 Okay, so let's have one final panel discussion before we break and talk about the North. We've got a mic open there. We have people lining up. Nicole. Hi. My question was about the adult obesity clinic. What are the reimbursement barriers? I know the pediatric clinic kind of touched upon there really are no funding sources. I can imagine the same being true for the adult clinic as well. Okay, so finances is always a big problem, of course. So what we're thinking is that part of our clinic will be covered by insurance because patients will have comorbidities and we can bill insurance for those comorbidities. But we also think that patients might have to pay an initial fee. And if you look at the Bay Area weight loss programs, all of them have a fee. So I don't think that patients will be opposed to that. I should clarify too that in the pediatric clinic, our pediatric weight clinic does go through standard reimbursement, get standard reimbursement from MediCal and private insurers for the clinic setting. It's just our group program does not get reimbursed. It's not considered a... There's no... The insurance companies will not pay for that. And a lot of the employee assistant programs or the employee employer programs will not consider treatment that is primarily for the child to be something that they will include under those programs. If you pay full amount, it's $3,500, which actually sounds like a lot, but it's 25 weekly sessions of an hour and a half for both the kids and the parents. So it's compared to other medical programs, but we have had no luck. We've been working for 15 years to get insurance companies to pay for it. It's staffed by mainly people with a health education background, counseling background, but not too much. We actually like to have parents, lead groups, people who don't have necessarily a lot of counseling training because it's following a very set protocol, behavioral protocol. Dr. King. Thanks for three excellent presentations. Very interesting. I have two questions. The first one is for all three panelists, and it has to do with potential synergies between Tom's program, which is well-established. Tom is a behavioral scientist in his heart, not his training, you know, his MD training, and I would love to see the synergies in terms of the adult, the new adult vision for weight. So I'm wondering if you all can talk a little bit about that in terms of Tom's outreach and his vision and how some of that can be perhaps piggybacked into the adult thing. The second question has to do with Maya's slide where she showed the exercise specialist in parentheses. So what we're hearing, of course, is the one half of the energy balance story, which is pretty much what we hear worldwide these days. And it would be lovely to hear about both parts of the energy balance story. And I was actually looking for that in Tom's slides because I know Tom is a firm believer in the exercise part of the equation. And I didn't see it in your slides either, Tom, in terms of having expertise. Bring these exercise specialists to the table or else work out referral patterns because we have a plethora of incredibly well-trained exercise specialists in the community that could deal very effectively with your patients across the lifespan. So I'd love to hear some discussion on both of those issues. Well, I can start on the first one because as Tom was speaking, Maya and I were whispering and saying, gosh, what a model program you've established for the pediatric population. And I guess it's been one of the jewels, if you will, of LPCH to have an outreach program plus a home base for managing pediatric obesity or weight issues and adolescents. We would love to be part of a group effort to establish the same kind of presence on the adult side. And I think Stanford Hospital and Clinics doesn't really have any kind of dedicated effort this way. It's a bariatric clinic, but if you have someone that is an adult with obesity and you want a medical approach, there really isn't a center for that. And there are community efforts ongoing both in Santa Clara and San Mateo counties in the public health departments, but we aren't firmly linked in from a center point of view the way you would be. And I think it's a great opportunity. And I invite us to all take up this challenge to try to build that center. We're very keen on it, but obviously requires some help from programmatic planning and also from support from others. I don't know if you want to comment on that. Yeah, I completely agree with that. It would also be interested to see if you teach the parents to lose weight and at the same time the kids in the pediatrics center if you have better outcomes because then you have a whole family participating in the weight loss effort. And I should mention, because Mark Cullins, the Division of General Internal Medicine within the Department of Medicine is very eager to get something going with the hospital in this area. Most of the adult obesity work has been in my observation driven by the surgical programs in some ways too. And so we have talked to John for quite a while about having combined clinics and hopefully even shared space and stuff. And that was part of the plan at one point. I think things have changed in terms of space and other things, but it's because many of his patients and a lot of their patients have children too and obesity and overweight tends to run in families. And so it makes a lot of sense to work together and share resources, which is something that we've been trying to do for a while. It just hasn't really happened. And some of it is sort of structural barriers that exist between the way adult patients and pediatric patients are dealt with here and stuff, but I think it's possible. In terms of physical activity, we do, as