considerations for state obesity policy - women in … for state obesity policy scott kahan, md, mph...

Considerations for

State Obesity Policy

Scott Kahan, MD, MPH

Faculty, Johns Hopkins Bloomberg School of Public Health

Director, National Center for Weight & Wellness

Clinical Director, STOP Obesity Alliance,George Washington University School of Public Health/Health Services

Women In Government Annual Healthcare Summit – Washington, DC

November 13, 2014

[email protected]

Quiz

Which of the following results in significantly increased risk of morbidity (disease) and mortality (death)?

a. Diabetes (type 2)

b. Hypertension (chronic high blood pressure)

c. Heart disease

d. Obesity

e. All of the above

Quiz

Which of the following has significant genetic predispositions?



c. Heart disease

d. Obesity

e. All of the above

Quiz

Which of the following is governed by a complex system of biological factors (regulatory chemicals, hormones, etc)?



c. Heart disease

d. Obesity

e. All of the above

Quiz

Which of the following is associated with food intake and physical activity?



c. Heart disease

d. Obesity

e. All of the above

Quiz

Patients with which of the following are routinely regarded as lazy, irresponsible, and lacking self-control, and not given access to evidence-based treatments?



c. Heart disease

d. Obesity

e. All of the above

Clinical Obesity Prevalence, Adults, US

National Health and Nutrition Examination Survey, NCHS/CDC

Weight Gain is Normative

Severe Obesity Trends in Adults

Sturm R. Pub Health 2007;121:492-496.

Why Is It So Hard To Manage Weight?

Something Tells You to Breathe…

Because You’re Suffocating

Hypothalamic Appetite Regulation

Farooqi S. Cell Metab 2006;4:260-262

Valentino MA, et al. Clin Pharm & Therapeutics 2010; 87(6):652-62.

Endogenous Signaling of Appetite-regulating Hormones, Neuropeptides, and Neurotransmitters, and The Drugs That Target These Pathways

Why Is It So Hard To Manage Weight?

Hormone Changes and Hunger Persistently

Oppose Diet-Induced Weight Loss

Sumithran P, et al. NEJM 2011.

What Can We Learn From Successes In

Other Public Health Epidemics?

Armstrong GL et al, JAMA 1999.

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

Cig

are

tte

s p

er

Ye

ar

Initial studies

1st Surgeon

General Report

Broadcast

Ad Ban

Federal Cigarette

Tax Doubles

Nicotine

replacement

Medication

FDA approved

What Can We Learn From Successes In

Other Public Health Epidemics?

What Can We Learn From Successes In Other Public Health Epidemics?

• Education is necessary, but insufficient

• Prevention and environmental change is

necessary, but insufficient

• Affected patients need access to evidence-

based treatments

• Long term focus

• Multiple parallel approaches

CDC Framework for Addressing Obesity

Individual Factors

Behavioral Settings

Social Norms and Policies

� Home and family

� School

� Community

� Work Site

� Healthcare

� Genetics

� Psychosocial

� Knowledge

� Motivation

� Treatment

� Food and beverage

industry

� Agriculture

� Education

� Media

� Government

� Public health

systems

� Healthcare industry

� Business and

workers

� Land use and

transportation

� Leisure and

recreation

Sectors of Influence

CDC Prevention Recommendations

For Local Governments

http://www.cdc.gov/nccdphp/DNPAO/publications/index.html

Strategies to: • Promote availability of affordable

healthy food• Support healthy food and

beverage choices• Encourage breastfeeding• Encourage physical activity • Encourage communities to

organize for change• Create safe communities that

support physical activity

Chronic Disease State Policies

http://apps.nccd.cdc.gov/CDPHPPolicySearch/Default.aspx#

Treatment Works

Knowler WC, et al. NEJM 2002.

3234 adults with obesity and “pre-diabetes”

Placebo Metformin Lifestyle

Treatment Works

Ann Intern Med, 2012. NEJM 2013.

Treatment Works

Garvey WT, et al. Am J Clin Nutr. 2012;95(2):297-308.

3.7%

1.7%

0.9%

0

0.5

1

1.5

2

2.5

3

3.5

4

Placebo Phn/TPM 7.5 Phn/TPM 15

Pro

gre

sso

rs p

er

year

(%)

76%54%

Annualized Incidence of DM

Combining Treatments Works Even Better

Adapted from Wadden, et al. NEJM, 2005.

Placebo alone

Medication alone

Lifestyle modification alone

Combined therapy

Treatment Works

New England Journal of Medicine, 2007.

Treatment Works, Only If Used

0

20

40

60

80

100

% o

f e

lig

ible

pa

tie

nts

Samaranayake NR, et al. Ann Epidemiol 2012;22:349-53 and ASMBS.

