Skip to main content

Advertisement

Log in

Challenges with the Medicare Obesity Benefit: Practical Concerns & Proposed Solutions

  • Perspective
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

Obesity and the growing population of older adults are significant public health concerns in the United States. In 2011, the Centers for Medicare and Medicaid Services introduced a Medicare benefit for obesity counselling using Intensive Behavioral Therapy that would reimburse structured visits over a 12-month period. Although we applaud this new benefit that addresses the obesity epidemic in older adults, three major shortcomings limit its utility and potential effectiveness: 1) weight loss interventions differ in older and younger adults, yet the benefit relies predominantly on data from interventions studied in younger populations; 2) body mass index is not an accurate measure for identifying obesity; and 3) tying reimbursement to clinician visits may hamper the integration of this benefit into practice. To overcome these shortcomings, we propose: 1) obesity treatment should focus on improving quality of life and physical function and on mitigating muscle and bone loss rather than focusing solely on weight loss; 2) waist circumference or waist-hip ratio should be considered as additional anthropometric measures in ascertaining obesity; and 3) allied health professionals should be reimbursed for providing this benefit. Incorporating these suggestions will improve its usability in clinical practice and increase the chances that this well-meaning benefit will improve patient outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

BMI:

Body mass index

CMS:

Centers for Medicare and Medicaid

USPSTF:

United States Preventive Services Task Force

WC:

Waist circumference

WHR:

Waist-hip ratio

REFERENCES

  1. Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review. J Gen Intern Med. 2009;24(9):1073–9. doi:10.1007/s11606-009-1042-5.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14. doi:10.1001/jama.2014.732.

    Article  CAS  PubMed  Google Scholar 

  3. Gregg EW, Cheng YJ, Cadwell BL, Imperatore G, Williams DE, Flegal KM, et al. Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA. 2005;293(15):1868–74. doi:10.1001/jama.293.15.1868.

    Article  CAS  PubMed  Google Scholar 

  4. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861–7. doi:10.1001/jama.293.15.1861.

    Article  CAS  PubMed  Google Scholar 

  5. Schaap LA, Koster A. Visser M. Muscle Mass, and Muscle Strength in Relation to Functional Decline in Older Persons. Epidemiologic reviews: Adiposity; 2012. doi:10.1093/epirev/mxs006.

    Google Scholar 

  6. Guiding principles for the care of older adults with multimorbidity: an approach for c. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity.J Am Geriatr Soc. 2012;60 (10):E1-E25. doi:10.1111/j.1532-5415.2012.04188.x

  7. Batsis JA, Singh S, Lopez-Jimenez F. Anthropometric measurements and survival in older americans: results from the third national health and nutrition examination survey. J Nutr Health Aging. 2014;18(2):123–30. doi:10.1007/s12603-013-0366-3.

    Article  CAS  PubMed  Google Scholar 

  8. National Coverage Determination (NCD) for Intensive Behavioral Therapy for Obesity (210.12). 2011.

  9. Moyer VA, Force USPST. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373–8.

    PubMed  Google Scholar 

  10. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Canadian Family Physician Medecin de Famille Canadien. 2013;59(1):27–31.

    PubMed Central  PubMed  Google Scholar 

  11. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New Eng J Med. 2002;346(6):393–403. doi:10.1056/NEJMoa012512.

    Article  CAS  PubMed  Google Scholar 

  12. Look ARG. Eight-year weight losses with an intensive lifestyle intervention: the look AHEAD study. Obesity (Silver Spring, Md.). 2014;22 (1):5–13. doi:10.1002/oby.20662

  13. Brown T, Avenell A, Edmunds LD, Moore H, Whittaker V, Avery L, et al. Systematic review of long-term lifestyle interventions to prevent weight gain and morbidity in adults. Obes Rev. 2009;10(6):627–38. doi:10.1111/j.1467-789×.2009.00641.x.

    Article  CAS  PubMed  Google Scholar 

  14. Dahn JR, Fitzpatrick SL, Llabre MM, Apterbach GS, Helms RL, Cugnetto ML, et al. Weight management for veterans: examining change in weight before and after MOVE! Obesity (Silver Spring, Md.). 2011;19 (5):977–81. doi:10.1038/oby.2010.273

  15. Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon T, Caplan W, et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc. 2007;107(10):1755–67. doi:10.1016/j.jada.2007.07.017.

    Article  PubMed  Google Scholar 

  16. Lin JS, O′Connor E, Whitlock EP, Beil TL, Zuber SP, Perdue LA, et al. Behavioral Counseling to Promote Physical Activity and a Healthful Diet to Prevent Cardiovascular Disease in Adults: Update of the Evidence for the U.S. Preventive Services Task Force. Rockville MD2010.

  17. McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2003;139(11):933–49.

    Article  PubMed  Google Scholar 

  18. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. New Eng J Med. 2011;364(25):2392–404. doi:10.1056/NEJMoa1014296.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  19. McTigue KM, Hess R, Ziouras J. Obesity in older adults: a systematic review of the evidence for diagnosis and treatment. Obesity (Silver Spring, Md.). 2006;14 (9):1485–97. doi:10.1038/oby.2006.171

  20. Shea MK, Houston DK, Nicklas BJ, Messier SP, Davis CC, Miller ME, et al. The effect of randomization to weight loss on total mortality in older overweight and obese adults: the ADAPT Study. The journals of gerontology. Series A, Biological sciences and medical sciences. 2010;65 (5):519–25. doi:10.1093/gerona/glp217

  21. Villareal DT, Chode S, Parimi N, Sinacore DR, Hilton T, Armamento-Villareal R, et al. Weight loss, exercise, or both and physical function in obese older adults. New Eng J Med. 2011;364(13):1218–29. doi:10.1056/NEJMoa1008234.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Leblanc ES, O′Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(7):434–47.

