Obesity Medicine For Internists

[ColonelForbin]

Does anyone have any experience with practicing full-time obesity medicine? I am specifically interested in the possibility of transitioning from primary care and what a model for that would look like. I graduated from an academic IM residency in the northeast four years ago, passed the ABIM exam, and have been practicing as a PCP since then.

I recently discovered that the ABOM exists as a stand alone board, which as of now is not yet recognized by the ABMS, but which has been increasing in popularity fairly quickly with I believe 1,000 or so applicants last year. I believe they are working through the process of applying for ABMS recognition, but who knows if or when that will happen. Given the prevalence of the condition, inadequate training for PCP's, growing pharmacotherapy options, and new research developments (genetics, microbiome, etc.), it wouldn't surprise me if they achieve ABMS recognition at some time in the future if fellowship availability increases. There are currently 10 obesity fellowship programs in the U.S., which exist at pretty well-respected academic institutions.

My main concern is the economics and job availability. There are occasional job postings for obesity medicine providers at multi-disciplinary weight loss clinics which usually include Bariatric Surgeons, Obesity Medicine Physicians, Dieticians, Psychologists, etc. However, these positions seem to be relatively few and far between. I don't believe my area has such a multi-disciplinary program for adults. As far as I know, the Bariatric groups in my area do not have IM/FM/Endo trained physicians with obesity medicine background on staff. I'm guessing it may not make financial sense for them to do so.

Edit:
I work for a large group and have thought of taking the idea of having an obesity medicine provider on staff to them, which would necessitate them creating the position. I think it could certainly provide value in terms of patient care, a referral option for the other PCP's without the time or interest to manage these patients, and in terms of improving quality measures. However, reimbursement is a major concern. I don't believe an IM trained physician with ABOM board certification can likely bill consult codes. Given that many payors are moving toward capitation, there would be little in the way of fee for service reimbursement. Primary care is basically getting paid for annuals, AWV's, and new patient visits.

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[DrMetal]

I recently discovered that the ABOM exists as a stand alone board, which as of now is not yet recognized by the ABMS,

And I should hope they never recognize it. It need not exist. Are we going to start making 'board certifications' out of every disease process, every clinical diagnosis? Where's the ABDM, the ABFibromyalgia, COPD etc?

Obesity is a common diagnosis. You want to be trained in its management? Do an internal medicine residency.

My main concern is the economics and job availability.

A very valid concern. If COVID has taught us anything, it's that we're too hyper-specialized, and we won't get paid for such things, especially if it's something that can be reasonably managed by a PCP. We gotta trim the fat (pun intended here).

 

[ColonelForbin]

And I should hope they never recognize it. It need not exist. Are we going to start making 'board certifications' out of every disease process, every clinical diagnosis? Where's the ABDM, the ABFibromyalgia, COPD etc?

Obesity is a common diagnosis. You want to be trained in its management? Do an internal medicine residency.



A very valid concern. If COVID has taught us anything, it's that we're too hyper-specialized, and we won't get paid for such things, especially if it's something that can be reasonably managed by a PCP. We gotta trim the fat (pun intended here).

Those are valid points. Just out of curiosity, what do you think of Geriatrics and Palliative Care as stand alone specialties? One could argue in the same way that those should easily be within the purview of a general internist. However, they are obviously challenging populations and I think it's hard to argue that we receive optimal training in medical school and residency alone to truly appreciate the subtleties. Whether Obesity is in a similar category is a reasonable point of debate. Most internists feel comfortable managing DM and COPD, or if they don't, a specialty exists to refer them to. I wouldn't say the same is true, specifically regarding pharmacotherapy, for obesity.

 

[DrMetal]

Those are valid points. Just out of curiosity, what do you think of Geriatrics and Palliative Care as stand alone specialties?

Yeah actually, I kinda do. Geriatrics? That's 90% of IM. Palliative Care? We should all be well versed in it.

I'm not against any one taking an interest in something, learning more about it, and building their practice around it. For instance, with respect to Obesity medicine: why not just build a panel of such patients (you'll have no shortage of them), learn more about, go to conferences, take some classes (good CME), whatever, and then continue to practice in it?

What I don't like is how we in medicine feel the need to make a BC out of everything. Then comes a mandatory fellowship training to be eligible for said BC. Then comes the credentialing monkeys, administrators, and insurance companies that mandate you complete the fellowship and BC, in order to do that part of the job. (Palliative Care is a great example. We're pressured to always consult them, I can't just have the discussion with the patient myself.)

