The Vague Paternalism of Medicare Obesity Coverage

“At the end of the day, what we’d like to see is fewer obese people in the Medicare population about which we have to have these conversations.” Those striking words came Aloysius Cuyjet, MD, MPH. They came after he chaired more than five hours of evidence review at Medicare’s advisory committee on evidence and coverage for benefits related to bariatric surgery and procedures. It was a day of vague paternalism and occasional flashes of bias.

Modern Healthcare reported that the panel gave a low vote of confidence to the evidence for bariatric surgeries.

A Commitment to Put Patients First

The day opened with a visual reminding the panel of CMS strategic goals to put patients first. If that was the goal for CMS, then the words of the committee chair were frustrating to their purpose.

Early in the day, OAC president Joe Nadglowski made a plea to the committee: “Please do not let weight bias enter into your review today.”

But Cuyjet’s view seemed to be that we should not have to deal with so many “obese people.” He said:

I think we need to make a larger commitment to the public health side of the equation. Less video games, less fast foods, less television, less computer time. We need to be physically active and really make intelligent choices in our diet.

At the end of the day, what we’d like to see is fewer obese people in the Medicare population about which we have to have these conversations.

Those words might have been innocent or naive. But they reflect a bias that confronts people living with obesity every day. People with obesity are not unintelligent. We are dealing with a chronic disease that can devastate our health and our lives.

Nonetheless, those were the comments from the chair to introduce voting questions to the panel.

Hugely Important Decisions and Vague Questions

CMS coverage decisions are hugely important. ASMBS past president John Morton put it succinctly to Modern Healthcare: “If CMS sneezes, the rest of insurers get a cold.”

But the voting questions were exceptionally broad and vague. They did not address any specific procedure or technology. But rather, they lumped them all together in an undifferentiated group.

“How confident are you that there is sufficient evidence for an intervention?”

Make no mistake. This is a paternalistic process. CMS decides what Medicare will and will not allow. People with obesity deserve more careful and specific consideration.

Click here for the agenda and all the materials from the meeting. Video from the full day is available in two parts, here and here. For more from Modern Healthcare, click here.

Hand of God the Father, Sketch by Albrecht Dürer / flickr

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August 31, 2017