The Treat and Reduce Obesity Act of 2019

by Payal Sharma, MSN, RN, FNP-BC, CBN

Ms. Sharma is a doctoral student at Yale University School of Nursing and Nurse Practitioner in General Surgery at NewYork-Presbyterian/Weill Cornell Medicine.

Funding: No funding was provided.

Disclosures: The author has no conflicts of interest relevant to the content of this article.

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Abstract: This policy brief aims to summarize the steadily growing Medicare enrollment, increased life expectancy, and current and growing rates of obesity in older adults in the United States (US). Additionally, the current limitations in coverage of essential services, including intensive behavioral therapy (IBT) and US Food and Drug Administration (FDA)-approved pharmacotherapies for Medicare beneficiaries are outlined, and the benefits of supporting The Treat and Reduce Obesity Act (TROA) are provided.

Keywords: treat, reduce, obesity, TROA, nurse practitioners, Medicare, older adults, intensive behavioral therapy, IBT, primary care provider, dietitians, obesity medicine specialists, psychologists, psychiatrists, clinical nurse specialists, overweight, epidemic, obesity drugs, obesity medications

Bariatric Times. 2020;17(1):16–17.

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With our aging population, growing life expectancies, and incidence of obesity in the United States (US), initiatives to effectively address obesity in older adults are critical. This policy brief summarizes the issues that have led to the introduction of The Treat and Reduce Obesity Act (TROA) of 2019 and addresses reasons to support it.

The Medicare population has grown steadily since the program’s inception in 1966, with 44 million beneficiaries presently enrolled.¹ Enrollment is expected to rise to 79 million by 2030.¹ Life expectancy rates in the US are record high, with people born in 2005 projected to have an average life expectancy of 78 years.² These findings reflect a continuing trend of increasing life expectancy that began in 1955, when the average American lived to be 70 years old.² From 2007 to 2010, more than one-third of adults aged 65 years or over had obesity, which corresponds to approximately 13 million older adults with obesity.³ The US Centers for Disease Control and Prevention (CDC) estimate that about 41 percent of adults aged 60 years or over had obesity between 2015 and 2016, representing more than 27 million people.⁴ By 2050, the number of older American adults (i.e., people aged 65 years or over) is expected to more than double, rising from 40.2 million to 88.5 million.³

Obesity and Aging

Both aging and obesity contribute to increased healthcare use.³ Obesity accounts for 21 percent of national healthcare spending, which is roughly $210 billion/year.⁵ Treatment costs associated with obesity in patients on Medicare or Medicaid are estimated at $61.8 billion annually; eradicating obesity could result in 8.5 percent in savings in Medicare spending.⁵ An increase in the proportion of older adults with obesity might compound healthcare spending. As Americans live longer and the age distribution shifts so that there are more older adults, the number of older adults with obesity could grow, even without an increase in obesity prevalence.³ 

According to the National Institutes of Health (NIH), obesity and overweight are the second-leading cause of preventable death nationally, with an estimated 300,000 deaths annually attributed to the epidemic.⁴ Obesity increases the risk for chronic diseases, including high blood pressure, heart disease, certain cancers, arthritis, mental illness, sleep apnea, and diabetes.⁴ More than half of Medicare beneficiaries are treated for five or more chronic conditions yearly.⁴ The rate of obesity among Medicare beneficiaries doubled from 1987 to 2002 and nearly doubled again by 2016, with Medicare spending on individuals with obesity during that time rising proportionately to reach $50 billion in 2014.⁴ Men and women with obesity aged 65 years or older have decreased life expectancy.⁴ The direct and indirect cost of obesity was greater than $427.8 billion in 2014 and continues to increase.⁴ Medicare spends $2,018 more per patient annually treating beneficiaries with obesity compared to those of healthy weight.^4,6

Barriers to Effective Obesity Treatment

One of the barriers to effective obesity treatment is that US Centers for Medicare & Medicaid Services (CMS) limits coverage for intensive behavioral therapy (IBT) only to services that are provided by a primary care provider in the primary care setting.^4,7 IBT consists of measurement of body mass index (BMI), nutritional assessments, and intensive behavioral counselling that promote sustained weight loss through high-intensity diet and exercise interventions. In 2012, the US Preventive Services Task Force (USPSTF) recommended screening all adults for obesity and either referring or offering patients with a BMI of 30kg/m² or higher to intensive, multicomponent behavioral interventions.⁴ USPSTF’s evidence report concluded that these interventions are an effective component in obesity management, which can result in an average weight loss of 4 to 7kg and improve glucose intolerance, blood pressure, and other physiologic risk factors for cardiovascular disease.^4,6,7 This narrow coverage decision prevents healthcare providers, such as dietitians, who are best suited to effectively provide IBT from doing so.^4,7 Furthermore, Medicare’s decision is contradictory to the USPSTF evidence report, which highlighted that primary care providers have limited time, training, and skills to conduct the high-intensity interventions that have been shown to be the most effective to produce the greatest results.^4,7 Additionally, when Congress enacted the Medicare prescription drug program, there were no widely accepted FDA-approved obesity drugs.^4,7 There have been significant medical advances in the development of obesity medications over the past few years.⁷ That fact combined with our current and growing obesity epidemic illustrate that the Part D statute is both out of date and out of touch with the current scientific evidence surrounding these new pharmacotherapies.^4,7 The efficacy of IBT for obesity and the potential benefit of adding pharmacotherapy have been demonstrated in the literature.⁸

What is the Solution?

