Obesity Care Continuum Comments to AHRQ re USPSTF Recommendations for Childhood/Adolescent Obesity Screening and Treatment

November 28, 2016

ATTN: United State Preventive Services Task Force

RE: Draft Recommendation Statement: Obesity in Children and Adolescents: Screening

The Obesity Care Continuum (OCC) is pleased to provide the following comments in response to the United States Preventive Services Task Force (USPSTF) proposed 2016 draft recommendation statement entitled, "Obesity in Children and Adolescents: Screening." We appreciate the Task Force for updating these critical recommendations.

Before providing our specific comments below, we want to applaud the USPSTF for adopting people-first language in the text of the recommendation and supporting evidence documents. People with conditions such as autism, diabetes, or asthma prefer to be considered as people first, and not be defined by their condition. Research shows that people-first language affects attitudes and behavioral intentions toward persons with disabilities. Because of this, people-first language has become the standard for most chronic diseases and disabilities and we are pleased that the Task Force has adopted this approach regarding individuals affected by obesity.

Question 1: How could the USPSTF make this draft Recommendation Statement clearer?

The OCC believes that the Task Force should include language into the formal recommendation statement that encompasses the frequency and specificity of interventions outlined in the accompanying evidence report (Comprehensive, intensive behavioral interventions with a total of 26 contact hours or more) Absent clear language regarding these parameters in the recommendation statement itself, many health insurance plans will continue to define what the plan believes to be sufficient level interventions.

The Public Health Service (PHS) Act and federal regulations also allow plans to use "reasonable medical management" techniques to determine the frequency, method, treatment, or setting for a preventive item or service to the extent it is not specified in a recommendation or guideline. While there is no formal regulatory definition or parameters for reasonable medical management, medical management techniques are typically used by plans to control cost and utilization of care or comparable drug use. For example, plans can impose limits on number of visits or tests if unspecified by a recommendation, cover only generics or selected brands of pharmaceuticals, or require prior authorization to acquire a preferred brand drug.

The combination of these caveats and limitations has resulted in many questions about how plans should implement the preventive services policy. In particular, questions have arisen about the frequency, range of methods that can be used for certain services, and the types of providers that are subject to the policy. The Departments of Health and Human Services, Labor, and Treasury jointly issue memos as “Frequently Asked Questions” (FAQs) specifically on implementation of the Affordable Care Act which provide additional clarification on different aspects of coverage of preventive services.

For these reasons, the Tri-Agencies issued the October 23, 2015 FAQ advising against coverage exclusions for weight management services as part of the implementation of the ACA. As part of that FAQ, the Tri-Agencies highlighted how the 2012 USPSTF recommendation for weight management in adults “specifies that intensive, multicomponent behavioral interventions include, for example, the following:

  • Group and individual sessions of high intensity (12 to 26 sessions in a year),
  • Behavioral management activities, such as weight-loss goals,
  • Improving diet or nutrition and increasing physical activity,
  • Addressing barriers to change,
  • Self-monitoring, and
  • Strategizing how to maintain lifestyle changes."

Following the October 23, 2015 Tri-Agencies guidance, the obesity community conducted an analysis of obesity treatment coverage language contained in essential health benefit (EHB) benchmark plan submissions for each of the 50 states and the District of Columbia for 2017. The study focused on coverage language specific to obesity screening and referral for intensive, multicomponent behavioral interventions for weight management in adults.

In examining each state's certificate of coverage regarding weight management services under both the "excluded services" and "covered preventive health services" sections, we found that 24 states (AK, AR, CO, DE, FL, HI, IA, ID, KS, KY, LA, ME, MS, MT, NE, NJ, NV, NY, OR, SC, SD, WI, WV and WY) exclude coverage for weight/obesity management services and made NO MENTION of obesity screening and counseling services under the USPSTF covered preventive services section of the document. While the remaining state EHB benchmark plans (26 states and the District of Columbia) do indicate some mention of obesity screening and possibly counseling services under the covered preventive services section of the certificate of coverage, most of the language only referred broadly to USPSTF recommended services with A or B evidence rating. Of the states that did include frequency criteria, all but one (NC) came in under the USPSTF bar. For example: once every calendar year (AL); two visits per year for nutritional counseling (CT); four visits per year for nutritional counseling (GA); three months for participation in qualified weight loss program(s) each calendar year (MA); and nutritional counseling for obesity - Maximum Benefit Allowance of 4 visits per Member per Benefit Period (ND).

