The obesity epidemic

The United States has a weight problem. And physicians are being called on to adapt their practices to confront it.

According to the Centers for Disease Control and Prevention (CDC), in 2010, more than 78 million U.S. adults and about 12.5 million children and adolescents were obese. In fact, the United States has the highest rate of childhood obesity among 30 industrialized nations.

Obesity and its related health problems-type 2 diabetes, hypertension and heart disease, joint problems, sleep apnea, and cancer, just to name a few- represent an enormous cost to the healthcare system. Today, we spend roughly $150 billion a year on this disease. What’s more, a 2012 report by the Robert Wood Johnson Foundation, “F as in Fat, How Obesity Threatens America’s Future,” found that obesity-related healthcare costs could increase by more than 10% in 34 states and by more than 20% in nine states over the next 20 years.

Overweight and obese patients present additional complexity to the medical problems physicians face on a daily basis in their practices, as well as the costs associated with treating them.

UNPREPARED FOR CHALLENGES

No easy answer exists when it comes to helping patients manage their weight.

“Obesity is a much harder condition to treat than almost anything else,” says Charles Cutler, MD, FACP, a practicing internist and member of the American College of Physicians (ACP) Board of Regents. “There isn’t a...simple solution as there is with other common conditions we address in the primary care setting,” he says.

Adding to the challenges associated with treating obesity is the environment in which most independent doctors find themselves practicing today. A 15-minute office visit hardly leaves enough time for the range of medical issues with which patients present. What’s more, physicians rarely have the training to effectively manage obese patients, given the underlying diet, exercise, cultural, and psychological issues that often need to be addressed to make significant headway.

“The biggest barrier is that none of this is taught in medical school,” says Yvette Rooks, MD, executive vice chairwoman and residency director of the Department of Family and Community Medicine at University of Maryland School of Medicine. Rooks is also chairwoman of the American Academy of Family Physicians’ Americans in Motion – Healthy Interventions (AIM–HI) advisory board.

Given the growing population of people in this country who are overweight or obese, however, you will need to find ways of modifying your practice to effectively address these issues going forward if you are to keep patients healthy and maintain a successful practice, experts say.

TAKE THE LONG VIEW

As challenging as it is to consider altering the infrastructure of a medical practice, putting systems in place to help patients manage their weight is critical, particularly in light of the changing healthcare landscape, says Tarek Elsawy, MD, chief medical officer of Cleveland Clinic Quality Alliance and Cleveland Clinic Physician Community Partnership.  

“The model of care is changing so dramatically, from fee-for-service to more accountable care or population health management,” Elsawy says. “A typical internal medicine physician panel today is between 2,200 and 2,500 patients; in the future, your panel may grow to 5,000 or 6,000 patients, so it behooves you to pay attention to population management,” he says.

In addition, payment models are changing, requiring doctors increasingly to assume more financial risk. The emphasis on keeping patients healthy will be greater than ever.

For that reason, Elsawy says, it pays to think about your population years down the road. For example, a patient with a body mass index (BMI) of 30 today may well end up with a BMI of 38 a few years from now.

“At that time, the issues become much more complicated, and the patient will demand a lot more resources,” he says.

According to the CDC, the annual medical costs for people who are obese are at least $1,400 higher than those of people of normal weight. “The goal, then, should be to have a longitudinal view of your practice to address those issues with every patient,” Elsawy says.

What’s more, says Shikha Anand, MD, obesity program director with the National Initiative for Children’s Healthcare Quality, “as quality comes into sharper focus as part of the Affordable Care Act (ACA), there are increasing expectations that physicians review [BMI] and then provide counseling for healthy behaviors. These are expected to be a part of primary care.”

This is where electronic health record (EHR) systems can be used to track patients for whom weight is an issue and for physicians to take action to curb its effects. As an example, Elsawy points to the Cleveland Clinic’s having added BMI measurements as a component of patient visits and one of the metrics it monitors via its EHR system. A trigger is created in the system that allows doctors to refer patients to other experts.

“One thing we’re trying to do in leveraging an EHR is to make sure that when people’s BMIs are over 30 and over 35 and over 40 that different things are triggered that would allow physicians to easily get them into the appropriate setting, whether it’s dietary intervention, diet and exercise, certain support groups for patients and, at the extreme end, whether they need to see someone in bariatric medicine or bariatric surgery,” he says.

GET YOUR STAFF INVOLVED

Family physicians and their office staffs are in a unique position to affect change in the lives of their patients by promoting and modeling healthful eating and exercise habits. So when looking to modify a practice in a way that more aggressively addresses obesity, it pays to first look in-house.

“The message is, use the team you’ve got,” Anand says.

Rooks’ work and the AAFP’s AIM – HI program strongly focus efforts on affecting obesity levels by changing the behavior of office staff members so they become role models for patients and send a message about healthy behaviors even before the doctor gets into the exam room.

“We need to see model behavior and empower staff to be part of the education for the patient,” Rooks says.

And the changes don’t have to be major to be impactful.

