AMA Journal of Ethics^®

The American Medical Association (AMA) has a longstanding history of commitment to the betterment of the public health and to the eradication of obesity on all fronts that stems back even further than the Surgeon General. Call to Action.¹ AMA policy H.150.953 includes the statement that the AMA:

urges physicians as well as managed care organizations and other third-party payers to recognize obesity as a complex disorder involving appetite regulation and energy metabolism that is associated with a variety of comorbid conditions…[and to] work…to educate physicians about the prevention and management of overweight and obesity in children and adults.…[The AMA] urges federal support of research to determine...the causes and mechanisms of overweight and obesity…[and] urges the appropriate federal agencies to work with organized medicine and the health insurance industry to develop coding and payment mechanisms for the evaluation and management of obesity.²

Resolution 421 (A-04), introduced at the 2004 Annual Meeting of the AMA by the delegation of the Medical Society of the State of New York and referred to the Board of Trustees, asked:

That the American Medical Association urge the Centers for Medicare and Medicaid Services (CMS) to change the coverage issue for bariatric surgery so that obesity with the appropriate body mass index (BMI) is in itself considered as the appropriate criteria for coverage of this service under the Medicare Program; and

That the AMA urges CMS to recognize that obesity is a disease unto itself and Medicare beneficiaries should not be discriminated against by the requirement of a co-morbidity before having their disease treated.³

That second point places the AMA in a bit of an awkward position since the AMA has neither policy nor a position statement to the effect that we have explored the science and do, in fact, consider obesity a disease. The absence of such policy makes it difficult to request that another national agency of recognized authority take that particular position. The closest the AMA has come to a formal position on qualifying obesity is in policy D-440.980 Recognizing and Taking Action in Response to the Obesity Crisis which states that:

Our AMA will: (1) collaborate with appropriate agencies and organizations to commission a multidisciplinary task force to review the public health impact of obesity and recommend measures to better recognize and treat obesity as a chronic disease.⁴

Additionally, policy H-160.938 Disease-Specific Self-Management Programs says the AMA “will seek to have physician-directed benefits of evidence-based, disease-specific education and self-management training provided to the beneficiaries of Medicare, Medicaid, other publicly supported programs, and all other payers.”⁵

By way of background to this debate, those who argue that obesity is a disease often claim that “obesity is a physiological dysfunction of the human organism with environmental, genetic, and endocrinological etiologies.”⁶ Obesity modifies vital bodily processes, places excess burden on the heart, alters pulmonary functions, and increases stress on weight-bearing joints. Disease-model proponents would also argue that overweight and obesity are associated with large decreases in life expectancy.⁷ It is harder to point to characteristic signs and symptoms that are diagnostic of the “disease” because the only sign or symptom of obesity is obesity—ie, excess adipose tissue.

Those on the other side of the argument may say that obesity is an overproduction of adipocytes and that overproduction is not necessarily an impairment. They may go on to say that the tendency of the body to increase fat stores is a useful biological adaptation that has only been identified as dysfunctional because of drastic changes in the health care economics environment.⁸ They may point to the fact that the “characteristic signs and symptoms” criterion for calling a condition a disease is weak at best in the case of obesity. They may even argue that, while it is true that obesity has been linked to the development of other disorders, a direct causal relationship has yet to be established.

The present commentary does not attempt to decipher the arguments over whether or not obesity is a disease. The topic tends to arouse passion in many a scientist, physician, public health official, and other professional, and one can debate either side of the argument until blue in the face—indeed many do. Moreover, a corollary to D-440.980, Resolution 421, D-440.971 Recommendations for Physician and Community Collaboration on the Management of Obesity asks that the AMA:

...work with the Centers for Disease Control and Prevention to convene relevant stakeholders to evaluate the issue of obesity as a disease, using a systematic, evidence-based approach…⁹

Since 2 sides of the question are already being addressed, this commentary sets out to explore a third side of the discussion, namely, what is the goal of the debaters and can we reach this goal without having the argument?

