Monday, April 26, 2010

Dietary Counseling for Obesity As A Covered Benefit In Medicare: Is It A Good Idea?

In its past lives, it wasn't unusual for a C-Suite type to ask the Disease Management Care Blog to take a look at the outcomes of a care management and/or clinical and/or disease management and/or quality improvement program. The typical intent was to get the DMCB to prove that the initiative really worked as advertised, get the results published in a peer reviewed journal and help garner some marketing mojo.

Alas, the DMCB quickly learned these types of post hoc analyses are not only beset by numerous data flaws, they can also fail to show the program really worked. While the initial C-Suite response to the DMCB's pessimism was to find a more cooperative geek, what typically followed were instructions to adjust the program and then find the necessary proof to get it published.

Which is why the DMCB has some sympathy for whoever is going to be running the Center for Medicare and Medicaid Innovation. Even with the impressive name and all the zeros in its budget, one unspoken purpose of the CMMI may turn out to be eerily similar to what the DMCB went through. Policymakers, politicians and bureaucrats may assume that the CMMI exists to do the research that can justify covering something we already assume works.

Case in point? Ask the average health care provider, policymaker, regulator, politician or person if Medicare should cover dietary counseling for weight loss among obese persons, the answer will probably be a resounding yes. When confronted by the lack of any research showing that weight loss services actually work, the same average health care provider, policymaker, regulator, politician and person will respond that better research is needed. Once that's over with, we can get Medicare to cover it.....right?

Unfortunately, when it comes to dietary counseling and weight loss, more research may never get the answer we want. Check out this recently published review of every study ever published involving weight loss interventions for persons over age 60 years. A total of nine good studies were found mostly involving community dwelling overweight and obese elders with a chronic condition such as diabetes or arthritis. While there were methodologic problems involving blinding, intention-to-treat analyses and handling the drop outs, the studies were generally performed well and were also disappointing: the average weight loss amounted to a measly six to seven lbs. What's more, no significant improvements were detected in cardiovascular risk factors, exercise capacity or quality of life. The authors indicate that the lack of high quality studies doesn't preclude the possibility that dietary advice may work. The DMCB thinks they're being overly generous.

This is a useful review because it focuses on the Medicare-eligible population. The DMCB also suspects that it's likely that additional research - even if it's done by CMMI as part of a broader study of wellness, prevention and primary care - will simply replicate the outcome of modest weight loss that doesn't appear to translate into meaningful reductions in risk.

One last thought: dietary counseling in Medicare as well as younger populations is probably necessary but insufficient to lead to significant and meaningful weight loss. It's greatest potential is when it's combined with other interventions in the context of disease management or the patient centered medical home. Stay tuned.

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