AMA's Obesity Declaration Could Open Door for Coverage, Treatment

The American Medical Association’s (AMA’s) Board of Delegates voted June 18, years behind the rest of the medical establishment, to classify obesity as a disease,¹ a move many believe will eventually expand what insurers pay for and medical schools teach, shrink the stigma of obesity, and add important momentum to public health initiatives.

The Board of Delegates, disregarding a committee recommendation, voted to recognize obesity as a “disease state with multiple aspects requiring a range of interventions to advance obesity treatment and prevention.’’¹ The resolution supporting the AMA policy noted that the World Health Organization (WHO),² Internal Revenue Service (IRS),³ the US Food and Drug Administration (FDA),⁴ American Association of Clinical Endocrinologists (AACE)⁵ and the National Institutes of Health (NIH)⁶ already regard obesity as a disease.

“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately 1 in 3 Ameri-cans,” said AMA board member Patrice Harris, MD. “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.”¹

The policy is a sea change for the AMA and long awaited by obesity physicians and advocates. In 2009, the Board of Delegates voted not to recognize obesity as a disease for determining disability.

But this year, on the same day AMA announced the obesity policy, it separately announced complementary policies recognizing potential risks of prolonged sitting and encouraging the removal of sugar-sweetened drinks from the Supplemental Nutrition Assistance Program (SNAP).⁷ “This has tremendous symbolic importance,’’ said Ted Kyle, RPh, MBA and chair of the advocacy committee of The Obesity Society, whose more than 2000 members are active in basic and clinical obesity research. “The NIH adopted these guidelines in 1998, so it took AMA a long time to come around.’’

Obesity, perhaps unique among ailments, was commonly called an epidemic before it was officially classified a disease. According to the Centers for Disease Control and Prevention (CDC), 35.7% of adults and 17% of children are considered obese,⁸with the obesity rate among teens and children having tripled since 1980.8 CDC estimated medical costs attributable to obesity in 2008 at $147 billion, with per capita spending on obese persons $1,429 more than persons of healthy weight.⁹

John Morton MD, associate professor of surgery at Stanford University and secretary-treasurer of the American Society for Metabolic and Bariatric Surgery, said while AMA is last among medical associations and public health organizations to call obesity a disease, it is the most influential. “The AMA recognizing obesity is a disease has practical implications that cannot be overstated,’’ Morton said. “Some insurers might decide to cover it. This encourages us to look at obesity from a treatment model. Prevention is the first thing. I believe this will get people thinking (whether) advertising sugar to children is the right thing to do. This will open up discussion in the family, which is good because obesity is a family disease.’’

A 2004 Gallup poll found only 21% of Americans considered obesity a disease, while 75% of those polled, including those who were obese or overweight, viewed it as a problem resulting from poor eating and lifestyle habits.¹⁰ A Gallup representative said the firm will consider posing the question again. The AMA policy change can only help reduce that stigma of obesity, Kyle said.

“A lot of folks were clinging to old notions that obesity is a matter of choice,’’ Kyle said. “Folks who study this disease know there is complex biology going on. Choices matter, but that is not all that matters. Two people can eat the same diet and have much different weight.’’

A clause in the resolution supporting the new AMA obesity policy implicitly addressed bias, reading, “The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes.’’

The AMA policy change adds momentum to the recognition of obesity as a disease that requires treatment and the means to obtain treatment. As an example, in 2004, then-Secretary of Health and Human Services Secretary Tommy G. Thompson, testifying before a Senate subcommittee, called obesity “a critical public health problem in our country that causes millions of Americans to suffer unnecessary health problems and to die prematurely.” Thompson announced Medicare would strip language from its policies that did not characterize obesity as a disease to remove barriers to necessary obesity coverage.

Nine years later, and the same day the AMA delegates voted on the new obesity policy, federal lawmakers cited the AMA action when they announced introduction of the Treat and Reduce Obesity Act of 2013. The law, introduced by US Senators Tom Carper, D-Delaware, and Lisa Murkowski, R-Alaska, and US Representatives, Bill Cassidy, R-Louisiana, and Ron Kind, D-Wisconsin, would require the Centers for Medicare & Medicaid Services (CMS) to “highlight and provide additional information regarding Medicare coverage’’ of obesity treatments and medication coverage, goals much like those Thompson had reached for in 2004.

Indeed, news reports in the immediate aftermath of the AMA vote predicted the policy change would be a boon for new obesity drugs and those under development, notably Belviq from Eisai and Arena Pharmaceuticals and Qsymia, sold by Vivus. Another company, Orexigen, is working toward FDA approval for Contrave, which is a combination of bupropion and sustained-release naltrexone.¹¹

There is no sign that health insurers will suddenly be more willing to pay for obesity treatments, especially surgery, in the wake of the AMA policy. Susan Pisano, spokeswoman for America’s Health Insurance Plans (AHIP), the national trade association of health insurers, said the AMA reclassification by itself would not change how insurers view obesity. “Whether you call obesity a risk factor, a condition or a disease, coverage is determined by what is a safe and effective treatment or service,’’ Pisano said. “What drives coverage is evidence that a treatment or service is safe and effective.”

What drives coverage decisions is far from clear to Ethan Lazarus, MD, director of Clinical Nutrition Center, an obesity medicine practice in Denver, Colorado, that performs bariatric surgery. “Unti now insurance companies could sit by and say this (obesity) is not a disease and not pay for treatment, even though people are dying from this disease at an alarming rate,’’ said Lazarus, who spoke in favor of the policy during the AMA debate as delegate from the American Society of Bariatric Physicians.

