The first national health insurance coverage for obesity management took effect in November 2011, when the Centers for Medicare and Medicaid Services (CMS) began covering intensive behavioral therapy.1 The CMS decision noted that sufficient evidence supports intensive behavioral therapy as reasonable and necessary for prevention and early detection of illness or disability. Coverage is available for patients who receive Part A benefits or are enrolled under Part B.1 This benefit complements the US Preventive Services Task Force (USPSTF) earlier recommendations on obesity screening and management in adults.2
CMS designated the primary care setting as the point of care for obesity management because primary care providers have an ongoing relationship with patients and familiarity, and have broad understanding of their medical and social circumstances. The literature reveals physician counseling is a strong predictor of weight management efforts by patients.3
To implement the USPSTF recommendations, coverage is provided for:
* one face-to-face visit every week for the first month
* one face-to-face visit every other week for months 2 through 6
* one face-to-face visit every month for months 7 through 12 if the patient has lost 3 kg (6.6 lb) during the first 6 months.1
CMS notes that this initiative does not preclude referral to specialized personnel such as registered dietitians, exercise physiologists, or behavioral therapists. However, reimbursement is limited to primary care providers, defined as physicians, physician assistants (PAs), nurse practitioners (NPs), and certified clinical nurse specialists practicing in the primary care setting. Registered dietitian consultation is covered under a separate CMS provision for the diagnoses of diabetes and renal disease, but the provision does not cover weight management. The services of registered dietitians and other specialized providers may be billed “incident to” if the service is provided within the primary care clinic.1
EFFICACY OF INTENSIVE BEHAVIORAL THERAPY
Despite the rising prevalence of obesity and its association with chronic disease, CMS did not formally identify obesity as a disease until 2004. A 2008 review of state Medicaid manuals revealed that only 8 states covered all three distinct weight management interventions (nutrition counseling, pharmacotherapy, and bariatric surgery); all states covered at least one weight management option (most frequently bariatric surgery); and 26 states covered nutrition counseling.4 National CMS coverage for designated bariatric surgery was instituted in 2006.1 Nutrition counseling, customarily provided by registered dietitians with training in behavior management (for example, motivational interviewing and self-monitoring), includes aspects of intensive behavioral therapy. However, the 2011 CMS decision emphasizes the emerging role of the primary care provider in implementing intensive behavioral therapy for weight management. Although the new CMS rule is an important first step, national comprehensive CMS coverage for other components of obesity management and services provided by trained specialty providers has not been universally achieved.
Multicomponent behavioral interventions for obesity management have historically met with modest success. Key findings of a recent systematic evidence-based review revealed that a 3 kg or greater weight loss over 12 to 18 months could be achieved with behavioral weight management instituted in the primary care setting. Frequency of visits appeared to be important to patient success.3 The CMS initiative is further supported by increasing evidence that even modest weight loss is clinically beneficial and leads to improved glucose tolerance and reductions in physiologic risk factors of cardiovascular disease, hospitalizations, and mortality.2 However, further study is needed about implementing intensive behavioral therapy for obesity management in the primary care setting and evaluating its efficacy in CMS beneficiaries, who face many challenges and barriers to success.
PRIMARY CARE STRATEGIES
The components of intensive behavioral therapy are:
* screening for obesity in adults using BMI (with obesity defined as a BMI of 30 kg/m2 or greater)
* dietary (nutrition) assessment
* intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high-intensity interventions on diet and exercise.1
Also assess for obesity-related risk factors such as a waist circumference greater than 35 inches in women or 40 inches in men; cardiovascular risk factors such as hypertension, diabetes, and dyslipidemia; and obesity-related diseases such as obstructive sleep apnea, nonalcoholic fatty liver disease, incontinence, osteoarthritis, and polycystic ovarian syndrome.5 When taking the patient's weight loss history, ask about patterns of weight gain, including history of childhood and adolescent obesity, weight gain during pregnancy, and lowest and highest adult weight; previous weight loss attempts; motivation; and patient perceptions of the causes of weight gain.
