Medical Weight Loss “Mini-clinics” in Primary Care.
Mohammed Tarrabain, MD. Family medicine and obesity medicine (double board certified)
St. Vincent Health, Indianapolis, USA
Dr. Tarrabain consultant speaker (2016) for Novo Nordisk (Saxenda) and reported no potential conflict of interest relevant to this article.
Introduction and background:
Primary care is arguably an ideal place to provide weight management as most health service contact with obese people occurs there, and people may be more responsive to advice when it is linked to health-related issues.1
In the USA, guidelines for screening and management of obesity in adults have been extensively updated (Table1). The American Medical Association (AMA) adopted a policy in June 2013 recognizing obesity itself as a disease, with the hope that doing so will help change how the medical community tackles this costly epidemic.2,3The National Institutes of Health (NIH) 4
U.S. Preventive Services Task Force USPSTF5
The Endocrine Society 6
The American Heart Association (AHA)/American College of Cardiology (ACC)/The Obesity Society (TOS)7
(table1) Current obesity guidelines.
Pharmacotherapy according to the new guidelines can be considered as an adjunct to comprehensive lifestyle interventions.3The rationale for use of medications is to help patients adhere to a lower-calorie diet more consistently.7 More recently, there was the introduction and marketing of new FDA drugs for weight loss.8-11
Reported physician barriers to obesity guideline adherence often include time and reimbursement, competing medical issues, and lack effective weight loss tools. 12, 13This results in negative perceptions of patients’ unwillingness or inability to change.
According to new Centers for Medicare and Medicaid Services (CMS) guidelines, physicians are now allowed to bill for intensive multi-component counseling for weight loss. 14 Reimbursement for these health care services would be collected by providers as long as it remains only in the primary care setting. (Table 2) Physicians would follow usual procedures and proper medical documentation when treating obesity and its comorbidities.15 (Table 3)CMS obesity coverage; (allowed number of visits) / notes
One face-to-face visit every week for the first month; (4 visits)
One face-to-face visit every other week for months 2-6; (8 visits)
One face-to-face visit every month for months 7-12; (6 visits) / To be eligible for additional face-to-face visits occurring once a mo for an additional 6 mo, beneficiaries must have achieved a reduction in weight of at least 3kg over the course of the first 6 mo of intensive therapy.
Methods of reimbursement / notes
Diagnosis / Obesity unspecified.
Evaluation and management / Co-morbid conditions will increase the reimbursement level. Examples: dyslipidemia, and hypertension. And of course diabetes, or impaired fasting glucose, impaired glucose tolerance (insulin resistance), pre-diabetes and metabolic syndrome.
(Table 2) CMS obesity reimbursment.
(Table 3) Obesity and its comorbidities reimbursement.
Over the past 2 years, we have successfully implemented a guideline based obesity management program for our patients in the primary care. Presented here are highlights of this work and a discussion about obesity practice models.(16)
Patient Recruitment: Adult patients coming for wellness exams, or other medical issues including weight. In later stages, referrals from various sub-specialties (orthopedics, spine, pulmonary and GYN) and other primary care doctors and patients by word of mouth.
Clinic Personnel: Physician support staff consisted of one clinical medical assistant (who rooms patients, takes vitals, updates medication lists, and starts office notes), triage nurse (manages phone calls), and office front desk staff (scheduling and billing). No dietician or weight loss trained counselors were included.
Office Visits: Obese patients would be informed about medical weight loss treatment in our clinic. Then, he or she was given a specifically created “Obesity History Form” to fill out. (Table 4)“Obesity History Form” information
- Patient demographics.
- Does patient have a primary care physician?
- Current medications (including over the counter)
- Medical history relevant to obesity: CVD, DM, and other as thyroid, PCOS and depression.
- Family history of obesity and comorbidities.
- Personal body weight trends (when started to gain weight, what were events or reasons, and why wants to lose weight now)
- List of previous diets (here we ask if patient has ever considered bariatric surgery in past)
- Dietary patterns in a typical day (meals, snacks, fast food and drinks). Eating behaviors including food cravings, hunger and satiety; in addition to stress and emotional eating.
- Lifestyle and activity (description of usual energy levels, personality traits, occupation) and exercise.
- Assessment of levels of confidence and motivation to change habits and lose weight.
(Table 4) Obesity History Form (Original form concept by American Society of Bariatric Physicians©)
After detailed history, the physician performs a physical exam and orders labs (fasting lipids, HbA1c, metabolic panel, thyroid levels and other per clinical relevance ex. fasting insulin, vitamin D). Brief counseling on lifestyle treatments was done by the physician himself and each patient was given printed handouts on diet and activity. Current FDA approved “anti-obesity” medications for treating weight were mentioned. The importance of achieving medically significant weight loss and then maintaining long term was discussed. Before the visit was concluded, weight goals were agreed upon. This entire initial visit was usually 30 to 45 minutes long.
The patient would then schedule a follow up appointment within two weeks for review of specific conditions and lab results. Weight loss assessment and lifestyle counseling continued. Here a weight loss medication was prescribed after risk and benefits of selected agent reviewed. The patient would be informed about the need for regular office follow up to monitor therapy and continue treatment plans. These visits were 15 to 30 minute encounters.
