WASHINGTON, July 20 (UPI) -- It's one thing for Medicare to declare obesity a disease -- making treatment interventions coverable under the senior health insurance program. That's the easy part.
It's another thing to figure out how to decide what is covered -- here, the healthcare industry has some advice -- and then actually decide to cover it. Well, maybe Medicare is on its own there.
Still, regardless of what might be covered someday, some say this decision may be sending the wrong message.
Dr. Alan Muney, chief medical officer of Oxford Health Plans in Trumbull, Conn., told UPI's HealthBiz: "I don't think classifying it as a disease makes any difference in terms of how we approach the issue. First and foremost, the issue for us is prevention. Generally, as a country we eat too much and move too little -- and that's not going to go away."
Clinical psychologist Gerard Musante, of Durham, N.C., also worries about the message -- which he said is the same for elderly as for other populations.
"The conclusion they reach is perhaps this is something out of their control," he told HealthBiz. "They (feel they) are helpless. That's a concern because, as everyone knows ... you have to eat less and exercise."
Muney said Oxford covers the radical weight-loss surgery -- bariatric surgery from about $30,000 to $50,000 -- along with gym memberships, nutritionist visits and counseling for the overweight, but he added that money also should be directed at prevention and lifestyle behaviors at the pediatric level.
Muney said health plans can help the Centers for Medicare and Medicaid Services make coverage decisions. There is a subset of obese for whom bariatric surgery, for example, is worth every penny -- these folks would develop or have coronary artery disease or diabetes or other life-threatening complications because of their obesity.
"So look at the high cost and complication rates in the context of if it works, you have added years on to a patient's life," he said. "Very importantly, in making the decision to allow this surgery to be covered, we had to look at issues such as evidence based guidelines as to who should have it and criteria for who should perform surgery and where it should be performed."
Oxford used criteria developed by the business consortium Leapfrog, on which patients are candidates for the surgery -- which is risky and has serious potential side effects -- and which surgeons or facilities should be used. Because utilization -- linked to cost -- always is a concern, Medicare needs to be aware, Muney said, if it is offered. People will want it even though not everyone will be a good candidate for surgery.
The CMS decision really opens the business horizon for companies offering less drastic interventions, such as the Internet-based My ePHIT.
David Hall, president of My ePHIT, told HealthBiz the CMS decision could allow the company to expand offerings to its health plan clients. Now, with 4 million members, My ePHIT is a value-added benefit that health plans offer employers to help their employees get and stay healthy -- potentially reducing healthcare interventions and cost.
"I think it's the right move," Hall said of the CMS decision. "Everyone from children to the Medicare population has a desire to improve their health and make their lives better.
The Internet is a crucial part of My ePHIT -- it is where people plan diets, exercise regimens and interact with their personal trainer on a host of lifestyle issues -- but Hall said he understands today's seniors might not be so Web savvy and he's willing to make adjustments should CMS approve coverage of the program through Medicare Advantage health plans.
"If they can get access through their health plan, we can use that to create a customer plan and feed it to people on a paper based system," he said, and added it is possible to even add senior focused offerings such as special nutritional or walking-based exercise programs.
Hall said My ePHIT can show health plans a return on investment with studies showing a 23 percent improvement in productivity -- fewer patients sick -- and a reduction in sick days and short-term disability of 77 percent.
Musante said he was "delighted" CMS is paying attention to obesity -- he just wants the correct message to go out,
"That people have to recognize they have to be participants in this solution."
The Center for Consumer Freedom also was critical of the government and industry for what it said was pushing research and lobby efforts that exaggerate the costs of obesity.
"The pharmaceutical and weight loss industry has manufactured an 'epidemic' to have the cost of its weight loss drugs and treatments underwritten by taxpayers," CCF executive director Richard Berman said in a statement. "Obesity is not a 'disease' if it can be cured by taking regular walks and eating less. We need to be careful not to dumb down the definition of the term disease at the expense of taxpayers."
CHECKING IN ON THE MEDICARE DRUG CARDS
There are now some 4 million Medicare seniors participating in the discount drug program that runs 2004-2005 until the permanent benefit kicks in -- but data presented to the Senate Special Committee on Aging shows less than 1 million of them have taken advantage of the additional $600 in low-income transitional money that can be added to the discounts.
Centers for Medicare and Medicaid Administrator Dr. Mark McClellan testified that 25,000 seniors were signing up for the discount cards each day -- the government estimates about 7 million will take advantage of the offer.
As for the Medicare reform that kicks in in 2006 -- with the permanent drug benefit and new managed care options -- there have been complaints about it taking so long to get started.
Gail Wilensky, former Medicare chief and now a senior fellow at Project Hope testified: "These complaints are usually made by people who do not understand the large number of operational decisions that need to occur. It will take a Herculean effort on the part of CMS to implement the major provisions of the legislation in the time specified."
DELAY IN FOREIGN CERTIFICATION
The Department of Homeland Security has delayed the new certification process for non-immigrant foreign healthcare workers, much to the relief of the American Hospital Association.
Rick Pollack, AHA executive vice president, issued a statement that said: "The shortage of healthcare workers in the U.S. is well documented and this regulation would have exacerbated that serious problem by requiring well-qualified foreign healthcare workers, who are already licensed in the U.S., to undergo unnecessary retesting."
Pollack said thousands of Canadians, who are licensed as healthcare professionals in the United States and travel across the border daily, also would have been prohibited from working.
A PUSH FOR MANDATORY HEALTH INSURANCE
The National Coalition on Health Care Tuesday said mandatory health insurance is one way to reform a healthcare system that is "literally in crisis," with insurance premiums and healthcare costs increasing at rates far higher than other economic sectors.
The coalition, which bills itself as a non-partisan group of some 100 businesses, unions, provider groups, insurers, pension funds and consumer groups, warned without changes in the system, annual health plan premiums for families could surpass $14,500 in 2006 -- more than double rates in 2001.
The coalition's goal is to bring healthcare costs back in line with annual percentage increases in the U.S. per-capita gross domestic product.
"We want to emphasize that health care coverage is now a major national economic problem," Dr. Henry Simmons, president of the coalition, told reporters at a news briefing. "It undercuts the viability of pension funds ... and is producing long-term budgetary problems."
The coalition made cost-reducing suggestions such as limiting increases on insurance premiums, providing patients and healthcare providers with better information about the system, and better defining rates of reimbursement for providers.
Money to pay for this reform, the coalition said, could come from general tax revenues, mandatory co-payments toward premiums from individuals and families, and contributions by employers.
(UPI's Brad Amburn in Washington contributed to this report)
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