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Financial penalties, incentives The Health Insurance Portability and Accountability Act of 1996 prohibits discrimination against individual participants and beneficiaries based on health status. A group health plan and a health insurance issuer could not require any individual to pay a premium greater than one for a similarly situated individual on the basis of any health insurance factor (including overweight and obesity). “But nothing shall be construed to prevent a group health plan, and a health insurance issuer from establishing premium discounts or rebates or modifying co-payments or deductibles in adherence to programs of health promotion and disease prevention.” [116] Some insurers, including Vitality, a consumer-driven health plan, offered participants in a weight loss program points to buy travel and other benefits (see discussion above of drugs/surgery). [117]
In 1995, two weight loss drugs, fenfluramine and dexfenfluramine, were widely used for long-term weight loss; 14 million prescriptions were written over 18 months. In September 1997, the FDA requested the voluntary withdrawal of both drugs due to the association between its use and increasing evidence of heart-valve defects. [118]
Physicians and Other Health Care Providers An expert task force convened by the U.S. Public Health Service concluded that the evidence was insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings. [119] It recommended intensive behavioral dietary counseling for adult patients with other known risk factors for cardiovascular and diet-related chronic disease by primary-care clinicians or by referral to other specialists, such as (nutritionists or dietitians). [120] One study concluded that if primary care physicians provided all the recommendations for an average patient panel they would require 1,773 annual patient hours, or 7.4 hours per day. Treatment of overweight and obesity would make up 2.2 hours of that amount (less than 30 minutes per patient). [121]
Most primary care physicians did not treat obesity, citing lack of time, resources, insurance reimbursement, and lack of knowledge of effective interventions as significant barriers. [122] In a study of diabetics, 78% of physicians felt patients were not interested in controlling diabetes nutritionally and 97% believed patients did not adhere to nutrition recommendations. [123] But, 30,000 consumers in a survey ranked one-on-one counseling from a professional second in effectiveness after “my own diet and exercise regimen.” [124]
Some published studies of physicians’ use of lifestyle modification and weight loss counseling indicated that:
Family practice physicians counseled 45% of diabetics, 31% of hypertensive patients, and 33% of obese patients in nutrition. The average time spent was one minute. [125]
Only 42% of obese adults were advised by their health care professional to lose weight. People who were advised to lose weight were significantly more likely to try. [126]
A limited number of quality measures were reported by health insurers and the quality data per physician were even more limited. [127] Data indicated that the effectiveness of care of chronic illness was generally suboptimal, as highlighted by the care of hypertension:
A 2007 Journal of the American Medical Association report of a randomized trial, which compared the Zone diet and one that follows the food pyramid, found that each popular diet modestly reduced body weight and several cardiac risk factors. “Overall dietary adherence rates were low, although increased adherence was associated with greater weight loss and cardiac risk factor reductions for each diet group.” Another found that mean weight loss at one year was 10 lbs. for Atkins (a low carbohydrate diet) and 5 lbs. for Ornish. Many more dropped out of the Ornish diet. [128]
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