Primary care physicians can assist their patients with weight management by using the 5As counseling framework (Assess, Advise, Agree, Assist, and Arrange).
Primary care physicians can use the 5As framework to build and coordinate a multidisciplinary team that: 1) addresses patients’ psychosocial issues and medical and psychiatric comorbidities associated with obesity treatment failure; 2) delivers intensive counseling that consists of goal setting, self-monitoring, and problem solving; and 3) connects patients with community resources to assist them in making healthy lifestyle changes. This paper outlines reimbursement guidelines and weight-management counseling strategies, and provides a framework for building a multidisciplinary team to maximize the patient’s success at weight management.
Over two-thirds of US adults meet criteria for overweight or obesity. Obesity has been linked to cardiovascular disease, type 2 diabetes, and several cancers. Intensive behavioral therapy for obesity has produced mean weight losses of 8%-10% of initial weight across clinical trials and significant reductions in the risk for developing diabetes and cardiovascular disease. Further, weight loss of this magnitude has been associated with improved diabetes control, lipids, and blood pressure across clinical trials. In 2011, the Center for Medicare & Medicaid Services (CMS) passed a decision to reimburse primary care physicians for delivering intensive behavioral therapy to treat patients with obesity. The US Preventive Services Task Force, and a joint statement by the American Heart Association, American College of Cardiology, and the Obesity Society also recommended that physicians screen for overweight and obesity in their practices and provide intensive behavioral counseling to patients with risk factors for cardiovascular disease. However, the rates of screening and counseling for obesity in the primary care setting are only 30%.
The Society of Behavioral Medicine is a multidisciplinary organization devoted to the science of health behavior change, and among its membership are experts who design and deliver evidence-based intensive behavior interventions for obesity. The purpose of this paper is to provide physicians with practical guidance on how to maximize obesity treatment for their patients with obesity.
Current Reimbursement Guidelines
The CMS now reimburses intensive behavioral therapy for obesity delivered by primary care physicians in a primary care setting. This reimbursement policy is limited to coverage for Medicare beneficiaries and reimburses only primary care practitioners. Alternative billing options exist for obesity treatment but vary widely across private payer groups. In brief, the CMS reimbursement model consists of 10-15-minute visits (maximum of 22 visits) on the following schedule:
- Month 1, one face-to-face visit every week
- Months 2-6, one face-to-face visit bi-weekly
- Months 7-12, one face-to-face visit monthly, contingent on the patient meeting the 3-kg (6.6-pound) weight loss requirement during the first 6 months of treatment.
One challenge is that reimbursement after 6 months is dependent upon the patient achieving a 3-kg weight loss during their initial 6 months of therapy. Several studies have identified that patients with low socioeconomic status, racial/ethnic minority backgrounds, and presence of medical comorbidities including sleep apnea, insomnia, chronic pain, and diabetes, or psychiatric comorbidities such as depression, attention deficit hyperactivity disorder, and binge eating disorder have more difficulty meeting this criterion. To avoid further exacerbating health disparities in these populations, early identification of at-risk patients and provision of additional support targeting these populations is critical.
The 5As Model for Weight Management Counseling in Primary Care
The recently updated 2013 obesity treatment guidelines include a treatment algorithm based on the 5As framework (Assess, Advise, Agree, Assist, and Arrange). This is an effective behavior-change counseling model. Studies have shown that each additional 5A step delivered by physicians has been associated with higher odds of patients increasing their motivation to lose weight, change their diet, and exercise regularly. In a recent study, physicians who used the 5As showed a twofold increase in obesity management (ie, diagnosis and coordinating follow-up) in primary care settings.
Behavioral medicine research has identified several psychosocial factors and psychiatric and medical comorbidities associated with poor obesity treatment outcomes and supports the importance of a team-based approach to obesity care. Below, we describe a modified 5As model in which the physician: 1) provides brief counseling; 2) identifies and arranges care for psychosocial issues and medical and psychiatric comorbidities associated with poor weight loss outcomes; and 3) builds and oversees a comprehensive treatment team that addresses the patient’s biopsychosocial needs
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-Stephanie L. Fitzpatrick, PhD, Danielle Wischenka, MA, Bradley M. Appelhans, PhD, Lori Pbert, PhD, Monica Wang, PhD, Dawn K. Wilson, PhD, Sherry L. Pagoto, PhD
This article originally appeared in the January 2016 issue of The American Journal of Medicine.
