“The scientific evidence is overwhelming. Obesity is a disease.”
ages physicians to broach the subject of payment for medical interventions for obese patients now. “The health plans are starting to have internal conversations about this, so I’m hoping the more physicians ask ques- tions, the more likely we’ll see positive change. I talk to the health plans about reimbursement for outpatient care for obese patients whenever I can,” he said. As a pediatrician practicing in the
trenches, Texas Pediatric Society (TPS) President Kimberly Avila Edwards, MD, has always considered obesity a disease and is “super excited” about the AMA’s determination.
She says insurance coverage barriers
AMA President Ardis D. Hoven, MD, said the delegates considered all the in- formation presented to them, “including the council report and testimony pre- sented by various physicians, state, and specialty societies. The council supports the view that the most important task moving forward is for the nation to do a better job of addressing the obesity epi- demic.” She said recognizing obesity as a disease will help change the way the medical community tackles the obesity epidemic and will heighten the impor- tance of developing new approaches to prevent and manage obesity.
Payment barriers Stephen Pont, MD, medical director of the Texas Center for the Prevention and Treatment of Childhood Obesity in Aus- tin, says the majority of private insur- ance plans in Texas, as well as Medicaid, generally don’t pay for treatment related to obesity. He adds Medicaid may pay
for obesity counseling when it’s part of a patient’s annual exam. “I don’t know of any private health plans in Texas that recognize obesity as a reason to go to the doctor. It’s one of the most common diseases affecting adults and children, but the plans don’t recognize the need to pay for medical in- tervention until the patient is suffering a condition resulting from obesity,” said Dr. Pont, a member of the TMA Committee on Child and Adolescent Health. Dr. Pont says he hopes the classifica- tion of obesity as a disease will eventu- ally prompt Medicaid and private health plans to pay physicians for treatment related to the disease. “I think health plans exclude outpa- tient care for obesity as a covered service because they fear it might cost money in the short term. But in the long term, these overweight and obese patients are developing health complications that are costly to treat,” Dr. Pont said.
Last year, Medi- Russell Kridel, MD Stephen Pont, MD 46 TEXAS MEDICINE January 2014
Kimberly Avila Edwards, MD
care began reim- bursing physicians for administering in-person behav- ioral counseling to obese patients. (Read “Federal Fat Fighters,” May 2012 Texas Medi- cine, pages 55–58.) Dr. Pont encour-
restrict her ability to effectively care for obese patients. For example, she exam- ined a 12-year-old patient who had an elevated liver function test and high cho- lesterol. She listed both as the primary diagnoses along with obesity and sub- mitted the claim to the insurance com- pany. The child’s parents got stuck with an expensive lab bill. “Obesity often gets carved out by in- surance companies, and they’ll use it as the basis to deny payment and coverage. I think the AMA’s recognition of obesity as a disease will eventually lead to im- proved insurance coverage for patients and payment for physicians. And it will allow physicians to intervene with obese patients earlier,” said Dr. Avila Edwards, a member of the TMA Council on Sci- ence and Public Health. At press time, no health insurer had indicated to TMA’s Payment Advocacy Department that AMA’s action would change their position on paying for obe- sity treatment.
Treatment resources Dr. Avila Edwards says finding time to address obesity in patients is difficult in the midst of an annual exam or immuni- zation visit. “Simply telling parents their children need to eat less and exercise more prob- ably won’t be effective. They need to be educated about specific actions and strategies that can improve their chil- dren’s health,” Dr. Avila Edwards said. As more physicians and health orga- nizations recognize obesity as a disease,
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