What Gets Measured Gets Changed: An Opportunity Missed?

We must first measure obesity in order to change it.

As a nurse practitioner with experience in preventive cardiology and an MPH student at the Colorado School of Public Health, I have followed with great interest the preventive mandate in the Affordable Care Act. Under this provision, certain recommended preventive services such as immunizations, colonoscopy screening, obesity screening and management, and mammograms must be covered by Medicare and most insurance companies without any cost sharing or co-pays.

Preventive services that are covered are those that have been determined to be effective based on evaluation of the scientific evidence by the U.S. Preventive Services Task Force.  After evaluating the evidence, the Task Force assigns a letter grade to its recommendations. Those recommendations receiving a grade of “A” or “B” must be covered. Medicaid is given an incentive to cover these services but is not mandated to cover them.

The U.S. Preventive Services Task Force recently updated their guidelines for obesity screening and management in adults. The task force recommends screening all adults for obesity through measurement of their body mass index (BMI). Those with a BMI greater than 30 are considered obese and intensive, multi-component behavioral interventions are recommended. Under the new preventive mandate, Medicare or the insurance company must pay for these services with no co-pay. This is an amazing opportunity to provide services to the obese population. It is also arguably one of the more expensive recommendations under the new preventive mandate.

This has raised many questions. Who should provide the interventions? Will community or commercial weight-loss programs be accepted, and if so which ones? How will the payment structure be constructed and implemented?  Will employee-based programs have a central role? What if the patient is not ready? The list goes on.

Unfortunately, I think we may be putting the cart before the horse. While management of obesity is certainly an important component of this guideline, we must first screen for obesity with BMI measurement. Sounds easy enough, right?

The data suggests we do a fairly lousy job of documenting patients’ BMI. According to an article in Obesity, nearly 50% of patient encounters lack the height and weight data necessary to calculate the BMI. Why do we do such a poor job of identifying people who are obese? How can we increase the number of patients who have their BMI calculated and documented?  These questions are crucial to the successful implementation of the new Task Force recommendations.

Lack of EMR (Electronic Medical Records) to calculate and track BMI, lack of provider and staff training and lack of reimbursement in the past for obesity-related diagnoses are three of the reasons BMI has not been consistently documented.

What makes it more difficult to effectively determine how to document BMI is the fact that we do not know who is and who isn’t documenting.

The Healthcare Effectiveness Data and Information Set (HEDIS, a tool administered by NCQA and used by more than 90% of America’s health plans to measure performance on certain dimensions of care and service) made BMI measurement a quality measure for physicians in 2009.

Unfortunately, much of this data is not available to the public. Hopefully this is changing.  The Colorado Department of Health Care Policy and Financing does publish an annual Colorado Medicaid HEDIS report. The Colorado Business Group on Health hopes to include this information in their annual quality report next year.  However, there is clearly work to be done. 

As clinicians, policy analysts, insurers and employers, we have an opportunity to focus the spotlight on BMI documentation. We must first measure obesity in order to change it.

Barbara Martin is an MPH student at the Colorado School of Public Health and is completing her practicum at CHI. She has worked as a nurse practitioner.