Lazarus cited the case of a recent new patient, an obese a 39-year old father of 2 young children. He was suffering congestive heart failure, type 2 diabetes mellitus, sleep apnea, depression, and psoriasis. The man’s cardiologist advised bariatric surgery, but his insurance company would not pay for surgery and stopped him from paying for it, according to the patient.

“I was told that if I paid for the surgery myself that I would not be covered medically for any complications that may arise from the surgery for (my) lifetime,’’ the patient, who asked for anonymity, wrote in an e-mail. “Given my diabetes and CHF I am at a higher risk for complications and the fact that they said for lifetime, who knows what they would blame on the after effects of the surgery and deny me coverage.’’

Lazarus said he’s hopeful the AMA recognition of obesity as a disease will eventually lead to a standard criteria for health insurance to cover surgery but also systemic changes. “This resolution is saying we should treat the obesity as we do the high blood pressure,’’ he said. “There needs to be coverage and medical school education. I am a board-certified physician and I got 4 lectures on nutrition and none on obesity in medical school.’’

Shortly after the vote, the AMA view of obesity as a disease had legal significance. An employee of Car-Mart Inc in Missouri filed suit in federal court claiming he’d been fired for being “severely obese’’ in violation of the American with Disabilities Act (ADA), the first time obesity has been cited in an ADA suit.¹² Jon Hyman, a Cleveland employment law attorney with Kohrman Jackson & Krantz specializing in the American with Disabilities Act, said the prestige of the AMA will inevitably makes its view on obesity a factor in disability claims. “That is the trade association of physicians, and when they speak or offer an opinion, people tend to listen,’’ he said.

LuAnn Heinen, vice president at the National Business Group on Health, based in Washington, DC, said employers shouldering the costs of health insurance have long been focused on obesity. “By itself the AMA action doesn’t mean that much for employers because they have been concerned about the issue for a long time,’’ Heinen said. “It improves the ability to analyze claims data because obesity is now coded. We are worried it might be used to drive more use of medical services when the message we need is to change our lifestyle and choices. Bariatric surgery is a covered benefit, but everybody would prefer it wasn’t needed, which is why many companies use Weight Watchers, online coaching, various incentives and benefits.’’

Many observers view the AMA’s obesity declaration as momentous, similar to its 1956 recognition of alcoholism as a disease or the Surgeon General’s warning on cigarettes in 1964. Neither action had immediate consequence or was binding on anyone. But both events proved to be turning points, after which there was a gradual shift in thinking: Instead of the conditions being viewed as the actions of individuals with health consequence, they were recognized as matters of treatment and public health.

“This (designation of obesity as a disease) is not on our radar screen among current issues but we’re aware of it,’’ said Jason Hammersla, director of communications for the American Benefits Council. He noted employers and insurers evolved substance abuse and mental health benefit packages for decades before the Mental Health Parity and Addiction Equity Act of 2008 required group health plans to treat mental health and substance abuse disorders on par with physical illness. “There is a long gestation period on something like this,’’ Hammersla said.1. AMA Web site. AMA adopts new policies on second day of voting at annual meeting. Press release, June 18, 2013. http://www.ama-assn.org/ama/pub/news/news/2013/2013-06-18-new-amapolicies-annual-meeting.page. Accessed September 1, 2013.

2. World Health Organization Web site. Obesity:preventing and managing the global epidemic: report of a WHO Consultation (WHO Technical Report Series 894) http://www.who.int/nutrition/publications/obesity/WHO_TRS_894/en/ Accessed September 1, 2013.

3. American Obesity Treatment Association website. Internal Revenue Service Ruling 2002-19. www.americanobesity.org/irsruling.htm Accessed September 3, 2013.

4. FDA Web site. Crawford, L. Combating the Nation’s Obesity Epidemic. Testimony before the House Committee on Government Reform. June 3, 2004. http://www.fda.gov/NewsEvents/Testimony/ucm113779.htm Accessed September 1, 2013.

5. Mechanick J, Garber A, Garvey WT. AACE Obesity Position Statement, Endocr Pract. 2012;18 (No.5):642-648.

6. NIH Web site. What are the health risks of overweight and obesity? July 13, 2012. http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks.html Accessed September 3, 2013.

7. AMA website. Press release. AMA Adopts Policy Addressing Obesity, Beverages with Added Sweeteners. Press release, June 20, 2013. http://www.ama-assn.org/ama/pub/news/news/2012-

06-20-ama-policy-addresses-obesity.page. Accessed September 3, 2013.

8. CDC Web site. Obesity and Overweight. http://www.cdc.gov/obesity/data/facts.html. Accessed Sept. 3, 2013.

9. Harvard School of Public Health website. Paying the Price for those Extra Pounds. Obesity Prevention Source. http://www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/

economic/ Accessed September 3, 2013.

10. Gallup website. Public: lifestyle, not disease, causes obesity. http://www.gallup.com/poll/12661/public-lifestyle-disease-causesobesity.aspx Press release. Accessed September 3. 2013

11. Japsen B. AMA’s obesity-as-disease vote should boost diet drugs. Forbes. June 19, 2013. http://www.forbes.com/sites/brucejapsen/2013/06/19/amas-obesity-as-diseasevote-should-boost-diet-drugs/. Accessed August 30, 2013.

12. Whittaker v. America’s Car-Mart, Inc. Case:1:13-cv-00108-SNLJ Doc. #: 1 Filed: 07/19/13. US District Court Eastern District of Missouri. http://www.manatt.com/uploadedFiles/Content/

4_News_and_Events/Newsletters/AdvertisingLaw@manatt/Whittakerv.AmericasCar-MartInc. pdf. Accessed September 3, 2013