Nov. 30, 2011 -- WASHINGTON -- Medicare will pick up the tab for obesity screening and intensive behavioral counseling, the Centers for Medicare and Medicaid announced late Tuesday.
CMS, which first floated the obesity coverage plan last September, said it expects more than 30 percent of the Medicare population to qualify for the new benefit.
Beneficiaries with body mass index values of 30 or more can receive weekly in-person intensive behavioral therapy visits for one month, followed by visits every two weeks for an additional five months, fully paid by Medicare with no copayment.
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Additional monthly sessions will be covered for up to six months afterward if the beneficiary has lost at least 6.6 pounds (3 kg) during the first six months.
The sessions should also include dietary counseling, the agency said.
Medicare patients who fail to lose the 6.6 pounds in six months may be reevaluated at the one-year mark after the initial screening. Those showing "readiness to change" and a BMI value still at 30 or more may receive another round of counseling paid by Medicare.
"It's important for Medicare patients to enjoy access to appropriate screening and preventive services," outgoing CMS administrator Dr. Donald Berwick said in a statement.
Counseling must take place in a primary care setting such as a physician's office. It will not be covered when provided in skilled nursing facilities, hospitals, emergency departments, outpatient surgery centers, or hospices.
A primary care setting is defined as "one in which there is provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community."
Peter Jacobson, a health policy professor at the University of Michigan in Ann Arbor, told MedPage Today and ABC News in an email that the decision is important in its own right, but will be even more significant if private insurers follow suit to cover such counseling.
But he took issue with the benefit's restriction to counseling provided only in primary care settings -- referrals to specialty practices or centers for counseling will not be covered by Medicare.
"Primary care is necessary but not sufficient to address the obesity epidemic," Jacobson said. "Without community-based services and referrals, the overall policy impact may not be as robust as would a policy linking medical care with public health."
A former president of the American Heart Association was also not 100 percent pleased with the new coverage.
Dr. Robert Eckel of the University of Colorado's medical school in Aurora, Colo., told MedPage Today in a phone interview that he was skeptical that the counseling to be provided would achieve major, lasting improvements in patients' health.
"The question is sustaining the benefit" of successful weight loss beyond the first year, he said. He said his initial reaction was that the coverage is "more money [paid out of Medicare] without proven benefit."
Another health policy expert, Robert Field of Drexel University in Philadelphia told MedPage Today and ABC News in an email that "if people are obese when they reach old age, they probably have a lifetime of bad habits that will be difficult to break."
Medicare to Cover Obesity Counseling
But both men said the move was positive on the whole. Eckel called it "a step in the right direction" that would "make me more capable as a clinician to deal with the [obesity] epidemic," and said he expected that the AHA would be very pleased with the decision.
Gail Wilensky, currently a senior fellow at Project HOPE and formerly a top adviser to Pres. Bill Clinton, said it would be "important and useful to set up a mechanism to evaluate the program in three to five years," modifying or killing it according to the results.
To qualify under the new benefit, counseling must be consistent with the "five A's" listed in a U.S. Preventive Services Task Force recommendation, according to CMS's decision memo:
Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
Agree: Collaboratively select appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior.
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.
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.
The agency had published the proposal to cover obesity screening and counseling under Medicare in early September, with a 90-day comment period to follow.
It based the decision on a review of studies and other evidence indicating that such counseling is effective in helping obese patients to lose significant weight, which in turn reduces risk of cardiovascular events and other adverse outcomes.