SPECIAL ARTICLE

Conflicts in Inconsistent Arthur Frank

the Care of Overweight Patients: Rules and Insufficient Money

The medicalization of obesity, the recognition and un- derstanding of the physiological abnormalities of food con- sumption and weight regulation, should put to rest its tra- ditional status as an outcast medical problem. Unfortu- nately, as we have seen an increase in the understanding of abnormal metabolism in patients with obesity, we have also seen an increase in confusion and contradiction in its clini- cal management. What kind of care should we provide for patients with obesity? Who should provide it? Who will pay for it?

Perhaps some of the confusion derives from our status as the sad beneficiaries of a legacy of 50 years of cultural and medical indifference to the problem of obesity. Perhaps obesity is a very special disease with characteristics so unique that ordinary clinical considerations are not appli- cable. Perhaps we have been the all-too-passive victims of a malevolent health insurance industry which has merci- lessly manipulated patients and health care professionals. Probably for all these reasons, and for others as well, we have been left with a remarkably difficult burden in the clinical care of patients with obesity. We are trying to cope with contradictory requirements for services, inconsistent expectations of comprehensive care, and imposed financial obstacles which are entirely incompatible with the scientific reality of the disease.

For this discussion ignore the difficult issue of com- mercialization, the store-front charlatans, and the sellers of prescriptions, the dead rat on the floor. Let us also delay an examination of what obesity specialists are doing. Consider instead, the real world of the care of people with obesity; the care provided by ordinary doctors, with or without medica- tions, for their struggling, overweight patients. How do these doctors and patients treat obesity? There is value in

Submitted for publication December 9, 1996. Accepted for publication January 7, 1997. From the George Washington University Obesity Management Program, Department of Medicine, George Washington University School of Medicine, Washington, DC 20037. Reprint requests to Arthur Frank, George Washington University Obesity Manage- ment Program, Suite 208, Three Washington Circle, NW, Washington DC 20037. Copyright 0 1997 NAASO.

exploring the simple issue of competent, caring, and knowl- edgeable physicians who recognize the serious implications of the disease and want very much to take good care of their patients. They are struggling with the dissonance of mixed messages in their efforts.

First there is the message from the patient who says: “Give me the pills,” and says this with a pleading fer- vor which is rarely expressed for other diseases. Patients who might ordinarily say: “I don’t do pills,” are now pursuing obesity medications with irrational intensity. And the troubled doctor says: “I have for decades been absolute. ‘No pills.’ I am a therapeutic purist. That’s what I learned in medical school and that’s the mandate from the FDA.”

Next there is the message from the pharmaceutical companies who say: “Use these medications. They will help your patient,” but are subtly and directly sending that same message to the patient and to the public. And the doctor wonders: ‘‘Are they creating expectations which are going to be impossible to fulfill?”

Then there are the message from the academics who say: “These medications will only be helpful to your pa- tients if they are very overweight and if you provide nutri- tion education, behavior modification and exercise therapy.” And the doctor asks: “How can I help patients who are not substantially overweight? What about the hope that early intervention will prevent serious illness? How can I provide all of these services? These people are not on my staff. ’ ’

And finally, there is the unambiguous messages from the payers (the insurance/managed care industry). “It doesn’t make any difference. Regardless of what you do, we are not going to pay for it.” And the good doctor, who says: “I’ll call it something else on the insurance form. Once again, obesity is more trouble than it is worth.”

The most dedicated doctors will avoid these contradic- tions. The most credible of them, the ones we need the most, are the least likely to get involved. The vacuum will be filled by the commercial opportunists, the bustlers and the quacks. The bad will drive out the good.

A management monster has been created. The mixed messages are creating a jungle of service inconsistences and

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The Care of Overweight Patients, Frank

financial confusion and a covert and deliberate underground of mislabeling of medical records and insurance claims.

The resolution of these conflicts depends on the will- ingness of the insurance and managed care industry and on government agencies to characterize obesity as a disease, and to provide benefits as they would for the treatment of any other disease. But health insurance companies do not pay benefits for the treatment of obesity. They offer several reasons, and a simplistic assessment of their analysis ap- pears compelling. It is useful, however, to put their analysis to a mote rigorous standard of inquiry. We get a different perspective if we try to compare their reasoning with their patterns for the payment of insurance claims for comparable medical problems (Table 1).

The arguments that claim that obesity is not a disease

or that it is simply willful misconduct have no merit in denying insurance coverage. Would we allow the denial of benefits for the nondiseases of senility or pregnancy, or would we assert that AIDS or motorcycle accidents are simply willful misconduct? It might be reasoned that obe- sity is a social or cultural problem or that it is simply the inescapable consequence of afluence and abundance. Both assertions are partly true, but both are irrelevant. Insurance benefits pay for the social and cultural problems of lung cancer and sexually transmitted diseases. Benefits also pay for the manifestations of affluence which are reflected in substance abuse, and abundance, which enables us to live long enough to develop Alzheimer’s disease.

