SBM Responds to Centers for Medicaid and Medicare Memorandum

SBM submitted the below statement in response to Centers for Medicaid and Medicare Services Proposed Coverage Decision Memorandum for Intensive Behavioral Therapy for Obesity.

Dear:

Louis Jacques, MD
Director, Coverage and Analysis Group

Tamara Syrek Jensen, JD
Deputy Director, Coverage and Analysis Group

Jyme Schafer, MD, MPH
Director, Division of Medical and Surgical Services

Sarah McClain, MHS
Lead Health Policy Analyst, Division of Medical and Surgical Services

Joseph Chin, MD
Medical Officer, Division of Medical and Surgical Services

These comments are submitted on behalf of The Society of Behavioral Medicine, a multi-disciplinary scientific organization representing social scientists, physicians, nurses, epidemiologists, registered dietitians, exercise scientists, psychologists, and public health professionals. SBM is dedicated to the study of the interactions of behavior with biology and the environment, and the application of that knowledge to improve the health and well-being of individuals, families, communities and populations. We are honored to have among our membership many of the clinician scientists who were involved in the development and evaluation of behavior therapy for obesity, including evidence-based protocols such as those used in the landmark Diabetes Prevention Program [1] and Look AHEAD [2] trials. A substantial proportion of our membership is currently involved in the study and clinical delivery of behavioral treatments for obesity. SBM is in strong support of the CMS proposal to cover behavioral therapy for obesity.

Since the USPSTF assigned a B rating to behavior therapy for obesity in 2003 [3] studies have further strengthened support for the efficacy of behavior therapy, most notably the landmark Look AHEAD trial which enrolled 5,145 individuals with type 2 diabetes and revealed weight loss exceeding that of the Diabetes Prevention Program up to 4 years [2, 4]. SBM would also like to note that since the original USPSTF report, behavior therapy for obesity has been shown to be cost effective [5]. The evidence overwhelmingly supports that behavior therapy for obesity is an effective and cost-effective service.

Recommendation to Expand the Definition of Provider

In this statement, SBM strongly concurs with the recommendations put forth in comments by The Obesity Society, The American Society of Bariatric Surgery, and a host of other commenters that the definition of provider be expanded to include psychologists, dietitians, social workers, diabetes nurse educators, and exercise specialists. Our concerns are captured in the following 5 points.
1. Allied Health Professionals Were Utilized in Clinical Trials. The behavior therapy protocols utilized in the majority of randomized trials for obesity (i.e., LEARN[6], Diabetes Prevention Program[7], and the Look Ahead [8]) were developed by clinical psychologists. In trials, protocols were typically delivered by clinical psychologists, dietitians, social workers, diabetes nurse educators, and exercise specialists, including both the Diabetes Prevention Program and Look Ahead trials. Therefore, we strongly urge CMS to reimburse the types of providers found to be effective in delivering obesity treatment, and encourage primary care providers (PCP) to refer to these clinicians. Fortunately, behavior therapy and health behavior change counseling are a regular part of practice for a variety of professionals that routinely work along with PCPs and to which PCPs routinely refer (e.g., psychologists, dietitians, social workers, diabetes nurse educators, and exercise specialists). Further support for a broader definition of providers comes from the NHLBI Obesity guideline which states that there is no evidence for differential efficacy of obesity treatment across health professionals.
Reason 2: Limiting to PCPs May Reduce Access. SBM is very concerned that limiting coverage to PCPs (per the stated definition) will severely limit access to effective obesity treatment given that PCPs have short appointment times, often lack space for group-based programs, lack training in delivering behavior therapy protocols, and are currently in short supply in the US [9, 10]. The allied health care professionals listed typically have longer appointment times and have repeat visits built into their practice structure, which is conducive to intensive counseling.
Reason 3: Limiting to PCPs May Lead to Insufficient Treatment Intensity. The availability/access barriers discussed about could result in insufficient treatment intensity (number of visits, time spent), and as a result, insufficient outcome. Studies routinely show that intensity of intervention is a strong predictor of weight loss [2, 11, 12].
Reason 4: Limiting to PCPs May Have Insufficient Impact on Minorities. Also a consequence of limited access is the possibility of under serving individuals from ethnic minority groups and those residing in low-income communities, who bear an excess burden of obesity and its comorbidities. Enabling additional qualified providers will increase access to essential treatment for these high-risk individuals/groups, thereby reducing health disparities.
Reason 5: Allied Health Professionals May Be More Cost Effective. The allied health professionals listed here have lower hourly rates than PCPs, thus covering these well trained professionals may be less costly than exclusive coverage of PCPs.

For these reasons, we strongly recommend that Medicare reimburse the qualified providers we have listed to do this work in their respective treatment settings.

Summary

In summary, SBM enthusiastically supports the CMS proposal to cover behavior therapy for obesity. We strongly urge that the definition of “primary care provider” be expanded to include the allied health care professionals that routinely deliver these interventions in health care settings as well as in the trials in which efficacy was originally established (e.g., psychologists, dietitians, social workers, diabetes nurse educators, and exercise specialists). We believe that the current definition is too narrow which will limit the availability of this treatment for patients who need it, possibly lead to insufficient treatment intensity, disallow appropriate coverage for practitioners who are able to effectively deliver this treatment, and unnecessarily inflate the expense of coverage. Expanding the definition will reduce cost and increase access, which together will greatly enhance our ability and capacity to impact the obesity epidemic in the US.

References

1. DPP Research Group, Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med, 2002. 346(6): p. 393-403.
2. Wadden, T., et al., One-year weight losses in the Look AHEAD study: Factors associated with success. Obesity, 2009. 17: p. 713-722.
3. U.S. Preventive Services Task Force, Screening and interventions for overweight and obesity in adults. 2003, Agency for Healthcare Research and Quality: Rockville, MD.
4. Wadden, T.A., et al., Four-year weight losses in the Look AHEAD study: Factors associated with long-term success. Obesity, 2011. epub ahead of print.
5. Herman, W., et al., The cost-effectiveness of lifestyle modification or metformin in prevention type 2 diabetes in adults with impaired glucose tolerance. Annals of Internal Medicine, 2005. 142: p. 323-332.
6. Brownell, K., The Learn Program for Weight Management. 10th ed. 2004, Euless, TX: American Health Publishing Company.
7. DPP Research Group, The Diabetes Prevention Program (DPP): Description of lifestyle intervention. Diabetes Care, 2002. 25(12): p. 2165-71.
8. Wadden, T.A., et al., The Look AHEAD study: A description of the lifestyle intervention and the evidence supporting it. Obesity (Silver Spring), 2006. 14(5): p. 737-52.
9. Schwartz, M., et al., Changes in medical students' views of internal medicine careers from 1990 to 2007. Archives of Internal Medicine, 2011. 171(8): p. 744-749.
10. Bodenheimer, T., Primary care--will it survive? New England Journal of Medicine, 2006. 355(9): p. 861-864.
11. Wing, R.R. and J.O. Hill, Successful weight loss maintenance. Annual Reviews in Nutrition, 2001. 21: p. 323-341.
12. Wing, R.R., et al., A self-regulation program for maintenance of weight loss. New England Journal of Medicine, 2006. 355(15): p. 1563-1571.