Conference Coverage

One practice’s experience with obesity treatment

The increase in the proportion of people who are overweight and obese presents gastroenterologists with new challenges and opportunities. Our internal medicine background, experience in nutrition, and role as endoscopists puts us in a unique position to manage obesity. In addition, many GI conditions are directly affected by obesity, including NASH, GERD, pancreatic diseases, and colon cancer. Good nutrition will always be the cornerstone of healthy weight, but nutritional advice alone results in modest (2%-3%) total weight loss. This can be augmented with medications, meal replacement, endobariatrics, and combinations of these.

Having said this, there are significant challenges to managing obesity as a gastroenterologist, and these stem almost entirely from the fact that there is poor coverage for these therapeutic options, as emphasized by Dr. Feldshon. However, it is still important to bring weight loss interventions into our clinical practice – for many reasons.

First, unlike other obesity management programs, we are typically not managing obesity in isolation. Usually, we are managing obesity in the setting of a disease state such as NASH. When we manage patients with NASH and stage 3 fibrosis, the patients’ decision making on how much to invest to prevent further progression is different; they’re more likely to take on some costs. Second, the degree of coverage for medications is improving. Similarly, although endobariatrics is not currently covered, with time it likely will be under certain criteria.

We need to build the clinical experience necessary to manage obesity and do so now, or other specialties will have become the main providers of weight loss interventions. This will become a lost opportunity for both medical and endobariatric management of these patients by us.

So despite the challenges raised by Dr. Feldshon, I would suggest that a practicing gastroenterologist interested in weight loss management focus on patients with obesity-related diseases first and expand their focus incrementally.

Wahajat Mehal, MD, DPhil, is a hepatologist and director of the Yale Weight Loss Program at Yale University, New Haven, Conn. He is an associate editor for GI & Hepatology News.


 

EXPERT ANALYSIS FROM DDW 2018

WASHINGTON – “We have heard about a lot of really interesting new things in therapy, but the reality is that they are just not economically viable at present,” said David Feldshon, MD, of Minnesota Gastroenterology (MNGI), speaking about his experience with offering obesity treatment in his practice.

One problem that Dr. Feldshon and MNGI faced was that they could never get enough patients into their weight loss program, a meal-replacement program priced at about $200 a month. Part of this program, Optifast, a commercially available low-calorie diet and behavior modification program, cost about $360 a month. Most patients found the cost to be prohibitive according to Dr. Feldshon. The program that MNGI offered was fairly competitive when compared with a number of other commercial diet programs like Nutrisystem and Medifast, which cost $300 and $329 a month, respectively.

Because of the economic pressure these programs can exert on patients, Dr. Feldshon spoke to the difficulty of recruiting patients with major metabolic and digestive disorders. “I work in the liver clinic, so I see people with NASH, NAFLD, cirrhosis, near-cirrhosis, diabetes. These are people that would really benefit from this type of program, and I could not get a single patient to sign up.”

For Dr. Feldshon’s program, patients were required to come to MNGI once a week, which led to higher dropout rates. This is troubling because it is important that patients meet with doctors and other patients as part of a weight loss program. But the inconvenience for patients and doctors is not just in physically attending meetings, but in the medical billing. The Affordable Care Act and Medicare cover obesity screening and counseling, but this is only for primary care physicians, nurse practitioners, physician assistants, or clinical nurse specialists. These limits may not extend into private insurance, but they remain a barrier for those covered by Medicare, according to Dr. Feldshon.

Another effective but ultimately expensive option is weight loss drugs. The cost of drugs can vary wildly. Even well-established drugs like phentermine can cost anywhere from $5 to $35 out of pocket a month, according to Dr. Feldshon. Some drugs, like Saxenda, can cost as much as $1,414 per month if paid for out of pocket. While Saxenda is effective, there is a catch in the prescribing and billing for this drug: “The moment you go above 2.4 mg per day, the insurance company says, ‘Aha! He’s treating obesity,’ and they stop covering it.” One drug that Dr. Feldshon recommends is topiramate because it is a multiuse drug. “Often, the insurance company can’t figure out why you’re prescribing it, so they’ll okay it,” said Dr. Feldshon.

One of the most effective nonsurgical methods of weight loss is intragastric balloon. From 2016 to 2017, MNGI used gastric balloons in 22 patients, resulting in 11.4% total body weight loss in these patients. Unfortunately, it was a “financial loser,” according to Dr. Feldshon. The global case rate charge for one balloon is $8,200. MNGI then incurred $2,000 per balloon, $3,000 in hospital charges, $750 for the medical weight loss program, $1,350 for office personnel and visits, and a calculated opportunity cost of $3,140 resulting in a net loss of $2,040 per balloon. The most important factor in this calculation is the opportunity cost, which includes travel to and from the hospital and phone encounters with patients, which took away Dr. Feldshon’s ability to conduct colonoscopies and GI consults.

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