The answer to the question, “What is the goal?” is easy enough. It is found in the first concern that Resolution 421 addresses—coverage and reimbursement for bariatric surgery as treatment of obesity. We'll take this a step further and say that the goal is not reimbursement solely for bariatric surgeons but for all physicians who manage obesity.

It is safe to say that the AMA has demonstrated willingness to promote the idea that obesity is a public health menace that must be recognized as a potential threat and subsequently and effectively dealt with. Hence, the AMA and debaters on all sides agree on the same endpoint, namely, that obesity is a major public health problem and that it is poised only to worsen unless given the societal, federal, public health, and financial endorsement needed to confront effectively a health threat of its magnitude. All sides also agree that a very effective method of achieving widespread treatment for any condition is ensuring that those who treat it, even in uncomplicated cases, are reimbursed for their services. So why the AMA emphasis on CMS? Simple. It is well established in the health arena that once CMS sets a precedent for covering medical conditions under Medicare and Medicaid, other health care payors follow suit.

But do we have to call obesity a disease in order to attain this goal? Perhaps not. To borrow from the words of the AMA's Council of Scientific Affairs (CSA) Report 4:

It is true that the ability to call a condition a disease gives enhanced credibility to the condition and its outcomes. It allows the public health community to feel confident and justified about the call to action and enlisting aid to fight the condition's untoward effects. To classify a condition as a disease strengthens public health's voice and position. In the case of obesity, it may even help enlist the aid of the government, scientific revenues, and social concern that is lacking in the current effort to control the epidemic, [and] it is true that obesity [and its] related illnesses deserve far more attention than they currently receive. Even if obesity is not classified as a disease, its public health impact is severe enough that the AMA should advocate strongly for policies such as reimbursement for management of obesity alone in addition to its co-morbid conditions and increased awareness of its effects.”⁹

Classification as a disease may not be the only approach that will attract the public health backing, the federal recognition, the social limelight, and the financial support we need to make headway as a community in controlling the spread of obesity. I tend to see parallels in this argument with the recent nomination of Harriet Miers to the Supreme Court. There was major outcry since she had never been a judge, and many seemed to feel that she was thus poorly qualified to be a member of the Supreme Court. The administration’s strategy was to point out quickly that this is not an unprecedented move, since 29 prior Supreme Court justices had no previous judicial history. Okay, the original 9 justices not withstanding, we can again take a further step back and point out that, to date, there has been no lasting legacy of poorly performing Supreme Court justices (presidents, yes, justices, no). Therefore, one does not have to have been a judge in order to be a satisfactory justice. Same way with obesity; it does not necessarily have to be classified a disease before it can be reimbursed.

Let’s look at other medical conditions that have gone the same route, by which I mean conditions that do not meet all the criteria for “diseases” but for which treatment reimbursement is currently received. The CSA Report 4-A-05, lists as the common characteristics of disease: (1) an impairment of the normal functioning of some aspect of the body; (2) that has characteristic signs or symptoms; and (3) results in harm or morbidity to the entity affected. Let’s apply this standard to, for example, common dermatological disorders, eczema, scarring, and acne. According to the above definition, all of these are conditions rather than diseases. Yes, each represents an abnormality of function of the integumentary system. Yet, for any given one, there is no multitude of accompanying signs, there are no related symptoms, and each has little if any impact on morbidity and mortality of the individual affected. Nevertheless, each of these has an ICD-10 code and a CPT code that allow reimbursement for its medical management. One can make this argument for many other conditions currently covered under the CMS reimbursement system.

Perhaps all this will cause some to think that, instead of taking on obesity as a disease and urging CMS to accept it as such, it might be better to point to past instances in which treatment for conditions like those mentioned above has been reimbursed and then to appeal to the general sense of justice and urgency about obesity that would drive the same result. There is a considerable amount of text within AMA policy that emphasizes the importance the AMA places on this health concern and that would enable the AMA to unreservedly support this tactic.