Obesity Counseling in Medicare

Current CMS coverage in primary care settings:

• 1 face-to-face visit weekly for the first month

• 1 face-to-face visit biweekly for months 2-6

• 1 face-to-face visit monthly for months 7-12 (if 6.6 lb loss)

“Intensive behavioral therapy for obesity…is

reasonable and necessary for the prevention and early

detection of illness and disability and is appropriate for

individuals entitled to benefits [under Medicare].”

CMS. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). November 29, 2011.

Medicaid Coverage of Obesity TreatmentNutrition: 6 states cover all obesity-related nutrition

counseling codes; 22 states cover none

Medicaid Coverage of Obesity-Related Nutrition Counseling Services

RI

WA

MT

ID

OR

CA

NVUT

NMAZ

KS

TX

CO

IA

AROK

ND

SD

NE

LA

WYWI

IL

TN

MS

MO

MN

AL

KY

OH

MI

IN

NC

VA

SC

GA

WV

NY

PA

FL

NJ

DE

MD

CT

MA

NHVT ME

HI

AK

Covers all obesity-related nutritional consult services

Covers some obesity-related nutritional consult services

Covers no obesity-related nutritional consult services

Undetermined/No Data Available

DC

Source: CPT Code Search of Provider Fee Schedules

Note: Common Nutritional Consult Services are defined as CPT codes S9452, 97802-97804, S9470

Kahan et al, 2014 (submitted).

Medicaid Coverage of Obesity TreatmentDisease Management: 0 states cover all obesity-

related disease mgmt CPT codes; 30 states cover none

RI

WA

MT

ID

OR

CA

NVUT

NMAZ

KS

TX

CO

IA

AROK

ND

SD

NE

LA

WYWI

IL

TN

MS

MO

MN

AL

KY

OH

MI

IN

NC

VA

SC

GA

WV

NY

PA

FL

NJ

DE

MD

CT

MA

NHVT ME

HI

AK

Covers all obesity-related disease management and

education services

Covers some obesity-related disease management and

education services

Covers no obesity-related disease management and

education services


DC


Note: Common Disease Management and Education Services are defined as CPT codes

99078, S0315-S0316, S9445-S9446, 98960-98962

Medicaid Coverage of Obesity-Related Disease Management and Education Services


Medicaid Coverage of Obesity TreatmentBehavioral Counseling: 2 states cover all obesity-

related behavioral consult CPT codes; 23 states have

no coverage

RI

WA

MT

ID

OR

CA

NVUT

NMAZ

KS

TX

CO

IA

AROK

ND

SD

NE

LA

WYWI

IL

TN

MS

MO

MN

AL

KY

OH

MI

IN

NC

VA

SC

GA

WV

NY

PA

FL

NJ

DE

MD

CT

MA

NHVT ME

HI

AK

Covers all obesity-related behavioral consult and therapy

services

Covers some obesity-related behavioral consult and

therapy services

Covers no obesity-related behavioral consult and therapy

services


DC


Note: Common Behavioral Consult and Therapy Services are defined as CPT codes 96150-

96155, S9499, S9451

Medicaid Coverage of Obesity-Related Behavioral Consult and Therapy Services


Medicaid Coverage of Obesity Treatment

Medications: 12 states cover obesity medication,

generally with restrictions and prior authorization;

34 states explicitly exclude

Medicaid Coverage of Obesity Pharmacotherapy


Medicaid Coverage of Obesity Treatment Bariatric Surgery: 44 states cover bariatric surgery;

5 states explicitly exclude

RI

WA

MT

ID

OR

CA

NVUT

NMAZ

KS

TX

CO

IA

AROK

ND

SD

NE

LA

WYWI

IL

TN

MS

MO

MN

AL

KY

OH

MI

IN

NC

VA

SC

GA

WV

NY

PA

FL

NJ

DE

MD

CT

MA

NHVT ME

HI

AK

Covers bariatric surgery

Explicitly excludes bariatric surgery


DC

Source: State Medicaid Provider Manuals

Medicaid Coverage of Bariatric Surgery


Coverage of Obesity-Related Services in

Essential Health Benefit Benchmark Plans

Kahan S, et al. STOP Obesity Alliance – Weight and the States, 2012.

Have you or anyone in your practice been specifically trained to deal with weight related issues? (n = 290)

Not sure: 4%

No answer: 3%

Most PCPs Report No Training in Obesity

Kahan, in preparation

Final Takeaways

• Health, not appearance– Obesity is no different from other chronic, behavior-

related health conditions

• Prevention and Intervention

• Treatment works, despite the aura of futility

• Think long term

• Need innovations– Access to care

– Health professional training

– Community-clinic partnerships

Thank you.

Scott Kahan, MD, MPH

[email protected]

considerations for state obesity policy - women in … for state obesity policy scott kahan, md, mph...

Documents