bad counseling can be worse than none at all. When the best a doctor can do is blame the victim -- "don't you know that being so fat is bad for you?" -- the net effect can range from an erosion of the patient's self-esteem, to outright estrangement of the patient from the medical system. The former is bad enough -- making a patient feel about an inch tall (note that if height goes down while weight remains constant, BMI actually goes up; talk about counter-productive!). The latter, however, can actually be life-threatening, when patients eschew vital preventive services, such as Pap smears or mammograms, or neglect essential care to avoid the associated denigration. This may sound like melodrama, but I have first hand knowledge of cases in which bad obesity counseling ultimately proved lethal, and other cases in which it was nearly so.
It is in this context that the new Medicare regulations must be assessed. The change is good in that lack of reimbursement has long been cited as one of the impediments to weight management counseling. Extending this line of reasoning, the case can be made that lack of reimbursement means lack of counseling; lack of counseling means lack of experience with, or dedication to, counseling; and lack of experience and dedication in turn mean that such counseling as does occur will tend to be poor. If this were the whole story, then reimbursement might fix everything.
But it's not the whole story. Docs don't tend to get much training in nutrition, and while this has been oft lamented, it is difficult to fix due in part to the intense competition for real estate in the crowded landscape of medical education. There is, it seems, ever more to cram into those four years.
Even if time for robust nutrition education were claimed, it would only be a start. Training in behavior modification also tends to be limited, and would need to be upgraded considerably. Perhaps less daunting than these, additional training would be required for effective promotion of physical activity as well, along with the proper ways to measure and monitor not just weight but body composition.
And because in unity there is strength, approaches to weight control that engage the whole family are best. One person on a diet is weak; a family seeking health together is strong. So good counseling should address all household members, another area in which physician training (with the possible exception of family practitioners) is limited.
Were all such upgrades to occur in medical education, formidable challenges would still remain. The first is obvious: those notorious "15 minute encounters," which are in fact often less, don't allow time for conventional behavior modification counseling even by those who know how to provide it.
The second, obvious to those of us in the medical trenches, is apt to be less so for others. The time-honored adage to describe medical education is "see one, do one, teach one." If trainees don't see their mentors practicing weight management counseling, they will be dissuaded from doing so. Getting beyond the impasse requires concurrent incentives for docs in practice -- which the new reimbursement scheme may provide -- and improvements in training so that the next generation of practitioners can do this job better.
There are ways to address these issues. One is to enhance medical school and medical residency curricula in these areas. That struggle is underway all around the country. Another is to deliver relevant material in time-honored ways, such as textbooks. Yet another is interactive on-line training specific to weight management in clinical practice, and incentivized with continuing medical education credits. CME credits are required to maintain medical licensure, and thus serve as a potent goad.
But even if all of this were to move forward in tandem, physicians would still be struggling to allocate time to weight management counseling and away from other matters. The solution to this is for physicians to initiate the counseling, and then defer to others better suited to address the details. Dietitians are the obvious choice. In some cases, health coaches could play this role as well. But for this strategy to work, there would need to be reimbursement for that counseling as well.
Another, and perhaps even better option, is for clinicians to be able to direct patients into well-established weight management programs. There is a lot to a comprehensive weight management program, and it's unlikely that even a highly skilled and motivated physician could address all of this on his or her own. Two very compelling recent studies (1, 2) suggest that Weight Watchers does a far better job at this than primary care -- so linking the two is attractive. But again, the reimbursement model does not yet correspond.
Another challenging issue is the linkage of reimbursement to outcomes. On the one hand, it is quite appropriate to ensure that we are "getting what we are paying for." And of course, we are paying -- since ultimately, Medicare and Medicaid resources derive from taxpayers. We should all want to know that counseling is actually working.
The danger in this is that weight change is the obvious measure of success, but not the right one. A physician might counsel well, and yet a patient with many other challenges in their life might not comply. Should a physician who takes care of especially challenging patients be financially penalized?
Even more compelling is the fact that two patients might be equally diligent about improving diet and activity, but one might lose weight and the other not -- due to genetic factors and other causes of relative weight loss resistance. Should that good faith effort by physician and patient alike -- an effort likely to improve health even if weight does not change -- be dubbed a failure? Pay-for-performance might more reasonably focus on behaviors individuals do control directly -- such as dietary choices and activity pattern -- than on weight, which they do not.
While good quality counseling may help with weight management, we should not get carried away with that idea. The metabolic complications of obesity are bona fide clinical problems, but weight gain over time is quite another matter. Weight gain is a result of more calories in than out, and that in turn is largely the result of a modern, obesigenic environment and the ways in which a majority of us interact with that environment. It is about daily use of feet and forks. It is about food marketing and food processing; suburban sprawl and drive-throughs; vending machines and video games; long days and labor-saving technology. Medical school does not provide a fix for any of these! The origins of prevailing weight gain and obesity are not clinical -- they are not about physiology run amok- they are societal.
Fixing obesity will thus require a societal response. It will require solutions populating the settings where people spend most of their time, and make relevant decisions about the use of feet and forks -- home, school, and work; supermarkets and shopping malls; online, in church, and so on. Empowering programming can be devised to populate all such settings- and physicians can guide patients to its use. One national physician organization has endorsed a supermarket-based nutrition guidance system to that end. Many more such linkages between enlightened clinicians and empowered patients will help us get to the prize.
So what, exactly, does reimbursement for obesity counseling give us? It can help make physicians a part of a comprehensive solution. Being a part of the solution is far better than being a part of the problem. So reimbursement for counseling is a good start- assuming we can make sure the counseling is consistently good.
But we clinicians, at our best, can never be more than a modest part of the comprehensive solution epidemic obesity requires. We will see the toxic tide of epidemic obesity turn when, and only when, we fix the problem at its many sources in our society -- and make eating well and being active the norm, rather than the exception. When health is found along the path of lesser resistance, rather than the road less traveled.
The promise of that day is great. We have miles to go to get there from here!
-fin
Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org