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On July 15, 2004, the Department of Health and Human Services'Centers for Medicare and Medicaid Services (CMS) announced a change in the Coverage Issues Manual (CIM). The change was from the statement "obesity is not considered an illness"to "obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension."So, basically, Medicare changed the perception of obesity from not being a disease to being an effect or a worsening factor of a disease. This article will discuss the reasoning behind the change in perception and how this change will affect coverage in the Medicare population.
The National Health and Nutrition Examination Survey (NHANES) from the period 1999-2002 found that an estimated 65% of US adults are either overweight (body mass index [BMI] 25.0-29.9) or obese (BMI ≥30). These results were dramatically greater than those of NHANES II, during the period 1976-1980, when only 47% of US adults fell into the category of overweight or obese. When looking specifically at obesity, 31% of US adults were found to be obese during 1999-2002an increase from 15% in 1976-1980. Two alarming factors are associated with these statistics: the number of people and the rate of increase.
With the increase in obesity comes an increase in disease state complications associated with obesity. In 2003, these complications were estimated to produce $123 billion of all US health care costs. Because of these dramatic costs and increased population percentages, CMS officials have decided to make changes that may open the door for scientific research in this area.
What Do These Changes Mean for Research?
The impact Medicare has on obesity research is presented in this statement from the policy revision: "Program payment may not be made for treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary."The key words in this statement are "reasonable"and "necessary." Only research can determine whether treatment is "necessary"to improve quality of life and reduce complications and whether it is "reasonable" to conserve health carerelated costs. Beneficiaries will be able to request a review of scientific evidence to determine whether treatments for obesity will be covered. In the past, this review of medical necessity would not have been executed. It is important that the medical sciences supply the research needed to support these requests. Changes in Medicare coverage depend exclusively on the scientific evidence needed to support them.
What Do These Changes Mean for Medicare Coverage?
In the past, Medicare and Medicaid programs covered sickness related to or aggravated by obesity, such as type 2 diabetes, cardiovascular disease, several types of cancer, and gallbladder disease. Before the revision to the policy, weight-loss medications and obesity treatments were not covered. Since the revision, the deficit in coverage remains the same. Medicare coverage has not changed, because obesity still is not recognized as an independent illness. Until research is presented that will prove obesity to be an illness that requires intensive treatment, the coverage will remain as it is. Medicare officials will review clinical data using the coverage-determination procedure established in 1999 and modified by the Medicare Prescription Drug, Improvement and Modernization Act of 2003. CMS Chief Medical Officer Sean Tunis, MD, has revealed that the Medicare Coverage Advisory Committee plans to begin discussing the evidence on obesity-related surgical procedures that may reduce the risk of cardiovascular and other illnesses.
When Should Changes in Medicare Coverage of Obesity Be Expected?
There will be no immediate effects from the change in the CIM relating to obesity. The process from beneficiary request to scientific review will be a time-consuming one. An example of the time line for change can be seen by reviewing the request that was made for the revision in the CIM that has been discussed in this article. The initial request for the revision was submitted in September 2001. The request was reviewed throughout the next 3 years, until action finally was taken in July 2004. As this was the time line for making changes that did not affect Medicare coverage, one can imagine how long it will take to implement changes that will dramatically change the coverage policy.
How Will Changes in Obesity Coverage Affect Pharmacy?
If Medicare policy makers decide to cover obesity treatment in the future, pharmacists have the ability to be great providers in this area. Pharmacists already are actively counseling patients on obesity in relation to heart disease, cholesterol, diabetes, hypertension, and other illnesses. Pharmacists answer many questions on a daily basis about OTC and prescription medications for the treatment of obesity. The education and experience of a pharmacist provide patients with the optimal source of information regarding diet, exercise, and medication.
Beyond the vast knowledge of obesity treatments a pharmacist can offer, the accessibility of a pharmacist could prove to be the most important tool for a patient fighting obesity. As difficult as it is to lose weight, imagine how difficult it would be to do it alone or without a support system to guide one through the difficult times. A pharmacist could serve as the patient's support system on a daily basis, while providing the medical expertise needed to treat obesity. What other health care professional has the ability to provide this day-to-day accessibility?
Medicare coverage for the treatment of obesity will be a great opportunity for pharmacists to be compensated for clinical services that they may already be offering in their practice or would like to offer if compensation is secured. It is important for pharmacists to be aware of the changes in Medicare policy and to be willing to adapt their practices to serve these needs.
Dr. Downing is a clinical coordinator for Kerr Health Care Center, Raleigh, NC.