Lifestyle Disease Prevention: Obesity

An Ounce of Prevention
Hospitals try to stem the tide of obesity with disease management and prevention programs.

Contracting executives need not read the newspaper or watch the news to realize that obesity is an epidemic. (See “The Obesity Epidemic” in the January/February 2005 issue of The Journal of Healthcare Contracting.) Most can gauge the extent of the problem simply by reviewing purchase orders from the past year or two.

They’re likely to find POs for oversized wheelchairs, scales, stretchers, beds and commodes, as well as ceiling-mounted and mobile lifting devices. Contracting professionals in integrated delivery networks with bariatric surgery programs may be contracting for devices peculiar to those procedures, such as extra-long laparoscopic instruments.

“If 30 percent of the adult population is obese, and they face a higher incidence of comorbidities, it’s just a matter of time before you see that 450-pound individual in your hospital,” says Leona Brandwene, director of coaching for clinical performance for Irving, Texas-based VHA.
Meanwhile, group purchasing organizations are helping members by creating portfolios of bariatric products and services.

A different approach
But as hospitals improve the ability to accommodate and treat obese patients, many are simultaneously pursuing different tracks, that is, helping obese people in their communities (and those working in their facilities) lose weight non-surgically, and helping overweight people avoid becoming obese.

The National Institutes of Health (NIH) defines obesity and overweight using a body mass index (BMI), which is a calculation of a person’s weight in kilograms divided by the square of his height in meters. An overweight adult is defined as one with a BMI between 25 and 29.9, while an obese adult has a BMI of 30 or higher. In children and adolescents, overweight is defined as a sex- and age-specific BMI at or above the 95th percentile.

Organizations such as the Centers for Disease Control and Prevention (CDC) and the Office of the Surgeon General have issued strong calls for community programs that encourage physical activity and sensible eating, and with good reason.

In 2001, the CDC’s Task Force on Community Preventive Services reported that physical inactivity and dietary patterns are second only to tobacco use as the leading causes of preventable death in the United States, and are leading contributors to morbidity and disability.

Overweight and obese individuals are at increased risk of illness from hypertension, lipid disorders, Type II diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems and certain cancers, according to the National Heart, Lung and Blood Institute of the National Institutes of Health. The total costs attributable to obesity-related disease are said to exceed $100 billion annually.

The risk of death, although modest until a BMI of 30 is reached, increases with an increasing BMI. Obese adults have a 50 percent to 100 percent increased risk of premature death, compared to adults with a BMI of 20 to 25. But even moderate weight excess of 10 to 20 pounds for a person of average height increases the risk of death, particularly among adults aged 30 to 64 years, according to the NIH.

“There is much that communities can and should do to address these problems,” said former U.S. Surgeon General David Satcher in December 2001, when his office released a report entitled “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.”

Even so, the CDC has acknowledged the difficulty of measuring the effectiveness of such programs in increasing physical activity and improving health outcomes. It also has raised questions about how healthcare providers can measure the long-term impact of such programs, about the effectiveness of such programs on various sociodemographic subgroups (e.g., those based on age, gender, race, ethnicity), and about the cost effectiveness of community-based programs.

Hospitals respond
Nevertheless, many hospitals are moving forward with obesity prevention and management programs.

“VHA hospitals consider obesity prevention a core mission of theirs is to act as stewards of the health of their communities,” says Brandwene. “So, not only are they in the business of taking care of sick patients, but also of making sure that community members don’t get sick and preventing the occurrence of diseases that can land them in the hospital.”

Two years ago, in response to members’ pleas for help in addressing the growing obesity epidemic, VHA did what it does best: It served as a conduit for members to share their experiences with others. “Our hospitals were looking for help and support in doing prevention work in their communities and stemming the tide (of obesity),” says Brandwene.

So, VHA sent out a call to participants in its Community Health Improvement Leaders program asking them to share what they were doing about obesity in their communities and workplaces. Each was provided a template with which to describe their programs, including such information as the name of the program, a description of it, sources of funding, resources needed and results. The material was assembled into a booklet and disseminated to VHA’s membership.

“One of the most powerful ways our members can learn is from each other,” says Brandwene. “That’s the premise behind VHA’s role as the facilitator of information sharing among our organizations.”

VHA’s Health Improvement Leaders program has metamorphosed into an electronic forum called resources in Community Health. VHA sponsors a listserv, on which members can share and request information about the programs. It also has created a Community Health section in an online library from which members can retrieve and share documents and program ideas. In addition, the VHA Health Foundation has created a “program in a box” for the prevention of Type II diabetes and obesity among middle-school children. Members are free to download the materials and implement them in their communities.

Community programs vs. surgery
Nobody claims that changing one’s lifestyle is easy. “When it comes to obesity and health education, there are a lot of good ideas out there,” says Brandwene. “But there’s been a lot of information about smoking cessation, too, and 22 percent of adults still smoke.”

Measuring the effectiveness of community-based obesity management and prevention programs is difficult as well. “The community is a messy laboratory,” says Brandwene.

Yet insurers, providers and patients want answers, because the alternative, bariatric surgery, is an expensive and potentially traumatic option.

NIH says weight loss surgery may be appropriate for a limited number of patients with clinically severe obesity: BMIs of 40 or higher, or 35 or higher when accompanied by a co-morbid condition, such as heart disease or diabetes. Surgery should be reserved for patients toward whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity, that is, who are 100 pounds heavier than their ideal weights, according to the agency.

The results can be dramatic. People who undergo weight loss surgery can lose 60 percent to 70 percent of their excess weights within 12 to 24 months after surgery, according to Baptist Health in Little Rock, Ark. Blood sugar levels and blood pressure often improve as well. However, like any surgery, weight loss procedures carry some side effects.

Complications such as pneumonia, blood clots and infection can occur, according to the Mayo Clinic. Rapid weight loss can result in fatigue, dry skin and temporary hair loss. A hernia or weakness, which may require surgery to correct, may develop at the site of the incision. What’s more, for the first six months after surgery, if the patient eats too much or too fast, he will experience nausea and other symptoms.

Finally, surgery for weight reduction can’t produce miracles. Patients can expect to lose weight and keep it off, but they must eat healthy foods and remain active. It’s a lifestyle change.

Reimbursement
Whether hospitals pursue weight loss surgery programs or community-based educational programs may ultimately depend on the amount of reimbursement for treating obese people. In that respect, the horizon is cloudy.

The federal government has wrestled with reimbursement for obesity treatment for years. But, recently, the Centers for Medicare and Medicaid Services removed language in its National Coverage Determinations Manual that stated that “obesity itself cannot be considered an illness.” Technically speaking, the change in policy still leaves treatment for obesity non-covered (if it is not accompanied by co-morbidities). However, it does leave wiggle room for providers, in that they can submit requests to CMS to determine if scientific and medical evidence demonstrates the effectiveness of obesity interventions in improving Medicare beneficiaries’ health outcomes. Presumably, if the answer were yes, such treatments would be covered.

However, just as Medicare moves in one direction, some private insurers are moving the opposite way. In Florida, for example, BlueCross BlueShield of Florida stopped covering obesity surgery, effective Jan. 1, 2005. The company’s decision to do so follows similar decisions by Cigna, United Healthcare and Humana in the same state.