Revised Policy Treats Obesity Under Medicare

WASHINGTON —  Federal officials Thursday announced a new policy on obesity that could make weight-loss treatments eligible for Medicare coverage.

“Obesity is a critical public health problem in our country that causes millions of Americans to suffer unnecessary health problems and to die prematurely,” Tommy G. Thompson, secretary of Health and Human Services, said at a Senate subcommittee hearing where he announced that Medicare officials were removing the statement that “obesity itself cannot be considered an illness” from the Medicare manual.

Under the new policy, Medicare beneficiaries would be able to obtain coverage for treatments -- such as gastric bypass surgery -- if “scientific and medical evidence demonstrate their effectiveness in improving Medicare beneficiaries’ health,” the department said in a statement.

The new policy comes as obesity has generated fresh concern on Capitol Hill, triggering legislation -- with titles such as the Healthy Lifestyles Act and the Obesity Prevention Act -- designed to reduce the problem.

Poor diet and physical inactivity, two major contributors to obesity, are closing in on tobacco use as the leading preventable causes of death in the United States, according to a report in March in the Journal of the American Medical Assn.

According to the National Institutes of Health, nearly two-thirds of Americans are classified as overweight (with a body mass index over 25) or obese (with a body mass index over 30). Body mass index is a measure of body fat based on height and weight.

Studies have shown that obese people are at high risk for diabetes, hypertension, sleep apnea, some cancers and other life-threatening conditions.

“Treating obesity-related illnesses and complications adds billions of dollars to the nation’s healthcare costs,” Thompson told the Senate Appropriations subcommittee on Labor, Health and Human Services and Education. “With this new policy, Medicare will be able to review scientific evidence in order to determine which interventions improve health outcomes for seniors and disabled Americans who are obese and its many associated medical conditions.”

Medicare covers medically necessary services for illness and injury for 41 million senior and disabled Americans.

The wording that obesity was not an illness could have barred Medicare from covering treatments for diseases related to obesity, the Department of Health and Human Services said.

While treatment for some illnesses that can cause obesity, such as Cushing’s disease and hypothyroidism, have been covered by Medicare, programs such as gastric bypass surgery -- which can cost upward of $30,000 -- have not.

“From the standpoint of Medicare coverage and the health of our beneficiaries, the question isn’t whether obesity is a disease or a risk factor,” said Mark McClellan, administrator of the federal Centers for Medicare and Medicaid Services. “What matters is whether there’s scientific evidence that an obesity-related medical treatment improves health.

“The medical science will now determine whether we provide coverage for the treatments that reduce complications and improve quality of life for the millions of Medicare beneficiaries who are obese,” he said.

The new policy does not affect the existing Medicare coverage of treatments of diseases resulting in or made worse by obesity, in particular surgical treatments for morbidly obese individuals, the department said in a statement.

A joint study by the federal Centers for Disease Control and Prevention and the North Carolina research group RTI, published in January in the journal Obesity Research, found that Medicaid and Medicare spent $75 billion last year on obesity-related illnesses. In a report issued last year, U.S. Surgeon Gen. Richard Carmona said that the nation spent $177 billion on obesity-related health costs in 2000.

One key issue will be how the government determines which types of treatments will be reimbursed under the new policy, said James Hill, director of the Center for Human Nutrition at the University of Colorado Health Science Center.

“From what I’ve read, it will be programs with proven effectiveness, and that’s a real key,” Hill said. “Everybody and his brother claims to be able to treat obesity, and I would hope that there will be some way to hold programs accountable. From a research point of view, hopefully it will stimulate programs to begin collecting data.”

In its revised policy, the department did not specifically define obesity as a disease, although advocates for the obese saw the action as moving in that direction.

Dr. Richard Atkinson, president of the American Obesity Assn., praised the policy change, declaring in a statement: “The decision by Medicare recognizes that obesity is not simply a cosmetic issue. It is a disease in its own right. In fact, obesity is the most prevalent, fatal, chronic disease of the 21st century. This decision will open the door not only for better insurance coverage but more medical research and increased education on obesity at the nation’s medical and other health schools.”

According to the association, a Washington advocacy and education organization, 37% of the Medicare population is overweight and 18% obese. From 1991 to 1998, the prevalence of obesity among people age 60 to 69 increased 45%, the association said.

Some public health experts said the policy shift legitimized their long-held view that obesity was a discrete and legitimate disease.

“This is very exciting, really meaningful and long overdue,” said Dr. Peter Pressman, an obesity specialist at the University of Southern California. “This new policy opens up coverage for interventions -- everything from medical and nutritional counseling, psychotherapy and bariatric surgery -- for those who are obese. But it also makes Medicare receptive to reviewing scientific evidence to help us in the field determine which therapies are effective.”

But Pressman said the new policy should also serve as a wake-up call for physicians.

“I’m hoping it will in effect coerce us as a profession to be more responsible about considering clinical nutrition and obesity as an expanding component of our formal education,” he said.

Now that Medicare has changed its policy, consumers will be waiting for private insurers to decide whether to follow suit. In recent months, many companies have restricted coverage for expensive procedures.

Michael Chee, a spokesman for Blue Cross of California, said his company provided the sort of obesity coverage anticipated by Medicare, and the announcement would not have any effect on the company’s policies.

*

Simon reported from Washington and Rivera from Los Angeles.