obesity

What gets prescribed and why: Opioids v. obesity meds

By M2|2018-12-06T18:37:08+00:00December 6th, 2018|Chronic pain, Evidence-Based Medicine, Health Care Trends, Insurance, Uncategorized, What do we pay for and why|

What gets prescribed and why: Opioids v. obesity meds

The U.S. health care system doesn’t always make sense. Sometimes, even when there is some logic to it, the reasons underpinning what gets prescribed by practitioners and covered by insurers are disappointing. Two pieces I read recently provide examples.

In one study, we learn that while primary care physicians are prescribing opioids less often, other specialists and nurse practitioners are prescribing them more often. Ultimately, opioid prescribing remains at a high level, despite known issues with misuse and abuse, and the availability of alternative pain treatments.

At the same time, while 40% of U.S. adults are obese, fewer than 2% of obese patients are offered medications for obesity, and ultimately “only about 1% of eligible patients fill a prescription for a weight loss medication.” Even when weight loss medications are prescribed, it is usually for a specific (fairly short) period of time, explained Dr. Caroline M. Apovian, a Professor of Medicine and Pediatrics, Department of Medicine, Section of Endocrinology at Boston University School of Medicine and the Director of Nutrition and Weight Management, Department of Endocrinology, Diabetes, and Nutrition, at Boston Medical Center, in an opinion piece in Medscape.

This is an example of what we like to call at M2: “what do we pay for and why?” If 40% of the public has a disease, why aren’t treatments prescribed and covered? Several chronic obesity management medications have been approved by the U.S. Food and Drug Administration (FDA) in the past few years, and have proven of efficacy of 5%-10% weight loss, but Dr. Apovian argues that “public perception of obesity as a matter of will power rather than a disease” is a key barrier to lower treatment rates for obesity.

The U.S. health care system doesn’t necessarily pay for what works, or the treatments people need. As with all policy decisions, there is a judgment about who deserves what, and who should pay for it. In the case of treating obesity with a prescription, Dr. Apovian succinctly explains the current policy stance: “If obesity is considered a moral failing, why treat it with a pill or surgery?”

What’s the hold up? Why do physicians not turn more frequently to the known effective treatments for obesity? Well, sometimes it is lack of proper training (discussed in our in April). Physicians have a lot to stay up to date on, and obesity treatments are often not prioritized despite the prevalence of comorbidities. As we discussed in a back in February, improved insurance coverage for proven effective weight loss treatments could help avoid expensive complications from obesity down the road and may improve quality of life. We suggest this is a better way to choose what is covered the current approach.

Pain affects a large number of people in the U.S. as well – more than 100 million adults. Nearly 40 million adults experience the highest levels of pain (category 3 or category 4), and there are more than 25 million adults who report chronic (daily) pain. Further, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain is clear: “Opioids are not first-line or routine therapy for chronic pain.” Despite this clear recommendation, as the recent study confirms, opioids continue to be frequently prescribed for pain, even though there are less addictive alternatives available. These medications aren’t that expensive so are frequently covered by insurance.

The M2 blog, Coverage Drives Treatment: The Case of Pain explains how insurance companies seem to prefer to cover what is inexpensive, and perhaps less effective, at least when it comes to opioids for pain.

Confounding situations like this are when we understand why an overhaul of the health care system is appealing to some. It would be an incredible opportunity to step back and create a new system that approaches all situations – obesity, pain, everything – from the perspective of longer term effectiveness. Ultimately this would reduce health care system costs overall, as less time (and money) would be spent covering up symptoms of something that is likely to cause greater expense down the road.

But in order to do this, we’d have to face who we think deserves what kind of care. These decisions are baked in to the system we have and rarely discussed. 2019 is around the corner. Should we start this conversation in the new year?

Obesity: Survey Finds Primary Care Providers’ Knowledge “Inconsistent” with Evidence-Based Recommendations

By M2|2018-04-26T20:09:32+00:00April 26th, 2018|Evidence-Based Medicine, Hospitals, Providers, Uncategorized|

Obesity: Survey Finds Primary Care Providers’ Knowledge “Inconsistent” with Evidence-Based Recommendations

Despite the high prevalence of obesity in the US, a new study finds that providers’ knowledge of evidence-based recommendations for obesity is low.

For example, only 15% were able to identify the “appropriate indication” for prescribing pharmacotherapy for patients: a BMI over 27 with an obesity-associated comorbid condition. Two-thirds said it is appropriate to continue long-term pharmacotherapy under conditions inconsistent with evidence-based guidelines. Providers were “most knowledgeable” regarding the physical activity guidelines, with 49% answering correctly.

In addition, “only 16% of respondents indicated that obesity counseling should be provided approximately twice monthly in an individual or group setting for at least 6 months,” in accordance with U.S. Preventive Services Task Force and CMS guidelines, according to the study by Monique Turner, George Washington University, Milken Institute of Public Health, et al., and published in the journal Obesity. (Shout out to my colleague at GWU, Dr. Monique!)

Overall, providers’ understanding of clinical care for obesity, which includes intensive behavioral therapy, physical activity, and pharmacotherapy, is “inconsistent with evidence-based recommendations” the study found – despite the fact that most health care providers believe they are responsible for ensuring patients are informed about obesity treatments.

Given the current obesity epidemic and the known costs associated with obesity, it seems obvious that primary care physicians should make it a priority to be up-to-date with current treatments and approaches to weight loss and optimal health. This would also help them advocate for better coverage of interventions.

