Tuesday, August 14, 2007

Medicare's Obesity Policy Flawed

An article below that has some wisdom in theory but not much in practice. Following the article are some comments sent to its author by a medical specialist

In government-run health systems, bureaucrats make the decisions about what treatments will be available, not patients and doctors. And sometimes, those decisions don't make sense

Case in point: The agency that runs Medicare - the Center for Medicare and Medicaid Services - is limiting access to the full range of obesity treatments even though Medicare's costs of covering obese patients are rising dramatically. This flies in the face of reason. Obesity is associated with heart disease, stroke, diabetes, respiratory problems and cancer. Its prevalence in Medicare has doubled in the last 20 years, and the share of spending by Medicare on obese patients has almost tripled, from 9.4 percent to nearly 25 percent.

Obesity is a serious problem in the United States, especially for Medicare patients. But CMS has its head in the sand. It has said that weight-loss drugs will not be covered under the Medicare drug benefit. In so doing, it has seriously limited physicians' options for treatment. The reality is that diet and exercise sometimes don't work, especially among elderly patients. Medicare will, however, pay for expensive bariatric surgery, the last-resort treatment for obesity.

When President Bush promoted the Medicare drug benefit, he argued that it didn't make sense for Medicare to pay for ulcer surgery but not ulcer medications. Now, CMS has repeated the same mistake - ruling that Medicare will pay for obesity surgery but not for medications that will help patients address obesity. Doctors can therefore prescribe medicines for problems caused by obesity, like coronary artery disease, high blood pressure and diabetes. But it will not allow health plans to include obesity medicines in their list of available drugs.

The proposal is bad public health policy. It is inconsistent with Medicare's new focus on care management and disease prevention. After all, this isn't simply about lifestyle choices for people who want to lose a few pounds on the latest diet drugs. We're talking about giving physicians and patients the tools they need so that together they can decide what treatment is best.

There are two widely recognized prescription obesity drugs approved by the FDA - Xenical and Meridia - and dozens of new promising therapies in development. If Medicare - the nation's largest health provider - decides against paying for these drugs, private health plans will likely follow.

One of the hallmarks of the Medicare Modernization Act of 2003 was to, well, modernize the program. That meant emphasizing preventive care and disease management to keep people healthier longer and giving physicians and health plans latitude to adopt modern disease-management models.

Medicare already is going broke, but its bankruptcy will be accelerated if it pays only for care after people get sick instead of allowing the whole arsenal of options for ensuring that people stay well. Prevention saves money and lives. As the obesity problem grows, Medicare needs to make sure that physicians and patients have all available treatment options.


Some comments:

I would respectfully disagree with the authors of your Aug 10 newsletter that Medicare's obesity policy is flawed by not offering a "full range of services". This could include health club memberships, steam baths, personal trainers, surgery, and a whole bunch of "treatments" that are of marginal benefit; for almost all these "treatments", benefits are transient. This exposes many taxpayer to abuse by overutilization.

Obesity is largely behavioral. Most Government programs to alter behavior have been failures, because individuals, family, community are the most effective "treatments". These include:

1 The public schools. "Soft" approach to discipline and low expectations have had the opposite result desired - students are LESS motivated to work hard.

2 Marriage initiative - not very effective.

3 Now plan to "encourage assimilation" for immigrants. What self respecting immigrant doesn't already know this? If anything, Government obstructs assimilation with its multi language and other multicultural requirements. There are many other examples.

Possible solutions - market based, such as graded insurance premiums based on risk - obesity is a CONTROLLABLE risk.

Personal story - born in 1943, in 1993 I lost an institutional job. Applied for private life insurance - turned down for obesity (5'5", 247 pounds. In about 3 months I was down to 186 for insurance physical. Walked for about an hour/day in Texas heat in fall, then rode exercise bike while watching movies with surround sound. Healthiest and happiest I have been in years; trying to re establish exercise habit. My obesity is behavioral - my behavior.

What about doctor's behavior? In NH doctor was sued by patient he told was overweight. Parents cry for prosecution of teachers who call children "fatso". Code of conduct does not allow students to say "you're too fat". Fat children are treated with kid gloves to not hurt their "self esteem".

Some places require a "fatness index" as part of a school report card. Can any sane person tell me this was effective - some parents were actually upset to learn that their child is "fat". How can any sane parent not know this?

Do breast implants triple the long-term risk of suicide?

