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August
2004
Evidence-Based
Medicare: A Start
With a stroke of the pen on July 15, obesity became a disease.
It already had been declared by one government agency as the second
leading cause of death in America, right behind tobacco. And the
government had already pegged the prevalence of overweight and
obesity at about two-thirds of the U.S. population, costing at
least $75 billion in federal money to treat.
So, with the epidemic of obesity having already reached a tipping
point, so to speak, and with an election coming up, it took no
great courage for the Department of Health and Human Services to
remove the rule that obesity is not a disease. Until now, Medicare
would not pay for treating obesity except insofar as it was associated
with another disease or if the patient was morbidly obese.
The interesting part, and the hopeful part from an administration
that has been pilloried for its cavalier attitude toward science
in other areas, is that future coverage will depend on evidence
that a particular intervention or therapy actually works.
No immediate changes are expected in the Medicare program, but
henceforth, individuals are free to petition Medicare to declare
obesity interventions medically necessary, and the decision will
be made based on the evidence of effectiveness.
The head of the Medicare
program, Mark McClellan, is both an M.D., and an economist -
professions right behind law in their reliance
on evidence. McClellan said, “The question isn’t whether
obesity is a disease or a risk factor. What matters is whether
there’s scientific evidence that an obesity-related medical
treatment improves health.”
The increasing, but as yet underappreciated, need for medicine
to rely on actual evidence rather than anecdotes and tradition
goes hand in hand with the need to look at disease as something
the victim is not always responsible for.
In another forum, McClellan
acknowledged to a gathering of health advocates that the buzzword “personal responsibility” can
be “a euphemism for abandoning people,” but it also
is a necessity for people to take charge of their own health care
as technology permits health care to become tailored to an individual’s
specific genetic makeup and medical history.
McClellan heads an agency
that by law is concerned with financing health care, not improving
it. So it is, indeed, refreshing to
have an M.D. in that position, saying, “As a doctor, I view
Medicare as a public health program” and that “we mean
it … that we are moving from treating the complexities of
disease to preventing disease.”
“Better evidence is at the center of better medical decision-making,” says
McClellan, who promises to start looking at outcomes research in
deciding which services Medicare and Medicaid will cover.
If only those notions
were shared by the policy makers who, contrary to the evidence,
decided that abstinence-only sex education really
works and that the morning-after pill really doesn’t.
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