The argument that the treatment of obesity does not work is not true. Even if it were, the payment of benefits for

Table 1. Health insurance benefits and the treatment of obesity

Common assertions about obesity

Are health The same insurance benefits

Is this assertion may be paid for assertion true? made for . . . these conditions?

Obesity . . .is not a disease . . .is willful misconduct . . .is a social, cultural prob-

lem . . .is the inescapable conse-

quence of affluence and abundance

The treatment of obesity . . .does not work . . .does not cure the disease . . .is difficult

. . .produces benefits which . . .are small . . .are remote

opportunists . . .is provided by commercial

. . .is not cost effective The cost of the treatment of

obesity . . .if paid by insurance, will

result in adverse patient selection

. . .is substantial . . .short term . . .long term

not true senility, pregnancy not true AIDS, motorcycle accidents partly true but irrelevent

partly true but irrelevant

lung cancer, sexually transmit-

substance abuse, Alzheimer’s ted diseases

disease

not true true and irrelevant true and irrelevant

senility, mental retardation hypertension, diabetes premature birth, anorexia ner-

vosa

not true and irrelevant true but incomplete partly true but irrelevant

Prader-Willi, pancreatic cancer cigarette smoking, osteoporosis cancer, pain, arthritis

probably not true (no data) AIDS, senility, cancer

true, unless there is a universal psychiatric illness, pregnancy benefit

marginally true possibly true (no data)

common cold, back pain schizophrenia, renal failure

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The Care of Overweight Patients, Frank

the unsuccessful treatment of senility or mental retardation establishes that futility of treatment is not an obstacle for the provision of insurance benefits. There is no dispute that the treatment of obesity does not cure the disease, but we do not deny benefits for the unsuccessful cure of hypertension or diabetes (or almost all medical problems). Similarly, we would agree that the treatment of obesity is dzficult; so, too, is the treatment of premature babies and anorexia nervosa.

It is asserted that the treatment of obesity produces benefits which are small and which are remote. The small benefits argument is false, and irrelevant in any case. We could also reason that the benefits of treating the Prader- Willi syndrome or pancreatic cancer are very small. The argument that benefits are remote is true, just as are the benefits for treating cigarette smoking or osteoporosis. It is often argued that the treatment of obesity is clouded by commercial opportunists. Sadly, this is also true, as it is with our marginal colleagues who treat cancer, pain, and arthritis by providing our desperate patients with copper bracelets, laetrile, and aroma therapy. It is asserted that the treatment of obesity is not cost effective, but it would also be difficult for financial analysts to establish the cost-effectiveness of the treatment of senility, AIDS, or can- cer.

Ultimately, we must consider the costs of the treatment of obesity. It is clear that paying benefits results in adverse patient selection for the individual insurance company. This would produce a commercial disadvantage for one company but would be of no consequence if obesity benefits were offered in a universal format. This universality of benefits is what makes it possible to pay for the care of psychiatric illness and pregnancy. Perhaps it could be argued that the costs of treatment are substantial. The short term costs of obesity care may be significant, but probably not more so

than the costs of treating the common cold or acute back pain. Finally, it is possibly true that the long term costs of treatment of the chronic and incurable disease of obesity are substantial, and that this financial burden could offer a com- pelling reason for denying benefits. I know of no data to establish that this is true any more than it is true in the provision of benefits for schizophrenia or renal failure. An equally compelling argument could be made that savings in the sustaining costs of the care of the common obesity co- morbidities (diabetes, hypertension, hyperlipemias, etc.) would more than compensate for the direct costs involved in the provision of obesity care.

It seems inescapable that the underlying reasons for denying insurance benefits for the treatment of obesity are two-fold: it will cost a lot of money, and insurance compa- nies see no reason to modify a self-serving policy that they have successfully manipulated for decades. A reasonably rational argument can be made that this cost analysis is unestablished and unproven. With equal reason, we could argue that obesity treatment could save money. It should not then be difficult to reject the status quo argument for much more compelling intellectual, financial, or moral reasons.

In any case, no claim to justify the denial of benefits for the treatment of obesity has any validity when held to the standards of health insurance otherwise available in the United States. It should be obvious that such a judgement is ethically unconscionable.

The exploration of the mysteries of obesity will be of interest to scientists and scholars, but it will be of no value to our patients unless we can devise some way of getting proper services to them. It should be our challenge to the health insurance industry, the managed-care industry, and to government agencies to analyze the existing system and accept the moral responsibility to modify their policies.

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