Weight-Loss Program in Medicare Could Save Billions

[cbayer]

http://www.medpagetoday.com/PrimaryCare/Obesity/28450


By John Gever, Senior Editor, MedPage Today
Published: September 10, 2011
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

The financial burden on Medicare could be cut by as much as $15 billion if it funded weight-loss programs for overweight and obese people, ages 60 to 64, with certain other risk factors, researchers said.

Assuming effectiveness like that seen in a recent community-based intervention trial, in which participants had average losses of 4.2% of body weight, enrolling 70% of the 60 to 64 age cohort with "prediabetes" or cardiovascular risk factors could reduce Medicare expenditures by a net $15.1 billion over the cohort's lifetime, according to Kenneth E. Thorpe, PhD, and Zhou Yang, PhD, both of Emory University in Atlanta.

Lifetime net savings with 55% participation would be $11.9 billion, they calculated.

Writing online in Health Affairs, Thorpe and Yang noted that Medicare's recently added "wellness benefit" -- part of the Affordable Care Act -- covers an annual visit, personalized care plan, and a referral if necessary. But the new benefit doesn't include payment for commercial or community-based diet-and-exercise programs that promote better health.

more at link

[HockeyMom]

1. Height/Weight, even BMI charts are out now

Waist Hip Ratios are the new measure (literally). Big problem with that. The health insurance I used to have "caught" people who never should have been caught. One case is a woman who I worked with. She was 60 years old, 5 feet tall, and weighed 90 lbs. Overweight? Not by any stretched of the imagination, BUT with this new measure of apple (bad) versus pear (good) shape measure of body shape and heart attack prone people, she was labled apple shaped and at risk of a heart attack by the insurance company. You see, her measurements were 24 inch waist (most women would KILL for that), but she only had 30 inch hips. So by the calcuclations she stored her excess fat (what fat?) around her middle, not her hips. Unfortunately, this woman was born with very small pelvic bones and both her 6 lb. children had to be born via C-Section. Now even this insurance could not tell a 90 lb woman she needed to LOSE WEIGHT. They told her she need to go to a gym to lose the "fat" around her waist. I suppose according to their "charts" she should have an 18 inch waist so she wouldn't be apple shaped anymore? Can you see how absurd all this is? No, GAINING weight around her hips would not solve the problem of the BONES she was born with. Besides which, there are people in this world, not according to science, who gain weight all over, not just either in the mid section, or on their asses.

Anyway, this woman was so furious with this insurance she dropped it. I would imagine when she turns 65 she would be just as furious if Medicare said the same thing to her.

[Psephos]

2. That's a good example of the Law of Unintended Consequences at work.

As your story shows, the problem with legislated/regulated approaches is that the assumptions they're based on often fail at the individual level. Furthermore, in the fields of nutrition and exercise, the science is incomplete and evolving, and what was strenuously recommended 20 or even 10 years ago is now obsolete and sometimes even harmful.

We should avoid simplistic statistical approaches, especially when financial pressure is involved.

[cbayer]

3. While that is an interesting anecdotal report, this program and the studies it is

based on are pretty sophisticated.

They emphasize risk factors for development of Type 2 diabetes and not a single measurement such as you describe.

[ingac70]

4. There was just a study how people who live longer cost more....

and how fat people and smokers were cheaper because they didn't live as long.

http://www.nytimes.com/2008/02/05/health/05iht-obese.1.9748884.html

[cbayer]

5. Oh, c'mon!

It's a 2008 study done in the Netherlands based on 2003 data for costs of illnesses and a mathematical model.

In short, it's one of the weakest things I have ever seen and hardly an argument for not trying to prevent diabetes and heart disease.

:banghead:

[ingac70]

6. It shows curbing them aren't money savers.

Did you actually read the whole article? Preventing that stuff is fine, but saying it saves money long term is blatantly false.

[cbayer]

7. I read it and the only thing it shows that is if you live longer, you cost more.

It was done by economists and not based on actual patients. It also didn't take into account lost economic productivity or social costs. In short, it's a great talking point for not providing care that is clinically proven to extend people's lives and improve their quality of life.