Man, we love our credentials, and we love piling them on. We never seem to be happy just practicing.

 

[rokshana]

And I should hope they never recognize it. It need not exist. Are we going to start making 'board certifications' out of every disease process, every clinical diagnosis? Where's the ABDM, the ABFibromyalgia, COPD etc?

Obesity is a common diagnosis. You want to be trained in its management? Do an internal medicine residency.



A very valid concern. If COVID has taught us anything, it's that we're too hyper-specialized, and we won't get paid for such things, especially if it's something that can be reasonably managed by a PCP. We gotta trim the fat (pun intended here).

yeah, yet we do a crap job at preventing a treating it...obesity is not really well taught in IM residencies and heck even in Endocrinology , Diabetes, and METABOLISM, we don't get that much training in it...its sub specialization in the same vein as hepatology in GI, MSK in radiology, Echo in cardiology, sleep in pulmonary, pain in anesthesia...it is hard to be a jack of all trades and a master of none.

and btw, the reason palliative became a sub specialty, is that we suck at discussing goals of care and telling people they are dying and accept it...heck we generally don't accept it for our patients and if they die, we have failed...it became a specialty, because the4e was and is a need.

 

[DrSnips]

and btw, the reason palliative became a sub specialty, is that we suck at discussing goals of care and telling people they are dying and accept it...heck we generally don't accept it for our patients and if they die, we have failed...it became a specialty, because the4e was and is a need.

Is the problem that we suck at them or that we don't have time? I think IM docs get a lot of consults for things that they might be able to handle on their own, but they are dealing with 8 problems per patient so we get the consult just to keep our heads above water. More subspecialists and more consults is not the answer. We need reasonable amounts of time to care for our patients, but the system we have is so broken that it compels all of these consults.

And I'm not saying that a PCP or hospitalist can handle everything on their own. Probably the best skill you can have as a general IM doc is to know when you are out of your depth. But I know for certain that many times I'm getting consults because of either gate-keeping (you can't order this test / treatment without subspecialist approval) or time (too many patients with too many problems for one doc to deal with).

Oh, and if you become ABOM certified and happen to gain some weight yourself, prepare for this conversation:

"What do you do for work?"
"I'm an obesity specialist"
"Oh yeah, you look it."

 

[rokshana]

Is the problem that we suck at them or that we don't have time? I think IM docs get a lot of consults for things that they might be able to handle on their own, but they are dealing with 8 problems per patient so we get the consult just to keep our heads above water. More subspecialists and more consults is not the answer. We need reasonable amounts of time to care for our patients, but the system we have is so broken that it compels all of these consults.

And I'm not saying that a PCP or hospitalist can handle everything on their own. Probably the best skill you can have as a general IM doc is to know when you are out of your depth. But I know for certain that many times I'm getting consults because of either gate-keeping (you can't order this test / treatment without subspecialist approval) or time (too many patients with too many problems for one doc to deal with).

Oh, and if you become ABOM certified and happen to gain some weight yourself, prepare for this conversation:

"What do you do for work?"
"I'm an obesity specialist"
"Oh yeah, you look it."

we probably suck at it, because of not having the time...from the other side, i get consults from PCPs for things that they could do, but don't have the time to be able to do or closely monitor...so i agree, the push on PCPs to see more patients for more things means they can give little time to each thing.

 

[anthroguy]

I did the certification. It costs 5k for the exam and all the cme, and about 5-6 vacation days. I'm FM trained and I agree the amount of specialization in medicine may be getting absurd, but many PCPs do not want to approach this from a pharmacologic standpoint or do not have the time to. They may involve a nutritionist at first, and at the extremes refer to bariatric surgery, but for the majority who would benefit from a pharmacologic approach, not much is done.

 

[ColonelForbin]

I did the certification. It costs 5k for the exam and all the cme, and about 5-6 vacation days. I'm FM trained and I agree the amount of specialization in medicine may be getting absurd, but many PCPs do not want to approach this from a pharmacologic standpoint or do not have the time to. They may involve a nutritionist at first, and at the extremes refer to bariatric surgery, but for the majority who would benefit from a pharmacologic approach, not much is done.