In an accompanying commentary, Robert Kushner, Northwestern University, Feinberg School of Medicine, appears to agree:

“Knowledge of the guidelines is a reasonable objective but is not sufficient to change practice behavior,” Kushner says. Nonadherence to practice guidelines “may be due to other factors independent of knowledge,” including fragmentation of care, disagreement between guidelines, and “external practice barriers.”

He cites the need for effective dissemination and implementation approaches for practice guidelines. He also points out that other educational initiatives are under way “that will impact the practice of obesity in the primary care setting,” for example, through the Obesity Medicine Education Collaborative (OMEC), which is “currently finalizing a set of 32 obesity-specific competencies” as part of undergraduate, postgraduate, and fellowship training. “By taking a continual and comprehensive educational approach, we are on our way to get primary care ready to treat obesity,” he concludes.

Obesity is a growing problem in the U.S. in terms of both health outcomes and costs; in fact, as I’ve about recently, it is also linked to declining mortality improvements in the US compared to other wealthy countries. Unfortunately, despite the availability of a range of non-surgical interventions supported by evidence-based practice guidelines, primary care providers generally are not appropriately trained in this area, nor do they keep pace with new treatment findings on how to address this problem. If we want to tackle the obesity problem and improve health outcomes, life expectancy and costs, we must find ways to address barriers of this kind, and our reimbursement policies will need to incentivize providers to focus on this issue.

Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

By M2|2018-02-21T15:54:35+00:00February 21st, 2018|Health Care Trends, Health Plans, Insurance, Reimbursement, Uncategorized, What do we pay for and why|

Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

Mortality improvements in the U.S. have declined relative to other wealthy countries, and a new study points to obesity as the culprit.

“Rising levels of body mass index [BMI] have prevented the United States from enjoying the full benefits of factors working to improve mortality,” according to study author Samuel Preston, professor of sociology at the University of Pennsylvania, et al. The study is published in the Proceedings of the National Academy of Sciences, as noted in a recent article in HealthDay.

In addition, according to the article, rising BMI has “reduced the annual rate of improvement in U.S. death rates between 1988 and 2011 by more than half a percentage point—equivalent to a 23% relative reduction in the rate of mortality decline—a large amount by international standards.”

“Heart disease deaths had declined consistently for nearly 40 years,” the article notes. “These declines have slowed or stopped altogether” and “rates of decline in cancer deaths have also slowed,” the article says. “At the same time, rates of obesity have been rising in the United States. From 1976 to 1980, 15 percent of Americans were obese. By 2014, 38 percent of Americans were classified as obese.”

The study’s researchers evaluated how much of the change in the death rate trend could be explained by rising BMI, and found that the increase in BMI reduced life expectancy by 0.9 years, almost 11 months, at age 40, and accounted for 186,000 excess deaths in 2011.

Despite rising obesity rates, another new study finds that many obese patients are not receiving antiobesity medications – and patients who are being prescribed medicines may be getting them because of provider bias. 80 percent are women, although obesity rates are similar for men and women in the U.S.

Fewer than 1 in 50 people in the U.S. eligible for antiobesity medications are receiving them, according to an evaluation of electronic records conducted by University of Colorado endocrinologist David Saxon, MD. Patients above a specific BMI threshold are eligible for weight-loss medication, but only 1.3% had received any prescription from 2009 to 2015, a recent Medscape article notes.

In addition, among patients who had received a prescription, 85% of the prescriptions were for phentermine, as opposed to newer agents. Primary care providers were most likely to prescribe these drugs.

Patients want “more information from their physicians about these medication options but there’s rarely the conversation,” Saxon says in the article. “Patients are probably more interested in them than the 1.3% who are receiving them.”

My friend and colleague, Scott Kahan, MD, is the director of the National Center for Weight and Wellness, and the medical director of Strategies To Overcome and Prevent (STOP) Obesity Alliance at George Washington University. Kahan explains that physicians historically have received little training in obesity management, and may hold misperceptions about obesity medications, including that they are unsafe, ineffective, or not well-studied.

“These misconceptions are likely a legacy of older medications that had lesser requirements for approval and were likely misused,” Kahan says. Another issue is lack of insurance coverage.

Yet another successful obesity treatment option is surgery. Two recent studies published in the Journal of the American Medical Association (JAMA) compared Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy in morbidly obese patients.

First, researchers at St. Claraspital in Basel, Switzerland, conducted a randomized trial of morbidly obese patients to determine whether there are differences between the two surgical options, in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events, as noted in an article in The Clinical Advisor. Excess BMI loss was not significantly different at 5 years: 61.1%, with sleeve gastrectomy vs 68.3% with RYGB.

In the second study, researchers in Finland also studied morbidly obese patients to examine the clinical equivalence of the two surgeries. The trial found the estimated mean percentage excess weight loss at 5 years was 49% with sleeve gastrectomy and 57% with RYGB, with no statistically significant difference in quality of life between groups and no treatment-related mortality. At 5 years, the overall morbidity rate was 19% and 26%.

In an accompanying editorial, David Arterburn, MD, MPH, and Anirban Gupta, MD, state that “these and other studies suggest that sleeve gastrectomy and bypass are overall quite similar in terms of their effects on weight and comorbid conditions through 5 years.” They also note that “these procedures may be associated with improved long-term survival compared with usual medical care. Overall, it seems that both procedures are excellent options for surgeons and patients to consider in the treatment of obesity.”

With the slowing gains in life expectancy in the US linked to obesity, patients need their insurance plans to cover effective treatment options. If these options are going to be accessible for patients, insurers will need to have reasonable coverage and reimbursement policies in place; today, with FDA-approved drugs available to treat obesity and promising research showing that the sleeve and bypass surgeries are two excellent options, we need policies that encourage use of both drug and surgical approaches.