Friday, June 21, 2013

Obesity as a Disease: All About the Economics

The American Medical Association has decided to recognize obesity as a disease.  This is a mistake, but not for the reasons you might initially think.

Let’s establish the logic behind the AMA’s decision.  There is no new study, no new statistic, no new discovery that has led the AMA to this decision.  This is about money, plain and simple.  And while I don’t object to the decision on these grounds (economic incentives can be powerful tools for behavior change), I’m not convinced the AMA has thought this all the way through. 
There is increasing frustration in the physician community around the expectation of doctors to “treat” what was previously the symptom or co-morbid condition known as obesity.  The time spent counseling patients on diet, exercise, weight loss programs, and underlying behaviors impacting weight has not been adequately reimbursed by government or commercial payers.  Thus, physicians are left with the need to treat a condition without an explicit payment mechanism for such treatment.  I understand and acknowledge that this has a negative impact on physician practice economics and/or on the overall health of obese injured workers and other patients. 
But calling obesity a disease will result in a plethora of unintended consequences. 
First, we risk creating a new fee stream to doctors that may yield little progress in the fight against obesity.  Altering physician behavior through economic incentives doesn’t necessarily translate to altering patient behavior.  This decision by the AMA (and the subsequent legislation introduced in Congress to mandate Medicare coverage of obesity treatments) is emblematic of the most basic flaw in our health care system: placing the physician at the center of the system instead of the patient.  We've been on this path for several decades now and it's not working for us.  If we're going to have a discussion about economics and obesity, let's center that discussion around the patient, not the doctor.    
Second, the economic basis for this decision is deeply rooted in the fee-for-service world in which we currently live.  While I believe the death of the fee-for-service model is greatly exaggerated by some, there is an undeniable movement toward outcomes-based payment structures for providers, both hospitals and individual doctors (the rise of the Accountable Care Organization being the most notable among such structures).  I don't know how long the transition will take, but I do believe the AMA will some day regret the classification of obesity as a disease.  When the time comes that physicians are paid NOT for mere diagnosis and treatment, but rather based on the actual weight loss of obese patients, doctors will face the harsh reality that physician accountability and patient accountability are not one in the same. 
Most physicians (but not all) would rather get paid for the treatment they render or suggest.  In a fee-for-service model, obese patients aren't likely to experience issues with provider access.  But when payment streams are linked to outcomes, will that remain the case?  When a physician's paycheck is subject to whether a 300 lb. patient can drop meaningful weight, how many physicians will be willing to see that patient?  Accountable Care Organizations will develop risk-adjusted models for measuring outcomes, but these models will be inherently complicated and difficult for the average physician to grasp.  The point here: in an attempt to create access and funding for the treatment of obesity in a fee-for-service world, the AMA may have inadvertently thwarted future access and funding for obesity in an outcomes-based payment environment.
The fight against obesity should be about accountability and responsibility, but we should be focused on the accountability and responsibility of the patient, not the doctor. 
On Twitter @PRIUM1


  1. I agree with and appreciate the post.

    I look forward to the day that health insurance premiums are measured by risk like life, auto, and all the other insurances...

  2. I agree, the responsibility/accountability should be of the patient. You have to want to lose the weight & eat better & sensible.

  3. This article was very-well thought out. I really liked the idea of physicians' pay checks being based on the success of whether or not the patient lost the weight. Very interesting.