Have you found it to be a worthwhile investment so far? Are you doing more pharmacotherapy and has your comfort level increased with it? Are you having more success with these patients using what you learned? Did you do it purely for educational reasons, or as a way to intentionally modify your panel to include more obesity medicine?

 

[VA Hopeful Dr]

I did the certification. It costs 5k for the exam and all the cme, and about 5-6 vacation days. I'm FM trained and I agree the amount of specialization in medicine may be getting absurd, but many PCPs do not want to approach this from a pharmacologic standpoint or do not have the time to. They may involve a nutritionist at first, and at the extremes refer to bariatric surgery, but for the majority who would benefit from a pharmacologic approach, not much is done.

Don't most of the weight loss drugs have pretty bad evidence re: efficacy?

 

[DrMetal]

yeah, yet we do a crap job at preventing a treating it...obesity is not really well taught in IM

So telling them to "shut their piehole" is not good training?

and btw, the reason palliative became a sub specialty, is that we suck at discussing goals of care and telling people they are dying and accept it

We should be good at it. It's embarrassing. Every doctor should have this skill, somewhat. Think about what you're doing: you're consulting another doctor to have a conversation with the patient. That's like your personal accountant referring you to someone else for a basic tax question.

Is the problem that we suck at them or that we don't have time?

Bingo,

"What do you do for work?"
"I'm an obesity specialist"
"Oh yeah, you look it."

We're already judged in such ways.

I did the certification. It costs 5k for the exam and all the cme, and about 5-6 vacation days. I'm FM trained and I agree the amount of specialization in medicine may be getting absurd, but many PCPs do not want to approach this from a pharmacologic standpoint or do not have the time to. They may involve a nutritionist at first, and at the extremes refer to bariatric surgery, but for the majority who would benefit from a pharmacologic approach, not much is done.

Again, no problem with someone taking an interest, tailoring their CME around it, building their practice etc etc. I just want to see a hard stop on the all the BC/BE/MOC bullsht going on in our profession. We're boarding ourselves to death.

Don't most of the weight loss drugs have pretty bad evidence re: efficacy?

Absolutely. My home clinic prohibits us from prescribing them (quite frankly most of them are readily available on line, without a rx). Again, "shut your piehole" seems to be the best advice.

 

[tantacles]

So telling them to "shut their piehole" is not good training?

Absolutely. My home clinic prohibits us from prescribing them (quite frankly most of them are readily available on line, without a rx). Again, "shut your piehole" seems to be the best advice.

What I'm gathering from your post is that I have the potential to be the #1 obesity doctor in the United States, no the WORLD.

and if you have anything to say about that, please shut your piehole.

 

[ColonelForbin]

So telling them to "shut their piehole" is not good training?



We should be good at it. It's embarrassing. Every doctor should have this skill, somewhat. Think about what you're doing: you're consulting another doctor to have a conversation with the patient. That's like your personal accountant referring you to someone else for a basic tax question.


Bingo,


We're already judged in such ways.


Again, no problem with someone taking an interest, tailoring their CME around it, building their practice etc etc. I just want to see a hard stop on the all the BC/BE/MOC bullsht going on in our profession. We're boarding ourselves to death.


Absolutely. My home clinic prohibits us from prescribing them (quite frankly most of them are readily available on line, without a rx). Again, "shut your piehole" seems to be the best advice.

I think a lot of generalists can relate to the lofty ideal of a "do it all" PCP. I think many go into IM/FM residencies for that reason. I just don't think it's possible any longer for both the academic and financial reasons already stated. Medical knowledge is advancing at an exponential rate. Take DM for example. Back in the early 90's you could offer a patient what, Metformin and a Sulfonylurea? Not much to talk or think about. Now you have the time and cognitive demands of discussing GLP-1 agonists, SGLT-2 inhibitors, DDP4 inhibitors, TZD's, different long-acting insulins, continuous glucose monitors, etc. That's one of what, their list of eight co-morbid conditions, along with any other acute issues and healthcare maintenance items they want to address? Insurance now mandates we do social determinants of care assessments, fall risk screening, depression screening, anxiety screening, substance abuse screening, smoking cessation, etc. When exactly is all of this supposed to occur? It's no wonder that obesity management in the primary care setting consists of "discussed healthy dietary changes and increasing physical activity to 20 minutes per day five days per week".

