Medicare Must Reevaluate its National Coverage Determination for Intensive Behavioral Therapy for Obesity
The Centers for Medicare & Medicaid Services (CMS) has considered rule making for obesity treatments for more than a decade, and the member groups of the Obesity Care Advocacy Network (OCAN) are pleased that the Biden administration is committed to action on critical health concerns. But there is no more urgent time to act than now. For the millions of people living with obesity who have struggled to manage their disease and face additional health risks like severe COVID-19, diabetes, heart disease, stroke, or cancer, modernizing Medicare could save their lives. And the potential implications for health equity cannot be overstated. Among adults, Black and Hispanic populations have significantly higher obesity rates than whites.1 Communities of color have historically faced chronic disease health disparities due to systemic inequalities that have manifested in reduced access to health care, healthy food and safe places to be active. A lack of treatment options for older adults with obesity only puts these communities more at risk and perpetuates health disparities.
Medicare Part B has approved coverage for intensive behavioral therapy (IBT) for obesity since November 29, 2011 when CMS issued its National Coverage Decision (NCD 210.12), but the benefit is designed in such a way that greatly restricts access. Chiefly, the service is restricted to only being billed for by primary care providers2 and only when delivered in a primary care setting.3 This restricts patients’ access to other highly trained providers—including obesity medicine specialists, registered dietitian nutritionists, psychologists, and others—and to evidence-based community-based weight loss programs.
The poor benefit design is partially a product of timing and the need to update Medicare’s preventive benefits in a timely manner after the passage of the Patient Protection and Affordable Care Act. In short, the Medicare Part B Intensive Behavioral Therapy for Obesity benefit is based on a long-outdated United States Preventive Care Services Task Force (USPSTF) recommendation that was never intended to be used for the purposes of coverage decisions or benefit design. In this case, USPSTF recommends that providers screen and provide intensive behavioral therapy for patients with obesity. Since the issuance of that NCD, USPSTF has updated their adult obesity recommendations twice (2012 and 2018) and now consistently recommends that primary care providers screen and then offer or refer their patients to IBT for obesity. And, in fact, the majority of the studies that the USPSTF recommendations are based on are delivered by providers and programs other than primary care providers in a primary care setting.
In 2011, CMS was obliged to use the USPSTF outdated 2003 recommendations for “Screening Obesity in Adults” as the basis of the newly designed IBT for Obesity benefit, as they were the prevailing USPSTF obesity recommendations available at the time. Not only were these 2003 recommendations based primarily on literature from the 1990s, but they were also drafted before the Task Force overhauled its processes, terminology, and manner of communicating their recommendations as part of its “commit[ment] to continually updating its methods and recommendations to maintain relevance to primary care practice” and in anticipation of the USPSTF’s transformed role under the ACA.
The benefit that has now stood for over a decade is failing Medicare beneficiaries with obesity. Utilization has been increasing since the benefit’s inception, but, as of 2017, only 0.72% of the more than 19 million Medicare Fee for Service beneficiaries with obesity received IBT for obesity.4 A study conducted by Avalere Health suggests that “[i]ncreasing coverage of IBT is expected to expand the pool of providers offering those services and lead to increased utilization of IBT by Medicare beneficiaries with obesity.”5
The IBT for obesity benefit also imposes restrictions that differ from how other chronic disease benefits are structured. Under the current benefit design, patients who do not lose an arbitrary amount of weight in the first 6 months lose access to care. For any other chronic disease, a lack of effect from treatment would warrant more intensive intervention, not less. Under the current policy, Medicare essentially gives up on patients with obesity if they struggle to lose weight, even if they have achieved documented improvements in other clinical markers or have reported positive behavior change.
This is especially problematic for beneficiaries from low-income or historically marginalized communities who may have reduced access to healthy foods and safe spaces to be active. The hard cut-points for weight loss and time are also problematic for individuals who may struggle with attendance. And, in fact, the NCD implies that beneficiaries who have not lost enough weight by 6 months are simply not “ready to change.” Boiling weight loss down to how much an individual wants to lose weight is ignoring the litany of social and economic factors that can impede weight loss. These cut-points also eliminate health care providers’ ability to use their clinical judgement to assess whether continued or modified intensive behavioral therapy would be clinically beneficial to their patients.
Because of these dated coverage policies outlined in the NCD, Congress as a whole urged, as part of report language included in the Consolidated Appropriations Act for FY 2021, that “CMS reexamine its Medicare Part B national coverage determination for intensive behavioral therapy for obesity considering current USPSTF recommendations.”
We echo the sentiments of the Congress and request that the Biden Administration consider instructing CMS to revise the Medicare Part B IBT for Obesity benefit to allow a wider range of providers—including obesity medicine specialists, registered dietitian nutritionists, psychologists, and others—and to evidence-based community-based weight loss programs bill for the service, and to remove the arbitrary and non-evidence-based requirement that coverage be rescinded for individuals who do not lose a sufficient amount of weight within 6 months of starting treatment.
1 Washington, DC: Trust for America’s Health. https://www.tfah.org/wp-content/uploads/2020/09/TFAHObesityReport_20.pdf.
2 A “primary care practitioner” means an individual who is a physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or is a nurse practitioner, clinical nurse specialist, or physician assistant.
3 A primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
5 Avalere Health. Estimated Federal Budget Impact of H.R.1953 – Treat and Reduce Obesity Act of 2017. Washington D.C.; 2019.