    Article  PubMed  Google Scholar 

  23. Park Y, Subar AF, Hollenbeck A, Schatzkin A. Dietary fiber intake and mortality in the NIH-AARP diet and health study. Arch Intern Med. 2011;171(12):1061–8. doi:10.1001/archinternmed.2011.18.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Sui X, Laditka JN, Hardin JW, Blair SN. Estimated functional capacity predicts mortality in older adults.J Am Geriatr Soc. 2007;55(12):1940–7. doi:10.1111/j.1532-5415.2007.01455.x.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis. Age Ageing. 2010;39(4):412–23. doi:10.1093/ageing/afq034.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Newman AB, Yanez D, Harris T, Duxbury A, Enright PL, Fried LP, et al. Weight change in old age and its association with mortality.J Am Geriatr Soc. 2001;49(10):1309–18.

    Article  CAS  PubMed  Google Scholar 

  27. Heymsfield SB, Gonzalez MC, Shen W, Redman L, Thomas D. Weight loss composition is one-fourth fat-free mass: a critical review and critique of this widely cited rule. Obes Rev. 2014;15(4):310–21. doi:10.1111/obr.12143.

    Article  CAS  PubMed  Google Scholar 

  28. Batsis JA, Barre LK, Mackenzie TA, Pratt SI, Lopez-Jimenez F, Bartels SJ. Variation in the prevalence of sarcopenia and sarcopenic obesity in older adults associated with different research definitions: dual-energy X-ray absorptiometry data from the National Health and Nutrition Examination Survey 1999–2004.J Am Geriatr Soc. 2013;61(6):974–80. doi:10.1111/jgs.12260.

    Article  PubMed  Google Scholar 

  29. Stenholm S, Alley D, Bandinelli S, Griswold ME, Koskinen S, Rantanen T, et al. The effect of obesity combined with low muscle strength on decline in mobility in older persons: results from the InCHIANTI study. Int J Obes (2005). 2009;33 (6):635–44. doi:10.1038/ijo.2009.62

  30. Greiner KA, Born W, Hall S, Hou Q, Kimminau KS, Ahluwalia JS. Discussing weight with obese primary care patients: physician and patient perceptions. J Gen Intern Med. 2008;23(5):581–7. doi:10.1007/s11606-008-0553-9.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Miller GD, Nicklas BJ, Davis C, Loeser RF, Lenchik L, Messier SP. Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis. Obesity (Silver Spring, Md.). 2006;14 (7):1219–30. doi:10.1038/oby.2006.139

  32. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013;310(12):1263–73. doi:10.1001/jama.2013.277669.

    Article  CAS  PubMed  Google Scholar 

  33. Rejeski WJ, Brubaker PH, Goff DC Jr, Bearon LB, McClelland JW, Perri MG, et al. Translating weight loss and physical activity programs into the community to preserve mobility in older, obese adults in poor cardiovascular health. Arch Intern Med. 2011;171(10):880–6. doi:10.1001/archinternmed.2010.522.

    Article  PubMed  Google Scholar 

  34. Chronic Conditions Data Warehouse: Medicare Enrollment by Age Group 1999–2009. In: Centers for Medicare and Medicaid Services. 2014. https://www.ccwdata.org/web/guest/medicare-charts/medicare-enrollment-charts. Accessed April 23, 2014.

  35. Romero-Corral A, Somers VK, Sierra-Johnson J, Thomas RJ, Collazo-Clavell ML, Korinek J, et al. Accuracy of body mass index in diagnosing obesity in the adult general population. Int J Obes (2005). 2008;32 (6):959–66. doi:10.1038/ijo.2008.11

  36. Batsis JA, Sahakyan KR, Rodriguez-Escudero JP, Bartels SJ, Somers VK, Lopez-Jimenez F. Normal weight obesity and mortality in United States subjects >/=60 years of age (from the Third National Health and Nutrition Examination Survey). Am J Cardiol. 2013;112(10):1592–8. doi:10.1016/j.amjcard.2013.07.014.

    Article  PubMed  Google Scholar 

  37. Batsis JA, Sahakyan KR, Rodriguez-Escudero JP, Bartels SJ, Lopez-Jimenez F. Normal weight obesity and functional outcomes in older adults. Eur J Intern Med. 2014;25(6):517–22. doi:10.1016/j.ejim.2014.05.008.

    Article  PubMed  Google Scholar 

  38. Kuk JL, Ardern CI. Influence of age on the association between various measures of obesity and all-cause mortality. J Am Geriatr Soc. 2009;57(11):2077–84. doi:10.1111/j.1532-5415.2009.02486.x.

    Article  PubMed  Google Scholar 

  39. Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2013. doi:10.1161/01.cir.0000437739.71477.ee

  40. Angleman SB, Harris TB, Melzer D. The role of waist circumference in predicting disability in periretirement age adults. Int J Obes (2005). 2006;30 (2):364–73. doi:10.1038/sj.ijo.0803130

Download references

Acknowledgements

Funding

Supported in part by the Dartmouth Centers for Health and Aging, and the Department of Medicine, Geisel School of Medicine at Dartmouth-Hitchcock Medical Center.

Conflicts of Interest

JA Batsis—Received prize for the American Geriatrics Society/Merck New Investigator Award 2014.

KL Huyck—None.

SJ Bartels—Receives funding from the National Institutes for Mental Health and the Centers for Disease Control.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to John A. Batsis.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Batsis, J.A., Huyck, K.L. & Bartels, S.J. Challenges with the Medicare Obesity Benefit: Practical Concerns & Proposed Solutions. J GEN INTERN MED 30, 118–122 (2015). https://doi.org/10.1007/s11606-014-3031-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-014-3031-6

KEY WORDS

Navigation