Efforts to treat the third of Americans who are obese are futile until we train key actors in medical academies to effectively handle obesity management.
The catastrophic emergence of obesity as a public health challenge is as well-documented as it is perplexing. The incidence of obesity grew from a problematic 15 percent in 1980 to an epidemic 34 percent of the population in 2008. Not only is obesity a prominent risk factor for co-morbidities that run the gamut from diabetes to stroke to hypertension to cardiovascular disease, it also presents economic and national security challenges.
Most obesity policies today come in the form of prevention, in response to obesity treatment policy of the past focusing on “individual behavior change.” Realizing that the effort to educate obesity out of existence is ultimately futile, most policy is now fashioned to prevent obesity by changing the built environment to incentivize healthy decision-making. However, the effort to prevent obesity eclipses, and ironically prevents, the passage of policies to treat currently existing obesity. As more than a third of Americans are presently obese, this represents a dangerously large blind spot in the policy environment.
A recent ruling to include obesity treatment (in the form of screening and counseling) under Medicare is a step in the right direction. But even this step may be misplaced. While it will soon be incumbent upon a network of doctors, nurses, and other medical actors to engage obesity amongst their patients, few of these actors are prepared to do so. Indeed, 44 percent of doctors report not feeling qualified to treat obesity.
Medicare currently subsidizes the largest fraction of federal outlays to Graduate Medical Education (GME) at an annual $9.2 billion. These payments are designed to provide commensurate support for the supply side of the medical industry as Medicare works to make medical care more accessible, a move that increases demand for medical services. Given the increasing pool of insured Americans via the Patient Protection and Affordable Care Act (PPACA), it is projected that by the year 2015, nearly half the 28,500-person shortage in physicians will be of primary care doctors.8 Finally, the direct payments go toward teaching hospitals, which decide (with little recourse) how the funds will be used to train medical students. As a result, GME payments are partly responsible for the underproduction of primary care physicians in response to the highly lucrative payment schedules to specialists. Obesity is a disease first screened and then managed by primary care physicians. With obesity soon to come under expanded coverage via the recent rule change and the PPACA, the projected shortage of physicians is a projected catastrophe for health care management.
The Decision Memo released by the Centers for Medicare and Medicaid Services outlined the key actors, methods, and assessments necessary to the inclusion of Intensive Behavioral Therapy for Obesity under Part A and Part B of Medicare. Where the memo found screening, dietary assessment, and intensive behavioral counseling to be the therapies of choice, it also noted that this therapy would be administered in a primary care setting, be that delivered through physician, nurse practitioner, clinical nurse specialist, or physician assistant. With the use of team-based care eminent in the PPACA, it stands to reason that obesity treatment can be a shared enterprise both in the primary care setting and the funding model.
Federal outlays to GME should promote team-based care with respect to obesity. This can be accomplished in an already-existing funding scheme; where GME payments through block grants to states are currently unburdened by few requirements, a proportion of funds can be formally allocated to training primary care teams, rather than specializing individuals, in the management of chronic diseases. Team-based care is likely to lift the burden of perceived ignorance among physicians, reduce the barrier to obesity treatment, and concurrently improve accountability in federally supported medicine.