Not only that, but this is all occurring in the setting of the shift to capitation. Insurance will not pay for a bunch of E/M visits to manage your obesity panel, even if you have the interest and do the necessary CME to be competent. The irony there is, they will pay for the diabetes meds, BP meds, PCSK-9 inhibitor, knee placement, and CPAP machine. Maybe if obesity was a board certified specialty they would pay for consults and follow-ups. Not saying that's the way it should be obviously, but that's the way it is currently.

Every physician should of course be able to have a goals of care discussion, but a truly effective goals of care discussion is an art that takes practice and a considerable amount of repetition. More practice and repetition than is typical in a PCP setting. It's not uncommon to see elderly patients with end-stage life-limiting diseases receiving aggressive and often futile care, simply because there isn't time to have these discussions and it's easier to punt it to the next visit. That is true for both PCP's and specialists. They say, what, 25% of Medicare costs are spent in the last six months of life? And a lot of that without improved quality of life or increased life expectancy. If the existence of Palliative Care as a board certified specialty allows those conversations to take place, then I think it's hard to argue against that. That is to say nothing of the complexities of end of life symptoms management, the pharmacology of drugs like Methadone, etc. Again, all things that are challenging without adequate training and repetition.

I'm guessing you were talking at least partly in jest, but I'm sure you wouldn't tell a prescription opioid addict to "shut their mouth" and send them out the door. Many generalists would involve an addiction medicine specialist to explore psychosocial issues, discuss Methadone and Buprenorphine management, etc. Again, all things a dedicated PCP could pursue training in, but few can due to the complexities and time involved. I don't think obesity is that dissimilar.

Agree the board certification aspect is annoying. But, the existence of a board certified specialty doesn't stop a generalist from practicing that area of medicine should they choose. The existence of Endocrinology as a board certified specialty doesn't stop a PCP from managing a patient's diabetes if they feel comfortable and choose to do so. It's nice to have the option for referral in challenging cases and when there is not time.

 

[chessknt]

If you find it interesting go for it but I imagine you are going to build a panel of patients with more comorbid illnesses if you only select for class /3 obesity who will probably, base don my experience, have worse/no insurance than the average patient. Optimizing revenue in the outpatient setting does not generally involve loading up on the most complex patients with bad insurance.

 

[anthroguy]

Have you found it to be a worthwhile investment so far? Are you doing more pharmacotherapy and has your comfort level increased with it? Are you having more success with these patients using what you learned? Did you do it purely for educational reasons, or as a way to intentionally modify your panel to include more obesity medicine?

I just found out I passed the test so I haven't fully implemented this. I did this initially for purely educational reasons and its made me much more comfortable with pharmacotherapy.
In the future I hope to do this 1-2 days/week and family medicine the other 3-4 days. Covid has made implementation with patients difficult and being in the office will remedy that.

 

[anthroguy]

Don't most of the weight loss drugs have pretty bad evidence re: efficacy?

Qsymia, Contrave and Saxenda have pretty good evidence for efficacy. The contraindications are significant and I agree the older obese patients with multiple comorbidities may be difficult to start on any of the current medications.

I think for younger people, helping manage their obesity form their 20-30s could prevent joint, cv and endocrine complications in their 40s-60s.

there are significant hormonal changes that occur in obesity which prevent the "shut your pie hole" method of treatment. The current medicines do help in select populations and hopefully there will be more in the future that will go further.

 

[VA Hopeful Dr]

Qsymia, Contrave and Saxenda have pretty good evidence for efficacy. The contraindications are significant and I agree the older obese patients with multiple comorbidities may be difficult to start on any of the current medications.

I think for younger people, helping manage their obesity form their 20-30s could prevent joint, cv and endocrine complications in their 40s-60s.

there are significant hormonal changes that occur in obesity which prevent the "shut your pie hole" method of treatment. The current medicines do help in select populations and hopefully there will be more in the future that will go further.

Qsymia does?

 

[IM2GI]

GI will continue to increasingly manage this space as we have current and future procedures to address this problem and are already being referred to see their co-morbid fatty liver.

I would not waste your time/money as an internist who has a limited arsenal of drugs with questionable efficacy. You would need to become the medical director/open your own weight loss dedicated multi specialty clinic with nutrition, PT, GI, endocrine, surgery, etc and even then no ones gonna care if you have that credential IMO.

 

[anthroguy]

GI will continue to increasingly manage this space as we have current and future procedures to address this problem and are already being referred to see their co-morbid fatty liver.