The media report below says so but the actual journal article (abstract below) is more realistic: Women who seek breast augmentation are more likely to have problems in their lives to start with. There is NO evidence that the implants themselves cause anything. I imagine most readers also realize that the once-prominent health scares associated with implants were debunked long ago. If not, see here

Breast implants triple the long-term risk of suicide, claims a new study in the Annals of Plastic Surgery. The increased suicide risk from cosmetic breast enlargement -- together with a similar increase in the risk of death from alcohol or drug dependence -- suggests that women receiving breast implants should also have follow-up mental health checks, say the authors. They performed an extended follow-up study of 3527 Swedish women who underwent cosmetic breast implant surgery between 1965 and 1993. The average age at implant surgery was 32 years. Death certificates were used to compare causes of death between women with breast implants and the general female population. Over an average follow-up period of nearly 19 years, the suicide rate was three times higher for women with breast implants (based on 24 deaths among implant recipients). The risk was greatest -- nearly seven times higher than in the general female population -- for women who received their implants at age 45 or older.


Excess Mortality From Suicide and Other External Causes of Death Among Women With Cosmetic Breast Implants

By Lipworth, Loren et al.


An increased rate of suicide among women with cosmetic breast implants has been consistently reported in the epidemiologic literature. We extended by 8 years the follow-up of our earlier mortality study of a nationwide cohort of 3527 Swedish women with cosmetic breast implants to examine in greater detail suicide and other causes of death. The number of deaths observed among these women was compared with the number expected among the age- and calendar-period-matched general female population of Sweden. Women with breast implants were followed for over 65,000 person-years, with a mean follow-up of 18.7 years (range, 0.1-37.8 years). Overall, 175 deaths occurred among women with breast implants versus 133.4 expected (standardized mortality ratio (SMR) = 1.3; 95% confidence interval [CI], 1.1-1.5). Among women with implants, we observed statistically significant 3-fold excesses of suicide (SMR, 3.0; 95% CI, 1.9-4.5) and deaths from alcohol or drug dependence (SMR, 3.1; 95% CI, 1.0-7.3), as well as an excess of deaths from accidents and injuries consistent with substance abuse or dependence. The increased risk of suicide was not apparent until 10 years after implantation. Deaths from cancer overall were close to expectation (SMR, 1.1; 95% CI, 0.8-1.4). Women with cosmetic implants had elevated SMRs for lung cancer and chronic respiratory disease. There was no excess of breast cancer mortality. The excess of deaths from suicides, drug and alcohol abuse and dependence, and other related causes suggests significant underlying psychiatric morbidity among these women. Thus, screening for preimplant psychiatric morbidity and postimplant monitoring among women seeking cosmetic breast implants may be warranted.

Annals of Plastic Surgery. 59(2):119-123, August 2007


Just some problems with the "Obesity" war:

1). It tries to impose behavior change on everybody -- when most of those targeted are not obese and hence have no reason to change their behaviour. It is a form of punishing the innocent and the guilty alike. (It is also typical of Leftist thinking: Scorning the individual and capable of dealing with large groups only).

2). The longevity research all leads to the conclusion that it is people of MIDDLING weight who live longest -- not slim people. So the "epidemic" of obesity is in fact largely an "epidemic" of living longer.

3). It is total calorie intake that makes you fat -- not where you get your calories. Policies that attack only the source of the calories (e.g. "junk food") without addressing total calorie intake are hence pissing into the wind. People involuntarily deprived of their preferred calorie intake from one source are highly likely to seek and find their calories elsewhere.

4). So-called junk food is perfectly nutritious. A big Mac meal comprises meat, bread, salad and potatoes -- which is a mainstream Western diet. If that is bad then we are all in big trouble.

5). Food warriors demonize salt and fat. But we need a daily salt intake to counter salt-loss through perspiration and the research shows that people on salt-restricted diets die SOONER. And Eskimos eat huge amounts of fat with no apparent ill-effects. And the average home-cooked roast dinner has LOTS of fat. Will we ban roast dinners?

6). The foods restricted are often no more calorific than those permitted -- such as milk and fruit-juice drinks.

7). Tendency to weight is mostly genetic and is therefore not readily susceptible to voluntary behaviour change.

8). And when are we going to ban cheese? Cheese is a concentrated calorie bomb and has lots of that wicked animal fat in it too. Wouldn't we all be better off without it? And what about butter and margarine? They are just about pure fat. Surely they should be treated as contraband in kids' lunchboxes! [/sarcasm].

Trans fats:

For one summary of the weak science behind the "trans-fat" hysteria, see here. Trans fats have only a temporary effect on blood chemistry and the evidence of lasting harm from them is dubious. By taking extreme groups in trans fats intake, some weak association with coronary heart disease has at times been shown in some sub-populations but extreme group studies are inherently at risk of confounding with other factors and are intrinsically of little interest to the average person.


1 comment:

The Patients Advantage said...

www.thepatientsadvantage.com...If you are going to go down the cosmetic surgery road...better to be safe than sorry. Check them out.