The Treat and Reduce Obesity Act of 2019 (S 595/HR 1530) aims to effectively treat and reduce obesity in older Americans.^4,6,7 This bill addresses the barriers to effective obesity treatment by enhancing Medicare beneficiary access to healthcare providers who are best suited to provide this therapy, including specialized nurse practitioners, physician assistants, clinical nurse specialists, dietitians, obesity medicine specialists, endocrinologists, bariatric surgeons, and psychologists or psychiatrists and permitting Medicare Part D to cover FDA-approved obesity drugs.^4,6,7

Reasons to Support TROA

Weight management is important for older adults due to the risks associated with typical fat redistribution during aging and the prevalence of comorbid conditions in this age group.⁹ The number of older adults is projected to increase substantially, and addressing obesity is essential for the health of this rapidly growing population.⁹ Obesity in older adults impacts not only morbidity and mortality, but also impacts quality of life and the risk of institutionalization.¹⁰ Weight loss interventions can effectively lead to improved physical function. With the emergence of newer medications effective in weight management, older adults are increasingly asking about the possibility of taking such medications.¹⁰

Patients who received IBT from a dietitian for at least two years are twice as likely to achieve clinically significant weight loss, experience greater average weight loss, and exercise more than patients who did not receive IBT.¹¹ The expert consensus is that dietitians are the best suited to carry out IBT, as stated by the National Academies of Science, Engineering, and Medicine (formerly the Institute of Medicine), USPSTF and a majority of physicians.¹¹ Supporting dietitians to provide IBT is also cost-effective because their services cost 25-percent less per two pounds of weight loss. Additionally, their payment fee is 85 percent of fees charged by primary care providers. Dietitians can help minimize costs for nutrition services such as IBT, while delivering the best results. TROA enforces coordinated, interdisciplinary care that increases efficiency and efficacy, which improves healthcare quality and reduces costs.¹¹

Current status on TROA

Senator Pat Roberts co-sponsored TROA on September 25, 2019. Senator Joni Ernst and Senator Richard Burr co-sponsored it on October 16, 2019. Senator Bill Cassidy is in the process of submitting the bill to Congressional Budget Office for a score with Senator Chuck Grassley’s support.⁶ To take action in the House of Representatives, please contact:

• Alex Eveland in Rep. Ron Kind’s office at [email protected] or
  202-225-5506
• Sophie Trainor in Rep. Brett Guthrie’s office at [email protected] or 202-225-3501

To take action in the Senate, please contact:

• Robert Butora in Sen. Bill Cassidy’s office at [email protected] or 202-224-5824
• Lynn Sha in Sen. Tom Carper’s office at [email protected] or 202-224-2441

References

1. AARP. 2009. The Medicare beneficiary population: fact sheet. https://assets.aarp.org/rgcenter/health/fs149_medicare.pdf. Accessed January 3, 2020.
2. Reinberg S. 2019. U.S. life expectancy hits new high. https://abcnews.go.com/Health/Healthday/story?id=4508655&page=1. Accessed January 3, 2020.
3. Fakhouri TH, Ogden CL, Carroll MD, et al. 2012. Prevalence of obesity among older adults in the United States, 2007-2010. https://www.cdc.gov/nchs/data/databriefs/db106.pdf. Accessed January 3, 2020.
4. Obesity Care Advocacy Network. 2019. Treat and Reduce Obesity Act [Handout]. Capitol Hill, Washington, D.C.
5. Academy of Nutrition and Dietetics (2019b). Treat and Reduce Obesity Act (S.595/H.R. 1530) [Issue Brief]. https://www.eatrightpro.org/-/media/eatrightpro-files/advocacy/troaissuebrief-2019. pdf?la=en&hash=5B2887955411A60ED38 FCB665E1894F50185373A
6. Congress.gov. 2019. S. 595 – Treat and Reduce Obesity Act of 2019. https://www.congress.gov/bill/116th-congress/senate-bill/595/text. Accessed January 3, 2020.
7. Centers for Medicare & Medicaid Services. 2012. Intensive Behavioral Therapy (IBT) for obesity. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM7641.pdf. Accessed January 3, 2020.
8. Wadden TA, Walsh OA, Berkowitz R, et al. Intensive behavioral therapy for obesity combined with liraglutide 3.0mg: a randomized controlled trial. Obesity (Silver Spring). 2018;27(1):75–86.
9. Gill LE, Bartels SJ, Batsis JA. Weight management in older adults. Curr Obes Rep. 2015;4:379–388.
10. Batsis JA, Zagaria AB. Addressing obesity in aging patients. Med Clin North Am. 2018;102(1):65–85.
11. Academy of Nutrition and Dietetics (2019a). Treat and Reduce Obesity Act. https://www.eatrightpro.org/advocacy/legislation/all-legislation/treat-and-reduce-obesity-act Accessed January 3, 2020.

Tags: clinical nurse specialists, dietitians, epidemic, IBT, intensive behavioral therapy, Medicare, nurse practitioners, obesity, obesity drugs, obesity medications, obesity medicine specialists, older adults, Overweight, primary care provider, psychiatrists, psychologists, reduce, treat, TROA

Category: Brief Report, Past Articles