I would not waste your time/money as an internist who has a limited arsenal of drugs with questionable efficacy. You would need to become the medical director/open your own weight loss dedicated multi specialty clinic with nutrition, PT, GI, endocrine, surgery, etc and even then no ones gonna care if you have that credential IMO.

GI journals have published recommendations on pharmacotherapy tx of obesity. ie Clinical Gastroenterology and Hepatology from Feb 24, 2017.
In terms of who occupies this space, it could be a turf war in the future, but the patients will start at their primary care office and where they end up will be dependent upon how comfortable their physician is with counseling/treating obesity
Qsymia had trials going to 108 weeks (SEQUEL)
Contrave to 56 weeks (COR)
Liraglutide to 56 weeks (SCALE)

 

[CCM-MD]

GI journals have published recommendations on pharmacotherapy tx of obesity. ie Clinical Gastroenterology and Hepatology from Feb 24, 2017.
In terms of who occupies this space, it could be a turf war in the future, but the patients will start at their primary care office and where they end up will be dependent upon how comfortable their physician is with counseling/treating obesity
Qsymia had trials going to 108 weeks (SEQUEL)
Contrave to 56 weeks (COR)
Liraglutide to 56 weeks (SCALE)

There won't be a turf war because the pharmacotherapy doesn't make physicians money, the procedures do. Advanced endoscopy will keep the lucrative endoscopic bariatric procedures and will be more than happy to let their midlevel or PCP/endocrinologist prescribe the meds.

 

[sloh]

GI will continue to increasingly manage this space as we have current and future procedures to address this problem and are already being referred to see their co-morbid fatty liver.

I would not waste your time/money as an internist who has a limited arsenal of drugs with questionable efficacy. You would need to become the medical director/open your own weight loss dedicated multi specialty clinic with nutrition, PT, GI, endocrine, surgery, etc and even then no ones gonna care if you have that credential IMO.

And even then with nutrition, PT, endocrine (as hopeful as we'd like to be) adherence would likely be poor. Only bariatric surgery seems to make a dent in this patient population.

 

[rokshana]

There won't be a turf war because the pharmacotherapy doesn't make physicians money, the procedures do. Advanced endoscopy will keep the lucrative endoscopic bariatric procedures and will be more than happy to let their midlevel or PCP/endocrinologist prescribe the meds.

From the standpoint of an endocrinologist... nope... if you decide you are going to manage their obesity, Take ownership of the whole process.

 

[anthroguy]

From the standpoint of an endocrinologist... nope... if you decide you are going to manage their obesity, Take ownership of the whole process.

Total agreement. There is a long way to go between manage/treating obesity and needing any sort of interventional procedure.

 

[Raryn]

GI will continue to increasingly manage this space as we have current and future procedures to address this problem and are already being referred to see their co-morbid fatty liver.

I'd refer a patient to get bariatric surgery well before I'd ever consider any of the current endoscopic procedures for treatment of obesity. Hell, I *do* refer patients for bariatric surgery consultation - often several each week - and I've never even thought about sending someone for an intragastric balloon or god-forbid the abomination that is the "aspire assist".

ABOM certification seems like an extra tool for your armamentarium and I do know a couple docs who do obesity medicine full time. Personally, I was considering getting it - even signed up for one of this years obesity conferences before it got cancelled due to coronavirus. This coming year they're waiving the requirement for a conference attendance, so I'm debating doing the CME path if I can motivate myself to do the 60 hours between now and December. It's be a total of ~$3k or so - $1500 for the test and $1500 for the CME.

 

[anthroguy]

I'd refer a patient to get bariatric surgery well before I'd ever consider any of the current endoscopic procedures for treatment of obesity. Hell, I *do* refer patients for bariatric surgery consultation - often several each week - and I've never even thought about sending someone for an intragastric balloon or god-forbid the abomination that is the "aspire assist".

ABOM certification seems like an extra tool for your armamentarium and I do know a couple docs who do obesity medicine full time. Personally, I was considering getting it - even signed up for one of this years obesity conferences before it got cancelled due to coronavirus. This coming year they're waiving the requirement for a conference attendance, so I'm debating doing the CME path if I can motivate myself to do the 60 hours between now and December. It's be a total of ~$3k or so - $1500 for the test and $1500 for the CME.

