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01/20/2002 - Updated 07:30 PM ET

Weighing the cost of obesity

By Nanci Hellmich, USA TODAY

By Tim for USA TODAY

St. Louis physician Klein talks with patient

Beth Henk who has struggled to drop from 750 to 295 pounds.

Is being fat an illness that should be covered by

insurance?

It's true that obesity contributes to diabetes, heart

disease, arthritis and some types of cancer. But is obesity, on its own, a

disease? That's a question experts and advocacy groups are asking Americans

to consider. And the answer is likely to be costly.

Obesity is a growing problem in this country — about 26%,

or about 54 million adults, are obese, roughly 30 or more pounds over a

healthy weight, and about 300,000 deaths a year are attributed to obesity.

The surgeon general recently issued a call to action to reduce those

numbers, and he suggested talking about classifying obesity as a disease

that would qualify for reimbursement.

Such a move could open the door for more doctors' visits,

nutrition counseling and diet drugs to be covered. No one knows the exact

costs, but estimates suggest it could be several billion dollars a year.

Right now, some health insurers cover obesity treatments,

but it's far from universal. Physicians often don't tackle patients' weight

problems during office visits, because they won't get reimbursed for their

time. And in many cases, prescription diet drugs aren't covered.

The nation's leading obesity organizations are pushing to

change that. They say obesity is a disease that needs medical intervention

and should be covered by insurance, HMOs and Medicare and Medicaid. They

argue that more people would seek help if it were covered, and they say that

even modest weight loss of as little as 5% produces health benefits such as

lowering blood pressure and blood sugar and improving cholesterol levels.

And they argue those changes may save health care costs in the long run.

Medicare officials are expected to announce within the

next couple of weeks whether to classify obesity as a disease for the

program. The guidelines currently say that " obesity itself cannot be

considered an illness, " and Medicare usually doesn't cover treatments for

it. A change in the definition won't mean that Medicare will automatically

start paying for treatments, but it does leave an opening for more

discussions at national and state levels, experts say.

If obesity isn't covered, " people will continue to get

bigger and sicker, " says Billington, associate director of the

Minnesota Obesity Center in Minneapolis.

Downey, executive director of the American Obesity

Association, an advocacy group working to promote public policies on

obesity, says, " Obesity is the engine that is driving a lot of diseases —

heart disease, diabetes, hypertension, arthritis. We're paying for those

diseases, but not contributing nearly enough to deal with the underlying

cause, and that just doesn't make sense. "

But others argue that obesity is not really a disease but

a lifestyle issue that's a result of poor eating and exercise habits. They

say treating obesity would cost too much and would substantially raise

health care premiums for companies and individuals. And they argue that even

if people lost weight, there is no guarantee they'd keep it off.

" Historically, insurance companies have looked at obesity

as a condition that an individual should be able to manage through modifying

their own eating habits and increased exercise, " says Apgar, senior

medical director of care management for Blue Shield of California.

" Does one really need a doctor to accomplish these goals? "

If so, " should the individual pay for this, or is it

something your insurance company should pay for, i.e., all of us? " he asks.

Mayo Clinic professor Jensen, president of the

North American Association for the Study of Obesity, supports coverage but

says people also have to be realistic. " Let's face it. We cannot afford to

pay for doctors' visits for every overweight person in the United States.

There's not enough money in the world for that. "

On the other hand, he says, physicians should be

addressing obesity in people who have other medically significant issues.

Money part of solution

Obesity costs the country about $118 billion annually,

including direct health care costs for diseases related to obesity and

indirect costs, such as loss of productivity, according to an analysis by

Anne Wolf of the University of Virginia.

If more people started seeking medical and other

treatments for their weight, the cost could run into the billions, according

to USA TODAY estimates:

a.. Just one trip to the doctor a year by 25% of the 54

million obese Americans would cost more than $810 million, based on a doctor

visit charge of $60.

b.. If those same people took a year-long basic

nutrition/behavior modification treatment program at an estimated cost of

$450 a person, it would tally $6.1 billion.

c.. Prescription diet medication could cost as much as

$5.2 billion if just 10% of obese people went on a weight-loss drug for a

year, at a cost of $80 a month.

d.. If 100,000 severely obese people had gastric bypass

surgery, which creates a much smaller stomach and rearranges the intestine,

at a cost of about $24,000 a surgery, it would tally $2.4 billion.