This in contrast to the Purdue study which is based on extensive patient data and long term studies.

This forum is really interesting. It never occurred to me that the only responses would be attacking the notion of providing the means for patient's to avoid the biggest and costliest medical killers out there.

[Psephos]

8. I think you're misreading some of the responses.

We all want healthy outcomes. No one is attacking the notion of providing the means for patients to avoid poor health outcomes. What's actually going on is that not all of us trust the methods that some wish to apply, and with good reason.

The problem isn't with the statistical foundations (that's well-tilled soil).

The problem is that large-scale programs cannot be designed in a way that accommodates all individual circumstances and heterogeneity, leading to ridiculous or even dangerous "unforeseen" situations, as the O.P. describes. Anyone with an experience of bureaucratic administration of regulations and public initiatives knows this is a universal feature of them.

A bigger problem is that the well-meaning people who design and administer large-scale public health initiatives often believe that the science behind their programs is sound and settled. It's not. They act arrogantly or dismissively towards those who want more than authoritative statements to validate interventions in other peoples' lives. When those in charge believe they possess unassailable science, they stop thinking about how they could be mistaken, and instead, criticize or insult those who might question their pronouncements. As always, it's the skeptics who actually advance science, by pushing against this inflexibility.

Here are some examples of "settled science" that have recently been re-examined and found lacking in recent research. (This is intended for conversational purposes only. This is a discussion board, not a research journal.)

* Salt is bad for cardiovascular health. Right?

“…a meta-analysis of seven studies involving a total of 6,250 subjects in the American Journal of Hypertension found no strong evidence that cutting salt intake reduces the risk for heart attacks, strokes or death in people with normal or high blood pressure.” (2011) http://www.scientificamerican.com/article.cfm?id=its-time-to-end-the-war-on-salt

* LDLs are the bad form of cholesterol.

“The so-called “bad cholesterol” – low-density lipoprotein commonly called LDL – may not be so bad after all, shows a Texas A&M University study that casts new light on the cholesterol debate, particularly among adults who exercise.” (2011) http://tamunews.tamu.edu/2011/05/04/%E2%80%98bad%E2%80%99-cholesterol-not-as-bad-as-people-think-shows-texas-am-study/

* Saturated Fats Cause Heart Disease. Well, everyone knows that, right?

“We’ve spent billions of our tax dollars trying to prove the diet-heart hypothesis. Yet study after study has failed to provide definitive evidence that saturated-fat intake leads to heart disease.” (2007) http://www.msnbc.msn.com/id/22116724/ns/health-diet_and_nutrition/t/what-if-bad-fat-isnt-so-bad/

* More than a couple of drinks a day, every day, affects heart health negatively. No brainer, right?

“Drinking a bottle of wine a day, or half a dozen beers, cuts the risk of heart disease by more than half in men, shows a large-scale European study.” (2009) http://www.independent.co.uk/life-style/health-and-families/health-news/drink-half-a-dozen-beers-every-day-and-have-a-healthier-heart-1823218.html

*Being overweight will shorten your life. OK, now we're getting close to the specific topic of this thread.

“…in elderly persons followed for two to 23 years, a baseline body mass index (BMI) below normal (18.5-25kg/m2) was associated with a higher risk of mortality whereas a BMI above normal (>25kg/m2) was associated with a lower risk.” (2011 - multi year citations) http://www.nel.gov/evidence.cfm?evidence_summary_id=250331


I could fill pages all night with this stuff.

As I see it, scrutinizing public health initiatives may actually be doing more for positive patient outcomes than parroting the received wisdom, or prescribing one-size-fits-all approaches. Skeptical scrutiny is the soul of science.

[cbayer]

9. I appreciate the thoughtful response and see your point.

I think skepticism and critical thinking are the hallmarks of good science and good medicine. And I understand that "standardized" programs can lose their way.

However, if what we want is a single payer system based on the Medicare model, there will have to be some programs like this, imo.

[Psephos]

10. Likewise. :)

And I absolutely agree with you that such programs are both needed and a net positive. I hope that by keeping the discussion lively, open-minded people will be chosen as their architects.