Agree with the aspire assist, when I first learned about it all I could think of is "medically assisted bulimia?!?!?"

I think the one off change where conference attendance isnt required should push you to take it. You'll save vacation days and many hospitals/employers dont have a limit on board cert expenses so the expenses could be minimal if you get the cme reimbursed. I definitely picked up a lot of knowledge with the CME, but it was having to know it for an exam that really let it settle in.

 

[ColonelForbin]

I'd refer a patient to get bariatric surgery well before I'd ever consider any of the current endoscopic procedures for treatment of obesity. Hell, I *do* refer patients for bariatric surgery consultation - often several each week - and I've never even thought about sending someone for an intragastric balloon or god-forbid the abomination that is the "aspire assist".

ABOM certification seems like an extra tool for your armamentarium and I do know a couple docs who do obesity medicine full time. Personally, I was considering getting it - even signed up for one of this years obesity conferences before it got cancelled due to coronavirus. This coming year they're waiving the requirement for a conference attendance, so I'm debating doing the CME path if I can motivate myself to do the 60 hours between now and December. It's be a total of ~$3k or so - $1500 for the test and $1500 for the CME.

Yeah it seems particularly convenient to complete the CME pathway this year with all of the CME available online.

Of those you know practicing obesity medicine full time, are they all Endocrinologists or are any IM/FM with the ABOM certification? Do they tend to all be employed by multidisciplinary obesity medicine clinics, or are some practicing independently?

 

[Raryn]

Yeah it seems particularly convenient to complete the CME pathway this year with all of the CME available online.

Of those you know practicing obesity medicine full time, are they all Endocrinologists or are any IM/FM with the ABOM certification? Do they tend to all be employed by multidisciplinary obesity medicine clinics, or are some practicing independently?

I know one of each. An IM trained doc doing obesity full time and an endocrinologist who does mostly obesity. Both are employed by a large multispecialty system, one academic and one non-academic.

 

[ColonelForbin]

I know one of each. An IM trained doc doing obesity full time and an endocrinologist who does mostly obesity. Both are employed by a large multispecialty system, one academic and one non-academic.

My main concern coming at this with only IM training is the ability to generate any revenue, such that there will be no jobs. I know your background is Endo, so I don't know your familiarity with billing in the primary care setting. Most insurances are moving towards full or partial capitation. The only services that can be billed fee-for-service are annuals, annual well visits, and office procedures for many insurances now. Primary care is increasingly unable to bill for E/M visits. I don't know how a provider with only IM training could generate any revenue seeing only obesity medicine "consults" and follow-ups. I'm assuming insurances won't reimburse for consult E/M codes for an IM provider with ABOM certification.

Do you know if your acquaintance with the IM background has any trouble with that? I'm guessing larger or academic groups may offer salaried positions at a loss to be able to offer the multi-disciplinary service and maybe to boost internal referrals.

 

[IM2GI]

I'd refer a patient to get bariatric surgery well before I'd ever consider any of the current endoscopic procedures for treatment of obesity. Hell, I *do* refer patients for bariatric surgery consultation - often several each week - and I've never even thought about sending someone for an intragastric balloon or god-forbid the abomination that is the "aspire assist".

ABOM certification seems like an extra tool for your armamentarium and I do know a couple docs who do obesity medicine full time. Personally, I was considering getting it - even signed up for one of this years obesity conferences before it got cancelled due to coronavirus. This coming year they're waiving the requirement for a conference attendance, so I'm debating doing the CME path if I can motivate myself to do the 60 hours between now and December. It's be a total of ~$3k or so - $1500 for the test and $1500 for the CME.

Agree, except that we can do endoscopic sleeve gastroplasty, and better/less invasive devices will continue to come to market. I don't know anyone who is doing the Aspire Assist or thinks it is a good idea.

ESG is a cash-only deal right now, but I would guess insurance will start to pay for it as it is much cheaper for them than traditional bariatric surgery.

 

[Raryn]

My main concern coming at this with only IM training is the ability to generate any revenue, such that there will be no jobs. I know your background is Endo, so I don't know your familiarity with billing in the primary care setting. Most insurances are moving towards full or partial capitation. The only services that can be billed fee-for-service are annuals, annual well visits, and office procedures for many insurances now. Primary care is increasingly unable to bill for E/M visits. I don't know how a provider with only IM training could generate any revenue seeing only obesity medicine "consults" and follow-ups. I'm assuming insurances won't reimburse for consult E/M codes for an IM provider with ABOM certification.