At the six months mark, the total weight loss was calculated and a repeat of blood labs done. Medication and lifestyle interventions continued per current obesity guidelines for long term weight loss maintenance.
Obesity practice management is now very much evolved. 17 (Table 5) Research was long needed on different models of managing weight in primary care practice.18 Based on our program; we here discuss a few models of such medical weight loss “mini-clinics.”Obesity Practice Management
- Awareness of Societal Cost of Obesity
- Obesity Management Guidelines and Recommendations
- Reimbursement and Coding
- Policies and Protocols
- Staff Training Techniques
- Role of Team
- Communication and Collaboration
- Motivational Interviewing
- Patient/Family/Caregiver Engagement
- Culturally Tailored Communication
- Mental Health
- Cost Effectiveness of Treatment Options
- Presentation of Success Rates
(Table 5) Obesity practice management.
Chronic Care Model (CCM) model: described as “evidence-based interactions between an informed, activated patient and prepared, proactive primary care providers.” It aims to increase physicians’ efficacy which should ultimately have positive effects on their clinical practice and patient outcomes. From our experience, this requires increasing knowledge (CME, training), effective tools (accurate guidelines, medications), and support (staff, resources).
Patient centered medical home (PCMH) model: defined as “a group of physicians who practice together in collaboration with nurses and other health care professionals all responsible for ensuring health services in a given population.” This would result in improved accessibility and continuity of care. Obesity could be addressed in PCMH with patients as center of care or “triple aim” (Figure 1). Benefits of such framework include quality (patient outcomes, higher patient satisfaction), efficiency (lower total costs of care) and physician productivity (providing needed services).
(Figure 1) Patient centered care.
Obesity “teams” model: or discreet weight management clinics. 19 (Figure 2) This would have implications for obesity treatment approaches and tools including interdisciplinary referrals (medical, surgical). It may be the most integrated obesity management model and we currently have only begun to scratch its surface.
(Figure 2) Obesity management.
Suggestions and recommendations:
1) Weight loss medications approval and availability.
2) Adoption of “medical weight loss” joint principles. (Figure 3) (Figure 3) “Medical weight loss” joint principles.
Next Steps (Homework)
- Begin discussions about where the additional resources will come from.
- Build weight loss leading teams. (Figure 4)
- Launch pilot “weight loss mini-clinics.”
(Figure 4) Weight loss leading teams.
St. Vincent Medical Group. Westfield Primary Care team.
The “Obese” patient.
Mohammed Tarrabain, MD. 14828 Greyhound Court, suite 100. Camel, IN 46032, USA.
1. Wee C, Davis RB, Phillips RS. Stages of readiness to control weight and adopt weight control behaviour in primary care. J Gen Intern Med. 2005;20:410–415.
2. American Medical Association. AMA adopts new policies on second day of voting at annual meeting. Obesity as a disease. Published 2013
3. Hammond RA and Levine R. The Economic Impact of Obesity in the United States. Diabetes Metabolic Syndrome and Obesity: Targets and Therapy. 3:285-295, 2010.
4. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf (Accessed on March 2, 2016).
5. Moyer VA. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373-378.
6. Apovian CM, Aronne LJ, Bessesen DH, McDonnell ME, Murad MH, Pagotto U, Ryan DH, Still CD; Endocrine Society. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015 Feb;100(2):342-62.
7. Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, Hu FB, Hubbard VS, Jakicic JM, Kushner RF, Loria C, Millen BE, Nonas CA, Pi-Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM, Yanovski SZ. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. November 2013:1-69.
8. USFoodandDrugAdministration. V-0521(QNEXA) AdvisoryCommitteeBriefingDocument. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM292317.pdf. Published 2012. Accessed February 17, 2016.
9. US Food and Drug Administration. FDA Briefing Document – NDA22529 Lorcaserin. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM303198.pdf. Published 2012. Accessed February 17, 2016.
10. US Food and Drug Administration. FDA Briefing Document – NDA 200063 Contrave. http://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/drugs/endocrinologicandmetabolicdrugsadvisorycommittee/ucm235671.pdf. Published 2015. Accessed February 17, 2016.
11. US Food and Drug Administration. FDA Briefing Document - NDA 206321 Liraglutide Injection 3 mg. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM413317.pdf. Published 2014. Accessed October 14, 2015.
12. Rippe JM, Crossley S, Ringer R. Obesity as a chronic disease: modern medical and lifestyle management. J Am Diet Assoc. 1998;98:S9–15.
13. Frank A. A multidisciplinary approach to obesity management: the physician's role and team care alternatives. J Am Diet Assoc. 1998;98:S44–48.
14. Reimbursement for Providers Medicare http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R142NCD.pdf. Accessed October 14, 2015.
15. Beckley ET. Evaluating and Billing for Obesity. DOC NEWS 2(3): 6-12, 2005
17. Donahoo WT. Obesity Practice Management Bits and Bobs or The mortar that holds it all together? Obesity Week 2013 - American Society for Metabolic & Bariatric Surgery and The Obesity Society Joint Meeting 2013 (ASMBS TOS 2013)
18. Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review. J. Gen. Intern. Med. 2009;24:1073–1079.
19. Baillargeon et al. Impact of an integrated obesity management system on patient’s care - research protocol. BMC Obesity 2014, 1:19