Is There Value in Obesity Management?

This week, the New England Journal of Medicine published an extensive perspective on the value in health care by Harvard Business School’s Michael Porter.

The article is of particular interest as we call on health professionals and health systems to provide more more weight management services for clients with excess weight.

Although an overwhelming body of evidence supports the impact of excess weight on a health conditions ranging from diabetes to heart attacks, sleep apnea to osteorarthritis, and infertility to cancer, health systems are still spending virtually no money on managing obesity itself – rather, they appear addicted to pouring ever increasing amounts of money and resources into treating its complications.

While the taxpayers I speak to are not generally opposed to supporting the Canadian public health care system, they do appear increasingly interested in whether or not the money spent actually provides the best value.

As outlined by Porter, “Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent….system. If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health care system increases.

Porter furthermore emphasises that “value” should always be defined around the customer and should be measured by outcomes achieved rather than by volumes delivered.

In addition it is important to note that, “To reduce cost, the best approach is often to spend more on some services to reduce the need for others.

This later statement is of course well documented for obesity interventions both in terms of preventing complications in high-risk individuals as well as in terms of the tremendous savings seen with bariatric surgery in severely obese individuals.

Thus, while even modest weight loss of only 5% can reduce the risk for type 2 diabetes by 60%, bariatric surgery for someone with diabetes virtually pays for itself in health cost savings within 2-3 years. There is therefore little doubt that obesity treatments can provide substantial value for money.

However, is this value perceived by the recipients and payers?

Anecdotally, the “thank you” notes and accolades we regularly receive from our patients certainly support the notion that our services are highly “valued” – but is this enough to convince decision makers that these are dollars well spent?

One of the key determinants of “value” according to Porter is the sustainability of the health improvements achieved.

Thus, although many patients attending weight management centres can achieve clinically significant weight loss, this in itself does not provide “value” unless the results can be sustained.

Given the sheer numbers of individuals, this role of helping patients sustain their weight-loss has to fall to primary care – our biggest fear for any patients we treat our centre is that they will not receive the required follow up and will thus not sustain the health benefits.

Thus, improving obesity management services cannot be a matter of simply increasing the number of patients seen in speciality clinics. Without an infrastructure that provides long-term follow-up and monitoring of these patients, any money spend in speciality clinics may well not provide real value in the long term.

Indeed, only an integrated system, where the right patients are referred to the right level of care and are regularly followed in a chronic disease program, is likely to provide real value.

Thus, despite the remarkable short-term success of patients in speciality clinics (as for example seen in patients undergoing bariatric surgery), we know that without the appropriate long-term follow-up and guidance, much of the benefit may be lost. This is even more relevant for conservative management, where recidivsm (weight regain) without follow-up may reach 95%.

On the other hand, we have ample data that even minimal follow-up and intervention can help most people keep weight off. Thus, for e.g. the over 5,000 “placebo” participants in the SCOUT study managed to stay well under their initial weight over 5 years with minimal but regular follow-up.

As blogged before, when the treatment (read: follow-up) stops, the weight comes back.

If we are expecting to see value for dollars spent on weight management, it is important that we provide both short-term interventions to help with weight loss as well as long-term follow-up to ensure that the weight is kept off.

This means that any investments in obesity management have to occur across the continuum of care – community services, primary, secondary, and tertiary care.

Without tertiary care, the most “costly” patients cannot be helped – without primary and community care, the initial weight-loss success cannot be maintained.

In the end the recipients of this care (including their families and friends) will need to be the judge – if they perceive “value” in these services, it is likely a good use of their hard-earned tax dollars.

On the other hand, if taxpayers perceive greater “value” in continuing to spend ever increasing proportion of the healthcare budget for hips, knees, heart attacks and cancers, then it is unlikely that we will ever find the resources to treat obesity itself.

Edmonton, Alberta