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In a small but significant development, the federal Center for Medicare & Medicaid Services (CMS) has reversed a long-standing policy and recognized obesity as a disease entity by itself.
The Medicare program will for the first time classify obesity as a disease, opening the door to reimbursement for treatment, said Health and Human Services Secretary Tommy Thompson at a July 15 Senate hearing. Still, it could be years before Medicare patients receive coverage for most weight loss treatments— and some, including drug treatments, may never be covered.
Medicare can only cover treatments for illness and injury according to the 1965 law that created the program. One section of the Coverage Issues Manual, dating from its inception, explicitly states, "Obesity in itself cannot be considered an illness," and therefore could not be covered. This prohibition will be removed from the coverage manual.
The process of changing the regulation began in September 2001, when CMS initiated the formal review process, according to agency spokesman Don McLeod. The next step is a meeting of the Medicare Coverage Advisory Committee (MCAC), scheduled for November.
"From the standpoint of Medicare coverage and the health of our beneficiaries, the question isn't whether obesity is a disease or a risk factor," says CMS administrator Mark McClellan, MD. "What matters is whether there's scientific evidence that an obesity-related medical treatment improves health."
The designation "doesn't recommend that we cover or not cover something, it advises us on the availability and quality of the evidence," explains McLeod. "The MCAC will tell us if there is sufficient evidence upon which you can base a decision. They may tell us the evidence just isn't there."
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Additional regulatory procedures—including publishing draft decisions, public comment periods, revisions, and coding matters—are likely to stretch out the process for at least a year. "In the short term, there is probably not going to be that much difference" for clinicians, he says.
The sheer size of its patient population makes Medicare the "gold standard" that other insurers have looked to in their coverage of health interventions.
Over the last 5 years or so, many private insurers have awoken to the issues of overweight and obesity and have moved to implement programs to both prevent and treat the problem, says Mohit Ghose, director of public affairs for the trade association America's Health Insurance Plans.
A 2003 survey of employer-sponsored health plans by the human resources firm William Mercer offers evidence to support both sides. About half of the plans already cover bariatric surgery and a third support behavior modification programs. Some of this coverage is driven by state regulations.
"Doctors are going to continue to treat obesity, no matter how Medicare classifies it," says Ronald Davis, MD, a trustee speaking for the American Medical Association. At the association's annual meeting last June, a resolution calling on the CMS to treat obesity based on body mass index (BMI) alone was proposed but tabled for the time being (DOC News, July 2004).
Judith Stern, MD, vice president of the American Obesity Association, is decidedly enthusiastic about the designation. "We are delighted, this is going to make a major difference for obese people," she says. "It's not just Medicare, it's then what private insurers do."
How many patients fall into the Medicare gap in coverage—those who are obese but do not suffer comorbidities that would qualify them for interventions—and would gain coverage with the policy change? The CMS does not collect those data because the question has been beyond its mandate.
According to Diane Archer, president of the Medicare Rights Center, the lack of Medicare coverage for obesity has not been a major problem. "We handle about 10,000 cases a year but it could be that people aren't calling on this particular issue because they've been told it's not covered."
William Caplan, MD, director of clinical development at the Care Management Institute of Kaiser Permanente, the nation's largest health maintenance organization-style provider, is "sure [the gap population] is a small number because just the number[s] of patients with hypertension and abnormal lipids in this population are large. Probably more than half have comorbidities that would qualify them [for coverage]."
"Now if they have higher BMI levels, and most of them do, then that alone may qualify them, if they meet the other criteria for the procedure" of bariatric surgery under Kaiser's guidelines, according to Caplan.
Insurers are concerned that, "For the last year and a half, most of the discussion about obesity has centered around highly invasive, catastrophic interventions like gastric bypass surgery," says Ghose. "What we need to understand is that there should be a lot happening before people get to that point."
"Covering other kinds of intervention, structured weight management
programs, health education and promotion efforts, the role of nutritionists in
counseling members as part of a structured program, I think these make a lot
of sense," says Caplan. "Promotion of physical activity has a lot
of benefits, not simply from weight loss but the overall fitness and reduction
of cardiovascular risk. I'd like to see all of those supported" by
Medicare. 
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