Do you know if your acquaintance with the IM background has any trouble with that? I'm guessing larger or academic groups may offer salaried positions at a loss to be able to offer the multi-disciplinary service and maybe to boost internal referrals.

The one person I know who is IM/ABOM treats herself like a specialist. Doesn't do primary care, bills just new provider + followup codes, no capitation, minimal quality stuff. If she's not covered, she bills cash.

 

[anthroguy]

This thread is just from 2 years ago and with the weight loss results we see from Wegovy (semaglutide) and the even better results Mounjaro (for DM2 only at this point), it feels like interventional treatment for obesity will be on the decline in the future!

 

[MD46]

This thread is just from 2 years ago and with the weight loss results we see from Wegovy (semaglutide) and the even better results Mounjaro (for DM2 only at this point), it feels like interventional treatment for obesity will be on the decline in the future!

From what I am seeing is that celebrities are getting these as well and possibly see a shortage soon for people who actually need it medically......

 

[anthroguy]

From what I am seeing is that celebrities are getting these as well and possibly see a shortage soon for people who actually need it medically......

This is definitely an issue, people are incorrectly getting this for a 10-20 lb weight loss when overweight.

 

[chessknt]

This is definitely an issue, people are incorrectly getting this for a 10-20 lb weight loss when overweight.

Approved for BMI >30 so that might only be 10-20 lbs but still falls within the way it was studied. Drug shortages are nothing new. They need to price these better though--they have 140 million potential patients in the USA alone that can get this drug, making it cost 18k/year is way too greedy. Most people would easily pay 100/month out of pocket. People pay way more than that for cosmetic derm bull**** you can't even tell the difference on as opposed to these drugs which have tangible results. Even if only a third get on it that is still 1200*35 million=42B a year. That is almost half of the entire patented revenue cycle of Lipitor, but in a single year. They are sitting on an enormous goldmine, they just need to wake up and stop trying to overcharge--nobody can afford 1800/month.

 

[VA Hopeful Dr]

Approved for BMI >30 so that might only be 10-20 lbs but still falls within the way it was studied. Drug shortages are nothing new. They need to price these better though--they have 140 million potential patients in the USA alone that can get this drug, making it cost 18k/year is way too greedy. Most people would easily pay 100/month out of pocket. People pay way more than that for cosmetic derm bull**** you can't even tell the difference on as opposed to these drugs which have tangible results. Even if only a third get on it that is still 1200*35 million=42B a year. That is almost half of the entire patented revenue cycle of Lipitor, but in a single year. They are sitting on an enormous goldmine, they just need to wake up and stop trying to overcharge--nobody can afford 1800/month.

Contrave for everyone!

 

[chessknt]

Contrave for everyone!

Yea if you could show that achieved outcomes as good as bariatric surgery with minimal side effects ....

 

[VA Hopeful Dr]

Yea if you could show that achieved outcomes as good as bariatric surgery with minimal side effects ....

Minimal side effects and better than adipex... also cheap-ish. So kind of a win

 

[DrMetal]

Are there not risks of hypoglycemic events, if these injectibles are used in non-diabetic patients?

 

[PugsAndHugs]

Are there not risks of hypoglycemic events, if these injectibles are used in non-diabetic patients?

GLP1 agonists cause a glucose dependent insulin release, so those that are euglycemic should not have the increased insulin release.

 

[rokshana]

Are there not risks of hypoglycemic events, if these injectibles are used in non-diabetic patients?

No

 

[DrMetal]

So, the insurance companies (and the DoD healthcare system) that I've dealt with, is refusing to pay for these, in non-DM patients, for the sake of weight loss. Patients can still have it, if they pay cash for it. Has this been your experience as well? Are patients paying for it?

 

[VA Hopeful Dr]

So, the insurance companies (and the DoD healthcare system) that I've dealt with, is refusing to pay for these, in non-DM patients, for the sake of weight loss. Patients can still have it, if they pay cash for it. Has this been your experience as well? Are patients paying for it?

Its amazingly expensive so few can afford to pay cash.

Some insurance covers it, but most don't.

 

[DrMetal]

Its amazingly expensive so few can afford to pay cash.

How much? Are they paying for it?

