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Written by December 9, 2011

Gina Cortese-Shipley, MS

Associate Director of Education
The Cooper Institute

Medicare to cover obesity screening and counseling

On November 29 (2011) the Centers for Medicare and Medicaid Services (CMS) announced their decision to cover obesity screening and counseling as a preventive service under Medicare, free to beneficiaries. Despite the consensus on need for these services, there is controversy over the details.

CMS will cover screening and intensive behavioral counseling for obesity by primary care providers in settings such as physicians' offices, for Medicare beneficiaries with a body mass index (BMI) greater or equal to 30. Specifically, Medicare will cover:

  • 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 has achieved a reduction in weight of at least 3 kg (6.6 lbs) over the course of the first 6 months of intensive therapy.

So what's the controversy? Several issues have been raised:

  1. The service must be furnished by a "qualified primary care physician or other primary care practitioner." CMS's definition of a "qualified primary care physician" is a physician who is a general practitioner, family practitioner, general internist or ob/gyn. A "primary care practitioner" is defined as a physician with a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine or a nurse practitioner, clinical nurse specialist, or physician assistant. The problem with this is that many physicians (and nurses) have no training in weight loss counseling like assessing diet and cognitive/behavioral skill building. Likewise, they can't spend much time with each patient. Thus, many argue that physicians and nurses should assist with the assessment and motivation of patients, but registered dietitians or other trained health professional should provide the counseling for lifestyle change.
  2. More cost-effective weight management programs like evidence-based telephone- and internet-based programs are not included.
  3. The 1-year limit of counseling ignores that fact that obesity is a chronic condition and that needs lifelong follow up. Many people will relapse and need additional services.
  4. Patients who don't lose 6.6 pounds at the 6th month mark are no longer eligible for additional counseling. What if the patient wasn't "ready to change" during that time period but something in his/her life has now made him/her ready to make lifestyle changes and lose weight?

While most agree that this is a step in the right direction, many hope that changes are made before private insurers follow Medicare's lead. It will also be interesting to see how much Medicare will pay for obesity counseling, as it is in the process of establishing payment codes.

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