“There are small targeted strategies that can be used for employees and can impact communities by modeling great behavior,” according to Anand. She says it’s important to consider, for example, what message it sends to your patients if the person who greets them at the front desk is drinking a large, 800-calorie coffee drink.

Beyond modeling, the time constraints doctors face make it necessary to involve the rest of the staff involved in obesity screenings and counseling. Most PCPs today are likely to find it impossible to tackle both the acute medical need that brought a patient in to the office and the preventive issues in the time available.

“Do we continue to chase our tails…or do we do different things to make our office ready to combat some of these preventive things, namely obesity?” Rooks says.

As part of her office makeover, Rooks has reading materials available to patients while they sit in the waiting room. Also while they wait, she’ll have one of her staff members distribute a food diary that she’ll then review with the patient during the visit.

“So a lot of the work between the team is done before the physician enters the room,” she says.

In addition, research suggests that physicians often avoid the topic of weight for a host of reasons, not least of which is that plenty of doctors struggle with their own weight, making it more difficult to sell their patients on a lifestyle filled with healthier eating habits and more exercise. And then there’s the stigma associated with obesity, Anand says.

“In many communities, when you tell a family a child is obese, it’s seen as an insult, not a medical diagnosis,” she says. 

Here again, other members of your team may be able to help.

“For the providers really uncomfortable having those conversations, there might be others on their team who are more skilled and who have a different approach to patients,” Anand says. Those with a closer cultural or ethnic match to patients, for example, may have more success, given the highly cultural nature of eating habits.

BUILD YOUR REFERRAL SYSTEM

To effectively address the needs of patients who are overweight and/or obese, it’s critical for a practice to look beyond its own walls and connect with other professionals within the community who are trained to address the many and complex needs of patients in this population.

That means learning about and tapping into resources within your community to develop a referral list to registered dietitians, health educators, community centers providing physical activity, personal trainers, wellness centers, walking groups, psychologists and, for extreme cases, bariatric clinics, among other professionals. And it means keeping abreast of existing and expected therapies that might be appropriate for your patients.

NO NEED TO RE-CREATE THE WHEEL

The good news for physicians is that plenty of obesity resources and programs already exist and can be used as a model to modify their own office infrastructure.

The AAFP offers a practice manual that outlines its AIM – HI programs and how adjustments can be made to better address obesity within a medical practice. It includes recommendations for modifying office procedures so that clinicians and other staff members can have an effect by incorporating a fitness inventory into screenings, adding BMI and waist circumference to routine vital sign measurements, prompts to remind clinicians to address fitness with patients, weight management DVDs playing in the reception area, and making patient educational materials available in the waiting room.

The ACP has developed patient communication materials that address diet and exercise and can be made available in physician offices as well. All of its materials are available online.

And the National Initiative for Children’s Healthcare Quality offers a range of resources and tools on its Web site to provide guidance in implementing strategies for tackling obesity.

(See “Resources for your practice or patients” for links to these materials online.)

What difference do these practice modifications make? As one example, the AAFP National Research Network and the AAFP AIM – HI program evaluated the effect of its strategies and educational tools in 21 medical practices. It found that healthful eating behaviors increased and unhealthful eating decreased. Physical activity among patients increased as well. In all, these changes led to nearly 12% of patients losing 10 or more pounds within 4 months and almost 18% losing the same amount after 10 months’ time. 

GETTING PAID TO ADDRESS OBESITY

Getting a handle on obesity can help stave off costs to the larger healthcare system in the long term, experts say. But more immediate financial benefits are available to physicians as well.

According to Anand, the current payment system in states where obesity is a reimbursable diagnostic code includes an algorithm based on national expert guidelines associated with treating obese children.

“The expectation is that they be seen monthly for plan visits. So from a financial standpoint, even though those visits are potentially longer than, say, a visit for a cold, you’re having monthly visits with a fairly large population, so they should actually be good for business,” she says.

In addition, Cutler points out that as a part of the ACA, new private health plans and Medicare cover the cost of preventive services without patients having to pay a co-pay or co-insurance or meet a deductible at the time of the visit. Included in the list of covered preventive services is diet counseling for adults at risk of chronic illness, as well as obesity counseling. And screenings for illnesses that often travel with excess body weight, such as those for blood pressure, cholesterol, and type 2 diabetes, are paid for as well.

Prevention, Elsawy says, is something all doctors want to focus on. Anything you can do to keep your patients healthy is good for your bottom line, he says

“Good medicine and good business go hand in hand,” he says.

Resources for your practice or patients
 

To access the materials mentioned in this article,visit the following Web sites.

American Academy of Family Physicians Americans in Motion – Healthy Interventions:
www.aafp.org/online/en/home/clinical/publichealth/aim.html

American College of Physicians
patient communication materials about obesity:
www.acponline.org/patients_families/diseases_conditions/obesity/

National Initiative for Children’s Healthcare Quality obesity-related materials:
www.nichq.org/our_projects/obesity_projects.html

Even in states where obesity is not reimbursable, often its co-morbidities, such as joint pain, high blood pressure and cholesterol, and sleep apnea, among others, are reimbursable.

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