Op-Ed
The Chicago Sun-Times
(Chicago, IL)
Published in Chicago, ILSept. 04, 2004
Now that Medicare covers obesity, it's time to test remedies
By Jessie C. GrumanWith a stroke of the pen this summer, obesity became a disease.
It already had been declared by one government agency as the second leading cause of death in the America, right behind tobacco. And the government already had pegged the prevalence of weight problems at about two-thirds of the U.S. population, costing at least $75 billion of federal money to treat. At current rates, nearly everyone in the United States will be overweight by 2040!
Being overweight is no longer — if it has ever been — strictly a matter of individual moral failings. The causes are complex, and the remedies are more so. You can always quit smoking, quit drinking and quit having risky sex, but so far as we know, you can't stop eating.
There is a signification association between obesity and higher rates of cancer in the esophagus, colon and rectum, liver, gallbladder, pancreas and kidney. Overall, current patterns of overweight and obesity in the United States could account for 14 percent of all deaths from cancer in men and 20 percent of those in women.
With the epidemic of obesity having already reached a tipping point, so to speak, and with an election coming up, it took no great courage for the Department of Health and Human Services to remove the rule that obesity is not a disease. Until now, Medicare would not pay for treating obesity except insofar as it was associated with another disease or if the patient was morbidly obese.
The interesting part, and the hopeful part from an administration that has been pilloried for its cavalier attitude toward science in other areas, is that future coverage will depend on evidence that a particular intervention or therapy actually works.
No immediate changes are expected in the Medicare program, but henceforth, individuals are free to petition Medicare to declare obesity interventions medically necessary, and the decision will be made based on the evidence of effectiveness.
Most people would be surprised to know how much of their medical care is based not on what has proved effective but on anecdotal data or observation from physicians as to what they think works. Because federal dollars pay for much of biomedical research and all of Medicare, we ought to be demanding full use of the evidence we have paid to collect.
One person in a position of authority who does know the value of evidence-based medicine is the head of the Medicare program, Mark McClellan. He is both a medical doctor and an economist — professions right behind law in their reliance on evidence. McClellan says, "The question isn't whether obesity is a disease or a risk factor. What matters is whether there's scientific evidence that an obesity-related medical treatment improves health."
The increasing, but as yet underappreciated, need for medicine to rely on actual evidence rather than anecdotes and tradition goes hand in hand with the need to look at disease as something for which the victim is not always responsible.
McClellan acknowledges that the buzzword "personal responsibility" can be "a euphemism for abandoning people," but it also is a necessity for people to take charge of their own wellness as technology permits health care to become tailored to an individual's specific genetic makeup and medical history.
McClellan heads an agency that by law is concerned with financing health care, not improving it. So it is, indeed, refreshing to have an M.D. in that position, saying, "As a doctor, I view Medicare as a public health program" and that "we mean it . . . that we are moving from treating the complexities of disease to preventing disease.
"Better evidence is at the center of better medical decision-making," says McClellan, who promises to start looking at research into patient outcomes in deciding which other services Medicare and Medicaid will cover.
With obesity consuming so many public and private dollars from the economy, it is the most appropriate place to start applying the firm rigors of evidence-based medicine to the flabby research that has gone on before.
Jessie C. Gruman is a social psychologist and president of the Washington-based Center for the Advancement of Health.