Ahh how wonderful to be in Western medicine, in a 1st world country. I wonder if doctors in rural India or Africa are prescribing a $1000/wk injection for a 15% weight loss. Oh wait, they don't have to do that. Their solution for weight loss is rampant malaria and HIV. And that's for free.

 

[VA Hopeful Dr]

How much? Are they paying for it?

Ahh how wonderful to be in Western medicine, in a 1st world country. I wonder if doctors in rural India or Africa are prescribing a $1000/wk injection for a 15% weight loss. Oh wait, they don't have to do that. Their solution for weight loss is rampant malaria and HIV. And that's for free.

$1200/month give or take.

I have 1 patient who pays cash for it. Though it is looking like more may cover it this year, give me another few weeks and I'll know for sure.

 

[DrMetal]

$1200/month give or take.

I have 1 patient who pays cash for it. Though it is looking like more may cover it this year, give me another few weeks and I'll know for sure.

I should hope the insurance companies continue to refuse it. I agree with them in this case. We don't need to see premiums rise and the cost of healthcare escalate, all for the sake of a 10-20% weight loss (supposed, the research is very confounding), in a non-compliant and lazy population that'll continue to disregard many other aspects of their health.

This is wasteful medicine.

 

[rokshana]

So, the insurance companies (and the DoD healthcare system) that I've dealt with, is refusing to pay for these, in non-DM patients, for the sake of weight loss. Patients can still have it, if they pay cash for it. Has this been your experience as well? Are patients paying for it?

yes...and some, yes.

 

[rokshana]

I should hope the insurance companies continue to refuse it. I agree with them in this case. We don't need to see premiums rise and the cost of healthcare escalate, all for the sake of a 10-20% weight loss (supposed, the research is very confounding), in a non-compliant and lazy population that'll continue to disregard many other aspects of their health.

This is wasteful medicine.

this is a medication for OBESITY...not for being overweight.
insurances should cover medications for OBESITY since OBESITY is an actual (recognized ) disease state. It shouldn't even be prescribed just so someone can look good in their clothes...or look pretty ant someone's wedding.

These are chronic, lifelong medications...just like BP meds or HLD medications. Stop them and everything comes back.
My diabetes pts can't get these medications (even if there insurance covers)because of all the prescribing being done for weight loss...
weight loss medications SHOULD be covered for weight loss...not DM medications because that can be covered.

cost of healthcare is already high and will go higher for obesity related issues because we are not looking at prevention...but treat when the problem happens...maybe if Wegovy was covered for weight loss, then Ozempic wouldnt be needed for the inevitable DM.

OBESITY is not just a willpower or hand to mouth issue...sure its part of the problem, but its not the only problem.

 

[rokshana]

I should hope the insurance companies continue to refuse it. I agree with them in this case. We don't need to see premiums rise and the cost of healthcare escalate, all for the sake of a 10-20% weight loss (supposed, the research is very confounding), in a non-compliant and lazy population that'll continue to disregard many other aspects of their health.

This is wasteful medicine.

and not supposed...its quite evident in the research...you just need to stay ute with it.

 

[DrMetal]

this is a medication for OBESITY...not for being overweight.

If I failed to make that distinction, so too will many providers, and many more patients who insist on the medication. We have plenty of examples in medicine, where we don't diagnose correctly (or over-diagnose) and then proceed to treat figments of our imagination. See the debacles of ADHD (rx Adderall) , Chronic Pain (rx Narcotics), etc.

I guess, whatever. Let the sh!*show commence.

When the patients become real savvy, they'll realize that if they just let themselves go a little bit (A1c 6.3-->6.8), then they'll get the DM diagnosis. Claim a metformin intolerance, and they can go straight to the injectable, with coverage from insurance.

 

[rokshana]

If I failed to make that distinction, so too will many providers, and many more patients who insist on the medication. We have plenty of examples in medicine, where we don't diagnose correctly (or over-diagnose) and then proceed to treat figments of our imagination. See the debacles of ADHD (rx Adderall) , Chronic Pain (rx Narcotics), etc.

I guess, whatever. Let the sh!*show commence.

When the patients become real savvy, they'll realize that if they just let themselves go a little bit (A1c 6.3-->6.8), then they'll get the DM diagnosis. Claim a metformin intolerance, and they can go straight to the injectable, with coverage from insurance.

Which is why it probably should be restricted to who can prescribe it.