Sentence Deletion Could Signal Eventual Weight-Loss Coverages

WASHINGTON, DC — Medicare's decision to toss out one sentence in its guidelines could be a precursor to weight loss efforts being covered by the program and possibly future coverage by private health care. However, some experts caution that coverage could be years away.

This summer, Health and Human Services Secretary Tommy Thompson announced that Medicare's Coverage Issues Manual, which is the group's guideline for coverage, would no longer include the phrase, “Obesity itself cannot be considered an illness.” The change is not expected to have an immediate impact on Medicare coverage, the announcement said. It does not affect the existing Medicare coverage of treatments of diseases resulting in or made worse by obesity, in particular currently covered surgical treatments for morbidly obese individuals.

The change is a significant development, said Kevin Buckley, deputy director of government relations at the International Health and Racquet Sportsclub Association. However, he said, “It's still very much in the beginning stages. It means approval of treatments is possible.”

Before Medicare would change its policy to actually begin covering obesity-related treatments, the group would have to review published, clinical trial data that demonstrate that obesity-related treatments improve the health of Medicare beneficiaries.

“With this new policy, Medicare will be able to review scientific evidence in order to determine which interventions improve health outcomes for seniors and disabled Americans who are obese and its many associated medical conditions,” said Thompson during testimony before the Senate Appropriations Subcommittee on Labor, Health and Human Services and Education.

By law, Medicare covers specified medically necessary services for illness and injury. The prior manual language, because it stated that obesity was not an illness, could prevent Medicare from covering treatments for diseases related to obesity.

“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,” said Mark McClellan, M.D., Ph.D., administrator for the Centers for Medicare and Medicaid Services (CMS). “What matters is whether there's scientific evidence that an obesity-related medical treatment improves health. This change in Medicare's coverage policy puts the focus on public health. The medical science will now determine whether we provide coverage for the treatments that reduce complications and improve quality of life for the millions of Medicare beneficiaries who are obese.”

CMS expects to convene its Medicare Coverage Advisory Committee this fall to evaluate the evidence on obesity-related surgical procedures that may reduce the risk of heart disease and other illnesses, said Sean Tunis, CMS chief medical officer.

At least one private insurance company has said that the language change won't affect it at this point.

“I see at this point no changes coming in any of our clinical policies associated with weight management or people with weight problems as a result of the CMS change in language,” said Susan Millerick, spokesperson for Aetna.

However, Buckley said that private health insurance companies watch the Medicare model and if Medicare changes, then insurance companies may follow suit.

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