The second step, dietary (nutrition) assessment, can be achieved using a 24-hour recall, usual intake, or food record. These methods can yield information about the patient's portion size; meal patterns; food preparation methods; consumption of high-fat foods, condiments, and beverages; emotional triggers; and food insecurity. The food record, typically completed by the patient over 3 to 7 days, offers the advantage of freeing office time for counseling. Completing this step can help patients and primary care providers identify problem behaviors and barriers so together they can target specific and effective behavioral interventions.
The current CMS guidelines use the 5 A's framework (assess, advise, agree, assist, and arrange) for implementing and documenting intensive behavioral therapy, but do not address specific aspects of weight management. Table 1 summarizes specific strategies for weight management and guidelines for documentation under the 5A's framework.1,5–7
Although no single approach to weight management is universally accepted, several evidence-based strategies can be used in the primary care setting. The Plate Model, originally designed for diabetes management in Europe, has replaced the food pyramid and offers specific guidelines for weight management. Multiple resources are available online (http://www.choosemyplate.gov) from a simple visual to more detailed written patient education materials targeting weight loss. Additional patient education materials and a food record template are available through the Veteran Administration's MOVE! Weight Management Program (http://www.move.va.gov). Both sites provide nutrition and exercise guidance as well as patient education materials targeting common problem areas.
Five key target areas for office-based implementation of evidence-based intensive behavioral therapy are detailed in Table 2. A good patient history lets primary care providers individualize patient care, focus on high–effect interventions, best use limited office time, and maximize patient outcomes.
OVERCOMING COMMON BARRIERS
In spite of the known risks of obesity and the health benefits of modest weight loss, obesity screening, diagnosis, and management does not appear to be routine practice in primary care, with fewer than 50% of primary care providers making the diagnosis of obesity and only half of those initiating treatment.8 Barriers to diagnosis and intervention include lack of reimbursement, time constraints, providers' lack of confidence and competence, and the recognition that many providers harbor unconscious bias toward obese patients.5 The CMS reimbursement and guidance within the 5 A's framework provides a strategy to overcome many of these barriers.
Although the basic principles of weight management are simple (eat less and exercise more), primary care providers should realize that this may be very difficult for most patients. Many CMS beneficiaries face social barriers (including poverty, limited education, and homelessness), food insecurity, lack of transportation, and limited access to fresh foods. Assessing motivation through application of the “Stages of Change” is important to navigate the transition from the “advise” to “agree” taxonomies of the 5 A's framework.9 One caveat of the 2011 CMS provisions is that beneficiaries who fail to lose at least 3 kg in the first 6 months are required to wait 6 months before coverage is reinstituted for intensive behavioral therapy.2
The time constraints of primary care make it difficult to fully employ motivational interviewing to move patients toward a mutually agreeable plan of care. However, counseling techniques consistent with the principles of motivational interviewing (specifically empathy and supporting self-efficacy) have been shown to improve patients' weight-related attitudes and behaviors.10 Assisting the patient in setting one to three specific, achievable goals can promote gradual sustained weight loss. Small steps, if consistently applied, can make big differences. For example, reducing dietary intake by 100 calories per day can lead to a 10-lb weight loss in a year; patients who also increase energy expenditure by 100 calories per day can shed 20 lb in a year. Smaller-scale, less-complex strategies are easier for patients to maintain, and can result in clinically significant weight loss over time.6
3. Leblanc ES, O'Connor E, Whitlock EP, et al. 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
4. Lee JS, Sheer JL, Lopez N, Rosenbaum S. Coverage of obesity treatment: a state-by-state analysis of Medicaid and state insurance laws. Public Health Rep
5. Schlair S, Moore S, McMacken M, Jay M. How to deliver high quality obesity counseling in primary care using the 5 A's framework. J Clin Outcomes Manage
6. Rutledge T, Groesz LM, Linke SE, et al. Behavioural weight management for the primary careprovider. Obes Rev
7. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician
8. Smith AW, Borowski LA, Liu B, et al. U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients. Am J Prev Med
9. Prochaska JO. Decision making in the transtheoretical model of behavior change. Med Decis Making
10. Cox ME, Yancy WS, Coffman CJ, et al. Effects of counseling techniques on patients' weight-related attitudes and behaviors in a primary care clinic. Patient Educ Couns
© 2014 American Academy of Physician Assistants.