Medical circles digest the upshot of obesity classification

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Obesity: It's not a failure of willpower anymore.

The American Medical Association's decision Tuesday to officially label obesity as a disease at its annual meeting in Chicago is raising hopes among dieticians, bariatric surgeons and internists prescribing weight loss drugs that more of their services will be covered by health insurance.

"Take the stigma away so insurers will pay!" said Leslie Bonci, director of sports nutrition at the University of Pittsburgh Medical Center, in an email after the AMA's vote was announced.

But local insurers reacted more cautiously. "I think the standards are not going to change for right now," said Dr. Carey Vinson, Vice President of Quality and Medical Performance Management at Highmark.

A pronouncement by the AMA, he said, isn't going to affect coverage decisions -- allowing weight loss surgery for those who are on the lower end of the obesity scale, for example -- but conclusive medical research, gathered and disseminated over time, will.

"I think it's a little early," added Dr. Stephen Perkins, Senior Medical Director for UPMC Health Plan. The AMA's statement, taken in context, was aimed at increasing awareness in physicians about obesity's risks to the overall health of the patient, "but the AMA making a statement doesn't automatically change our benefit structure."

Moreover, "If you took a poll of doctors in Western Pennsylvania about the AMA's pronouncement, you would not get 100 percent agreement" that obesity is a disease. The mind-set that obesity still is about weakness and self-indulgence was also commonly reflected in comments on the Internet Wednesday.

"Being fat is a disease? So is being lazy a disease? Is making poor eating habits and choices a disease? Anyone that says they can't lose weight is full of it," said a poster dubbed WHATNOW44 on the CBS News website.

"ENOUGH with your EXCUSES!," said NATHAN36 on the Los Angeles Times website. "Moderation of junk food and physical activity with a smart and healthy diet isn't that hard of a concept to grasp."

Indeed, within the AMA, there was opposition to labeling obesity a disease. In a report, the organization's Council on Science and Public Health said "obesity results from personal choices to overeat or live a sedentary lifestyle."

If only it were that simple, said Daniel Gagne, a bariatric surgeon at West Penn Allegheny Health Care System.

"The whole notion that anyone who is overweight is just being lazy and overeating is not true," said Dr. Gagne, noting that he'd seen a patient Wednesday morning who weighed 400 pounds "and who eats all the right food. Some people are cursed with bad metabolism, they try to lose weight and it's very frustrating. It's a misconception that it's just about willpower."

Currently, obesity in adults is defined as having a body mass index, or BMI, of 30 or higher, a figure that is calculated by measuring body fat based on height and weight. Most insurers won't cover bariatric surgery, however, unless a patient has a BMI of 40, or 35 if other conditions, such as sleep apnea or diabetes, are present.

While a majority of state governments and private businesses include the surgery in their health plans, Pennsylvania is one of six states, along with Idaho, Kansas, Louisiana, Oklahoma and Montana, that don't offer it as a benefit to their government employees.

There are currently two weight loss drugs, both appetite suppressants, that insurers will cover. Qsymia, which promotes a loss of between 5-10 percent in excess body weight, has been on the market for about a year. Belviq, which is less effective -- losses of between 3 and 5 percent of excess body weight are reported -- hit pharmacies two weeks ago.

"They're to help you get started on a weight loss program, but we don't recommend taking them in isolation," said Marc Itskowitz, a primary care physician on the North Side whose practice mostly deals with problems caused by obesity. Some insurers, he noted, require a pre-authorization, a form completed by the doctor specifying the criteria for the medication.

But patients have found that the process for obtaining Qsymia -- which is only available through a 90-day mail order service -- too cumbersome, he added.

Then there's diet and nutrition counseling, which has often been categorized as a "lifestyle" benefit and isn't often covered by private insurers.

UPMC Health Plan provides weight loss management programs and counseling to every member, Dr. Perkins said, based on medical necessity -- although in an email, Ms. Bonci, a dietician, said "reimbursement has been an issue" when seeing patients at the UPMC Center for Sports Medicine.

"In previous dialogues the answer I have received is that diabetes and renal disease are the only diseases for which nutrition counseling is covered, but if that has changed I am delighted!"

Other changes in thinking about and paying for treatment for obesity may come soon, but not just because but the AMA has declared one third of all Americans -- the number estimated to be obese -- are sick, said Highmark's Dr. Vinson.

Rather, insurers make decisions based on a critical mass of studies indicating the need for a change in policy, he said. "I think over time, with more research and agreement as to what the parameters are" that define obesity, there will be adjustments, Dr. Vinson said, "but right now, based on what the AMA said, there will not be much change."

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Mackenzie Carpenter: mcarpenter@post-gazette.com or 412-263-1949.


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