Question 3: Based on the evidence presented in this draft Recommendation Statement, do you believe that the USPSTF came to the right conclusions? Please provide additional evidence or viewpoints that you think should have been considered.

In reviewing the "Clinical Considerations" section of the draft evidence report, we notice the Task Force did find benefit surrounding a cluster of studies with minimum contact hours between 26-51 hours and the greatest benefit found in the group of studies with 52 or greater hours. However, we note that the studies included in the former were actually between 30-45 contact hours and between 67-114 contact hours in the latter.

While the USPSTF groupings might be statistical, they are actually arbitrary from a clinical standpoint. The OCC collaborates with the researchers that have conducted these studies and should the 26-hour minimum make it into the final recommendation statement, it would end up requiring the development and implementation of a new intervention that doesn’t currently exist. At the same time, this minimum threshold could also provide language for payers to use to actually limit coverage for effective interventions, when there are no such studies or models or approaches at the 26 or 52 hour cut off levels. For example, the Diabetes Prevention Program is effective at the dose it was studied at and is provided at, not at a lower dose or fewer sessions. This is what Medicare will now cover and this same approach to the language should be applied regarding the treatment of obesity.

4. What resources or tools could the USPSTF provide that would make this Recommendation Statement more useful to you in its final form?

The OCC urges the Task Force to specify, from the studies, who are the intervention personnel delivering this treatment? We believe such information would be informative regarding development of additional intervention models.

It would also be helpful if the USPSTF Recommendation Statement include language about the recommended frequency/spacing of the contact hours (i.e., does it matter if the contact hours are all within a month or spread out over a year), or if there is insufficient evidence to make a recommendation on this, to include similar language to other key questions (i.e., "We have found no studies meeting out inclusion criteria…").

5. The USPSTF is committed to understanding the needs and perspectives of the public it serves. Please share any experiences that you think could further inform the USPSTF on this draft Recommendation Statement.

Based on evidence, USPSTF concludes that the most effective behavioral interventions to address childhood or adolescent obesity are comprehensive and intensive in nature. While we are extremely pleased with this recognition, we are also deeply concerned that these types of intervention are not uniformly available to many children, especially those in underserved settings. And even if they are available, it may be very difficult for children/parents to maintain consistent participation due to various barriers such as transportation or difficulty getting time off from work and school. Nor are many of these programs delivered with fidelity to the methods described in the studies when scaled-up for broader dissemination.

We certainly need novel and innovative strategies to help both prevent and treat obesity that are more feasible for both service providers and families while maintaining sufficient dose and fidelity. There is truly a need for more supported research to examine translation and dissemination of interventions to real-world community settings -- in formats that are not only effective, but also doable for both service providers and families.

Again, we appreciate the opportunity to provide these comments. Should you have any questions or need additional information, please contact me via email at chris@potomaccurrents.com or telephone at 571/235-6475. Thank you.

Chris Gallagher
Washington Coordinator
Obesity Care Continuum

About the Obesity Care Continuum

The Obesity Care Continuum was established in 2011 and currently includes the Obesity Action Coalition, The Obesity Society, the Academy of Nutrition and Dietetics, the American Society for Metabolic and Bariatric Surgery, and the Obesity Medicine Association. With a combined membership of over 125,000 healthcare professionals, researchers, educators and patient advocates, the OCC is dedicated to promoting access to, and coverage of, the continuum of care surrounding the treatment of overweight and obesity.