The decision that Medicare will pay for screening and counseling services to help obese patients lose weight has opened an old debate about who can best help people slim down.
Top national weight-loss experts salute the ruling as good news, but they are concerned that many doctors and their staffs are ill prepared and haven't the time to help obese patients.
"This is an incredibly positive move by the government in recognizing obesity as a contributor to many of our health problems," said Donna Ryan, an obesity researcher at the Pennington Biomedical Research Center in Baton Rouge. "But the devil is in the details, and many physicians have no training in weight-loss counseling -- zero."
In a recent survey of primary care physicians, 78% said they had no prior training on weight-related issues, said Christy Ferguson, director of the STOP Obesity Alliance. Of those, 72% said no one in their office had weight-loss training.
"I don't think we have spent enough time thinking about that," Ferguson said. "But things change in increments, and this is a step in the right direction."
The rule means that doctors can now be paid for weight-related counseling, and therefore may seek out training, she said. The Medicare benefits from the Centers for Medicare and Medicaid Services (CMS) will include screening for obesity and counseling for eligible beneficiaries by primary care providers in settings such as physicians' offices.
The services include face-to-face counseling every week for one month, then one counseling appointment every other week for the following five months for people who screen positive for obesity. CMS will require counseling be given by physicians, nurse practitioners, clinical nurse specialists or physician assistants.
More than 30% of people in the Medicare population are obese, which increases their risk of type 2 diabetes, heart disease and many types of cancer.
Some research suggests that physicians can assist patients in weight loss.
Thomas Wadden, director of the Center for Weight and Eating Disorders at the University of Pennsylvania's Perelman School of Medicine, published a study earlier this month that found physicians, with the aid of their medical assistants and meal-replacement plans, helped obese patients lose and keep off 10 pounds over two years. The medical assistants and physicians got weight-loss training before they started counseling patients.
Wadden said he hopes insurance companies will follow CMS' "bold lead" and pay for obesity treatment. He also said he believes CMS should consider reimbursing a range of weight-loss options, including telephone- and Internet-based programs, which have been shown to be effective. "Such programs could be coordinated with primary care providers efforts and delivered at a far lower cost than having physicians or nurse practitioners deliver lifestyle counseling."
Several other large clinical trials show that dieters who followed intensive weight-loss programs with trained professionals and a lot of one-on-one counseling lost an average of 9% of their starting weight, Ryan said.
However, most physicians can't spend huge amounts of face time with their patients, she said. "The physician should probably be part of the assessment team and the primary motivator, but someone else in the office should teach the lifestyle changes that will lead to weight loss.
"The problem is going to be how to make this efficacious and affordable. It's a question of economics," Ryan said.
Not everyone agrees that counseling is the best approach. Deborah Cohen, a physician and senior natural scientist at RAND Corp., a think tank, said that as dieting, counseling and nutritional information have increased, the obesity epidemic has continued to grow. "It shouldn't be doctors," she said.
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