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Policy initiative

CMS to offer obesity screening and counselling

Medicare patients to gain access to screening and preventive services
New measure could reduce the number of heart attacks and strokes over the next five years
Donald Berwick

The Centers for Medicare and Medicaid Services (CMS) has announced that it will cover preventive services aimed at reducing obesity. This new benefit will be available without any cost sharing, as with other Medicare preventive services under the Affordable Care Act. 

More than 22 million Medicare beneficiaries in the US received at least one free covered preventive service in 2011. The preventive services currently offered under the Medicare program complement a new joint initiative by CMS and the Centers for Disease Control and Prevention called the Million Hearts. Medicare estimates that approximately 30 per cent of beneficiaries are considered obese and that unhealthy weight can lead to a number of chronic conditions, including cardiovascular disease and diabetes. CMS believes that by addressing obesity now, it can reduce the number of heart attacks and strokes over the next five years and improve the health of Medicare beneficiaries. 

“Obesity is a challenge faced by Americans of all ages, and prevention is crucial for the management and elimination of obesity in our country,” said CMS Administrator Donald M Berwick. “It’s important for Medicare patients to enjoy access to appropriate screening and preventive services.

Screening and counselling

Obesity screening and counselling for eligible beneficiaries will be offered by primary care providers in the office setting. Patients with a body mass index (BMI) of greater than or equal to 30kg/m2 would receive one face-to-face visit for counselling each week for one month as well as a visit every other week for an additional five months. In addition, a beneficiary who has lost at least 6.6lbs during his or her first six months of counselling is eligible to receive an additional six face-to-face visits over the course of a six-month period. 

The Centers for Medicare and Medicaid Services (CMS) has determined “The evidence is adequate to conclude that intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥ 30kg/m2, is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF). 

Programme

Intensive behavioral therapy for obesity consists of the following:

1. Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/2); 

2. Dietary (nutritional) assessment; and

3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

The intensive behavioral intervention for obesity should be consistent with the 5-A framework that has been highlighted by the USPSTF:

1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

For Medicare beneficiaries with obesity, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting, CMS covers:

  • One face-to-face visit every week for the first month;
  • One face-to-face visit every other week for months 2-6;
  • One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg weight loss requirement as discussed below.

Eligibilty

At the six month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg over the course of the first six months of intensive therapy. This determination must be documented in the physician office records for applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight loss of at least 3kg during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six month period.

Screening for obesity and counseling for eligible beneficiaries by primary care providers in settings such as physicians’ offices are covered under this new benefit. For a beneficiary who screens positive for obesity with a body mass index (BMI) ≥ 30kg/m2 the benefit would include one face-to-face counseling visit each week for one month and one face-to-face counseling visit every other week for an additional five months. The beneficiary may receive one face-to-face counseling visit every month for an additional six months (for a total of 12 months of counseling) if he or she has achieved a weight reduction of at least 6.6 pounds (or 3 kilograms) during the first six months of counseling.

“This decision is an important step in aligning Medicare’s portfolio of preventive services with evidence and addressing risk factors for disease,” said Dr Patrick Conway, CMS Chief Medical Officer and Director of the Agency’s Office of Clinical Standards and Quality. “We at CMS are carefully and systematically reviewing the best available medical evidence to identify those preventive services that can keep Medicare beneficiaries as healthy as possible for as long as possible.” 

STOP

According to the STOP Obesity Alliance, the overall costs of being overweight over a five-year period are $24,395 for an obese woman and $13,230 for an obese man. Thirty-four percent of U.S. adults are obese, according to the alliance, which expects that percentage to rise to 50% by 2030.

“As small of a weight loss as 5% to 7% can lead to a huge health improvement,” said Christy Ferguson, director of the STOP Obesity Alliance.

“This is good news for the millions of Americans who struggle with obesity and its serious consequences and for their doctors who care for them,” said Gary Foster, director of the Center for Obesity Research and Education at Temple University in Philadelphia.

Although the rule change means that, technically, Medicare beneficiaries should immediately be able to start receiving the services without having to make a copayment, in the absence of billing or coding guidelines, it may prove difficult for physicians to provide or even refer patients for a particular service, Hughes said.

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