(Currently, there are an estimated 56,000 surgeries a year; some are covered

by insurance.)

Estimates of obesity costs are purely pie-in-the-sky

numbers, some experts say. " Any projections are questionable because of the

many assumptions you have to make, " says Klein, director of the

Center for Human Nutrition at Washington University School of Medicine in

St. Louis.

But the topic needs to be tackled, Billington says. " As a

society we have to start talking about how to deal with this, and money is

part of the discussion. "

, associate director of the Clinical

Nutrition Research Center at the University of Alabama-Birmingham, says the

bottom line involves more than the price tag: " The critical question we need

to be asking is: Will an investment in obesity treatment and prevention

yield a good payoff in health, happiness and longevity? "

Boundaries questioned

The costs of treating obesity are hard to determine for a

number of reasons. Exactly who would qualify? Just the heavyset with medical

problems? What about the millions of pudgy Americans who weigh a little too

much and are on the road to becoming even fatter? What would the treatments

be —doctor visits, trips to a nutritionist, Weight Watchers, Craig and

other commercial diet programs?

" Everyone is concerned if they set a precedent, it's going

to break the bank. My feeling is that obesity is going to break the bank if

they don't do something, " says Hill, director of the Center for Human

Nutrition at the University of Colorado Health Sciences Center in Denver.

" Right behind this obesity epidemic is a diabetes epidemic, and that's very

expensive. "

There are a lot of questions about where the boundaries

for treatment would be, but " we have to start somewhere, " Hill says.

Like many obesity researchers, he believes coverage should

include visits to primary care physicians. " We want physicians to take on

obesity, and there is no way to take it on unless they get paid for their

time. "

Hill also thinks coverage should include prescription

weight-loss medications for some people. Two of the newest drugs on the

market are Meridia, which works on brain chemicals to control appetite, and

Xenical, which blocks some fat from being absorbed by the body.

" We're going to have to reimburse for them, or we're not

going to get the next generation of drugs, " Hill says.

Obesity experts say most doctors don't have the time or

expertise to really help patients learn new eating and exercise habits, so

they believe coverage also should include referrals to registered

dietitians, behavior modification experts or exercise physiologists. That

presents questions about who would be considered qualified to offer these

services and whether they'd be required to hold a special license.

" You'd have to make sure you cover legitimate practices

that treat obesity, not scam operations or fly-by-night programs, " Klein

says.

Some health plans are considering obesity coverage, and

others already have it. Kaiser Permanente, the largest non-profit HMO in the

country, offers treatment for obesity including doctors' visits, programs

with dietitians and nutritionists, weight-management courses and bariatric

surgery.

Blue Cross Blue Shield of Massachusetts also has obesity

coverage in its plan, including doctors' visits, lab tests,

medical-nutrition therapies, certain medications and certain surgeries. The

company also gives discounts for health clubs and Weight Watchers, among

other things. " We cover obesity like we would any other condition, because

we see it leading to other things, " says Anne Meneghetti, the vice president

of health policy.

Does all of this really help Americans' expanding

waistlines? Numerous studies on everything from prescription diet medication

to behavior modification show that dedicated dieters lose about 10% of their

weight in three to six months. For many people, that translates to about 20

pounds or so. Then the weight loss seems to slow down or halt. Some people

are able to lose and keep off more, but not everybody loses weight, and a

number who do are unable to keep it off.

Studies now are looking at whether treating obesity is

cost-effective, reducing the amount needed to treat the illnesses associated

with obesity. In the final analysis, Apgar says, " it's a matter of

allocating how you are going to use your health care resources. The cost is

going to come back to the consumer. "

Adds Klein: " Helping obese patients lose weight will treat

current obesity-related diseases and prevent new diseases from occurring. An

ounce of treatment now may prevent a pound of costs later. "

Contributing: DeBarros

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