December 2000 • Volume 6 Number 12
Reimbursement remains an obstacle
BY SHERI PORTER
The murky waters of physician reimbursement for diagnosis and treatment of obesity cause frustration for family physicians, says Cynthia Romero, M.D., of Virginia Beach, Va.
"Despite the growing number of obese patients, reimbursement for office visits and treatment is still quite poor," says Romero, who submitted the "Obesity as a Disease" resolution to the 1998 AAFP Congress of Delegates on behalf of the new physicians' constituency.
The Congress adopted the resolution, prompting a September 1999 letter from the Academy to the Health Care Financing Administration. The letter pointed out that obesity is an established diagnosis within the International Classification of Diseases and questioned HFCA officials about the Medicare regulation, "Program payment may not be made for the treatment of obesity, no matter what form the treatment may take."
"We fail to understand the rationale for HCFA's refusal to pay for the treatment of obesity," said the AAFP.
More than a year later, the number of obese Americans continues to escalate -- and Medicare payment methods remain unchanged.
A primary diagnosis of morbid obesity will be reimbursed, says HFCA spokesperson David Clark. "It's the treatment of obesity that's not a covered service."
And therein lies the dilemma: What's the logic behind reimbursing physicians for diagnosing obesity but then tying their hands in the treatment phase?
Romero says insurance providers have been slow to realize the cost benefits of treating obesity. If a patient is obese, that's not only the primary problem, says Romero, but also an underlying problem that worsens other disease states. "There's a misperception that obesity is a 100 percent self-induced problem -- the insurance companies presumably don't want to reimburse for diagnoses that could be changed if the patient had self-motivation," she says.
The good news is that a few organizations are getting it right. One example: HealthPartners Central Minnesota Clinics in St. Cloud, Minn. Family physician A. Clinton MacKinney, M.D., M.S., is medical director for the not-for-profit health care system, which employs 500 physicians and owns both a hospital and an HMO insurance product. HealthPartners stresses preventive health measures, including proper weight maintenance. "We are compensated for obesity counseling time," says MacKinney, adding that physicians there must adhere to strict documentation rules.
MacKinney, a member of the AAFP Commission on Health Care Services, also sits on a HealthPartners committee that reviews new and promising obesity therapies. Weight-loss medications are not covered, says MacKinney, "but I'm not in favor of them anyway. I don't think that's a good place for us to spend our patients' resources when other interventions have demonstrated greater long-term success and safety."
Richard Coorsh, assistant vice president of communications at the Health Insurance Association of America, says his organization doesn't compile statistics on how its members reimburse physicians for obesity visits. But he suggests that in most cases, "there will be reimbursement for conditions associated with morbid obesity."
This "ring around the rosy" logic from insurers and HCFA frustrates Romero. "HCFA may say it's reimbursing, but I'm getting claims denied," she says. Sometimes physicians select another primary diagnosis -- a cold, hypertension, cardiovascular disease, sleep apnea -- relegating the patient's obesity to the second or third diagnosis on the chart.
The unintended consequence? Skewed statistics. The number of doctor visits for obesity are grossly underestimated, says Romero. Other physicians agree that underreporting of obesity will mean fewer research dollars down the line to help fight America's growing health problem.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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