TOTAL POUNDS LOST = 56,179
The Price of Obesity
by Valerie Sutherland, MD
(The following is a condensed version of a lecture Dr. Sutherland gave recently on the economic implications of obesity.)
Nearly 40% of Americans have the disease of overweight/obesity (a body mass index (BMI) over 30. Obesity is not a lack of willpower; it is a biologic, environmental, and behavioral disease. As such it should be treated like a disease and without judgement. The implications of this disease are far-reaching. Obesity is linked to three of the five leading causes of death (heart disease, cancer, and stroke) and tied to 400,000 deaths each year. As such, it is considered one of the top preventable causes of death. In addition to physical complications experienced by obese individuals, there are economic consequences that impact those suffering from obesity, the doctors and hospitals who treat them.
ECONOMIC BURDEN ON DOCTORS AND HOSPITALS
Not surprisingly, these complications also come with financial costs. Many of the risks facing patients with obesity translate to economic challenges for the health care system. Patients with post-operative infections or who are readmitted to a hospital, both of which are more likely for obese patients, can result in financial repercussions for a health care system. The Hospital Readmission Reduction Program created by the Centers for Medicare & Medicaid Services (CMS) penalizes hospitals for “higher-than-expected” readmission rates in several categories. This is discriminatory because hospitals serving socially disadvantaged patients, including those who may not be able to afford medication or do not have the resources to follow-through on post-surgical rehabilitation, are held to the same standards as more selective hospitals. Additionally, reviews of surgical outcomes are based on standardized measures. Surgeries that are more complicated or time-consuming, such as those required by obese patients, do not fall within the identified parameters. As a result, providers may not be reimbursed fully by insurers like Medicare.
The length of time required for surgical procedures also has financial implications for doctors and hospitals. Most hospitals follow a fee-for-service model. These are based on surgical protocols developed with the assumption of an “average” no-risk patient. Consequently, the additional time required for surgery on obese patients results in a receipt of a lower fee. Additionally, while the cost of providing services have increased, Medicare typically provides a flat reimbursement which does not cover the cost associated with “more expensive” patients. This problem was exacerbated when CMS implemented reduced reimbursements for off- campus hospital outpatient departments.
Because of these risks, patients with obesity may be discouraged from getting surgery. The National Health Service in the United Kingdom proposed the controversial measure of restricting elective surgery for up to a year for patients who have obesity or smoke. During this period the patients would receive support and monitoring while waiting to become eligible for surgery. Public outcry was immediate and severe. The plan was viewed as discriminatory because obesity is an illness and it was seen as “rationing on the basis of poverty.” This practice is not limited to the U.K., however, and patients with obesity in the United States have had similar experiences. Treatments including elective procedures and organ transplants, might be denied because they are less effective or too risky for the patient.
Despite these practices, there is overwhelming consensus that delaying or denying surgery is not a viable option. Symptoms can worsen or lead to additional conditions if not treated. Moreover, failing to provide adequate care to obese patients is discriminatory24 and hospitals have a responsibility to provide a quality of care to all patients irrespective of the costs. Opposing viewpoints remain a topic of debate in the medical community and with obesity rates continuing to increase across the nation, it will remain a contentious issue.
MINIMIZING REVENUE LOSS
In reaction to the health care crisis, a variety of approaches have been implemented in an attempt to provide affordable, quality care for patients. Patients with obesity, in particular, face unique challenges that jeopardize not only their health but their financial well-being. This has a ripple effect with doctors and hospitals bearing the economic brunt. In the absence of a long-term, comprehensive solution, possible measures that consider treatment and outcomes for obese patients and the economic burden to providers are discussed below.
Prevention offers the greatest benefits to the myriad of issues associated with obesity. For most, however, it is not an easy or quick fix. Dieting and weight maintenance are likewise challenging. Many people, regardless of body type, have difficulty losing weight and physical and emotional obstacles are a further hurdle for obese individuals.
For many patients with obesity, surgery cannot be avoided. As such, doctors must be educated on the tools and equipment necessary to treat obese patients, as well as procedural adaptations that may be needed. Recommending less invasive practices also reduces costs and minimize negative health outcomes.28
Obesity among Americans is at epidemic levels and effective, long-term options are scarce, underfunded, or ineffective. As a result, the need for medical treatment for obesity-related diseases continues to rise, as does the economic burden for patients, doctors and hospitals. The medical community must consider new and different methods that provide the level of care patients deserve and counter the medical and financial burdens associated with serving obese patients. This requires a present and future view that addresses obesity as a medical condition while simultaneously treating the physical and mental health issues it generates.