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Intensive Behavior Therapy for Obesity Works with the Right Training
posted 02.20.2013

By Mindy Haar and Tobi Abramson

Numerous health problems arise as a result of being overweight or obese. The Center for Disease Control and Prevention reports increasing rates of hypertension and Type II diabetes mellitus correlating with rising obesity rates. According to the New York State Department of Health, New York ranks second in the United States for adult obesity–related medical expenditures, with total spending in New York rising from $6.1 billion in 2003 to $7.6 billion at present—81 percent of which is paid by Medicaid and Medicare.

Many studies show that even moderate changes can have a dramatic impact on some diseases. According the Diabetes Prevention Group, for those with pre-diabetes, an average weight loss of only 9 pounds over three years, and 20 minutes of daily exercise reduced the risk of diabetes by half.

Early research on weight loss in older adults did not distinguish between intentional and unintentional weight loss and so did not conclusively recommend weight reduction for this population. Other studies targeting intentional weight loss in this group indicated uncertainty over benefits versus risks.

Recent work in this area emphasizes a growing trend, in consistent agreement, that weight reduction reduces chronic illness morbidity and can improve physical functioning in older adults. For this reason the Centers for Medicare and Medicaid Services (CMS) has determined there is adequate evidence to conclude that intensive behavioral therapy for obesity is reasonable and necessary for the prevention or early detection of illness or disability. Such therapy is appropriate for individuals entitled to benefits under Medicare Part A or enrolled under Medicare Part B, and is recommended with a grade of A or B by the U.S. Preventive Services Task Force.

Intensive behavioral therapy for obesity consists of the following:

  1. Screening for obesity in adults using body mass index (BMI) measurement;
  2. Dietary (nutritional) assessment; and
  3. Intensive behavioral counseling and therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

As of November 2011, Medicare CAG-00423N will cover the following for its obese beneficiaries:

  • One face-to-face visit every week for the first month;
  • One face-to-face visit every other week for months two through six;
  • One face-to-face visit every month for months seven through twelve, if the beneficiary meets the 3-kilogram weight-loss requirement.

These services will be covered only when counseling is provided by a qualified primary care physician or other primary care practitioner including a nurse practitioner, clinical nurse specialist or a physician assistant. While referrals may be made to outside dietitians, psychologists, social workers or mental health counselors, these visits would not be covered under Medicare, as the emphasis is on incorporating these services within the primary care environment. Only when the dietitian or mental health professional is employed by the primary care provider and provides services in the same office as the primary care provider is he or she eligible for reimbursement.

Many primary care providers covered by this Medicare provision are not prepared to provide these services. While nursing students are required to take one course in nutrition, physician assistant and medical school curricula do not require this subject. Several studies document medical students’ and residents’ dissatisfaction with their nutrition education and perceived lack of confidence in providing adequate nutrition counseling to patients. Similarly, while these health professions include psychology in both didactic and clinical rotations, the instruction pales in comparison to the training of a mental health professional. That leaves us with a professional void in knowledge of nutrition and behavior therapy in those who should be providing these important health services for older adults, if they provide them at all.

As experts in facilitating behavioral change, mental health professionals should be aware of this recent legislation and coverage. Lobbying for increased recognition as expert providers of such services is important to spur future similar coverage decisions. Promoting nutrition and mental health employment positions as part of primary care practices will also assure a more complete attention to both physical and mental health needs of older adults.


 

Mindy Haar, Ph.D., R.D., C.D.N. is director of program development in the Department of Interdisciplinary Health Science at the New York Institute of Technology in Old Westbury, New York. Tobi Abramson, Ph.D., is director, Mental Health Counseling Program, assistant professor, and mental health counseling director, Center for Gerontology and Geriatrics at the New York Institute of Technology.

This article was brought to you by the editorial committee of ASA’s Mental Health and Aging Network (MHAN).

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