part of the traffic light program, even that program is, we do point systems and physical activity is rewarded just as much as changes in diet for that too, but very behavioral. And in the pediatric setting, we don't do as much, we don't send kids, we do exercise with them in some of the sessions, but you don't send them to a gym necessarily, or you send them to try and get them hooked up with an after-school program or programs at a YMCA or things like that. We do a lot of work to try and help them with that. Walking and running or just exercising for exercise's sake has never been very successful, at least in our patients. Yeah, we are certainly not going to neglect the exercise and the fitness component, so we will have the goal of 175 minutes per week and 10,000 steps, but it would be nice to have a dedicated exercise physiologist, but of course it's a funding issue. If you continue that, go to the mic because they're videotaping it and they can't hear on the videotape if you don't talk into the mic. Thanks, Abby. Anyone else? Dr. Veronica Yang. Thank you all. In light of, I know a lot of the barriers being funding, in particular not just with the exercise physiologist, but with the group visits and yet the data showing that these do help. And in light of the emerging CMS potential approval for at least on the adult side having intensive behavioral therapy for obesity reimbursed for physicians or the equivalent providers, are any of you aware at a national level about movement towards reimbursement, whether for group visits or others? Because over the past week, the Centers for Medicare and Medicaid has released its proposal to reimburse for intensive behavioral therapy sessions with an MD or equivalent provider, which certainly I'm happy about. But I know that I may not be the best person to deliver these intensive behavioral interventions. And so I think it's a major oversight on the part of CMS to not explore some other options. So for those of you who are more connected than I am, I wonder at a higher policy level whether this is being discussed. Do you have any ear to the ground comments about that? So I'm not sure if the group therapies are included in that. And if you look at the wording, it's within the primary care setting. Exactly. So it needs to be within a primary care setting. Since we are in the Department of Internal Medicine, I hope that we can take advantage of this. But the group therapies still I think need to be funded just like in pediatrics out of individual... So I guess I was wondering, Tom, if you've been involved in any more national policy debates, because again, while I'm thrilled that this has come out, I'm very disappointed that it's again going to be me being reimbursed for doing intensive behavioral therapy with my patient in my one-on-one exam room, and while I do think that I'm fairly good at it, I think that the evidence shows that there are probably people who are much better than I am. Yeah, there are group visit codes that can be used, but they're for licensed. I think the consultants tell us we can only use it for licensed providers who are generally, as you suggest, may not be the best trained and they're also the most expensive. And so, yeah, I don't know where work is going on in terms of groups going. There is... I mean, the big thing last year was when... Was it last year, the year before when Medicare actually took obesity off the list of exclusions of things that they'd paid for, right? It was a... I mean, it took about a decade to get obesity removed from the list of things that you couldn't... that were not covered, I guess. But there's just a lot of resistance. And you know this, there's a real double standard with things and that they say that, yeah, well, if your patient has diabetes, then all of a sudden everything's covered, but until they get diabetes, you have to fend on your own. A quick comment from the Society of Behavioral Medicine standpoint. So there has been a comment period specific to what Veronica was just saying and there are organizations that are giving feedback to CMS that just limiting it to the doc is not going to probably be the best roadmap for trying to have effects that needs to be broadened. So hopefully, people are getting feedback on the policy level, whether they're going to do anything about it, I don't know, but people have caught the same issue and are trying to provide that input. I'm going to look over to Mark or Randy. Do you know anything? No. I've written a lot of proposals to foundations saying that in the next five years we expect there to be reimbursement and so this will be sustaining and it seems like I keep doing that and the frame keeps moving. I had a question about the pediatric weight control program. I was wondering if you could talk a little more about how you address maintenance and what is your message to parents about what's a healthy way to, for obese kids to gain weight over time as they grow? Okay. Well, in terms of sustaining the changes and stuff, we do about half of the 25 weeks is spent on focusing on maintenance issues and a lot of it is focused on problem solving and what to do if you have problems, if you all of a sudden sort of fall off of your goals, what do you do? How do you start again? How do you deal with people trying to sabotage your progress like other family members? What do you do with holidays? How do you deal with things going on at schools and parties, things like that? So a lot of it is problem solving that occurs through that treatment to try and promote maintenance. We actually don't know what happens after six months yet because we don't have the resources to follow the patients beyond there either so just providing six months is actually not that short for a lot of weight loss for 1000 kids. And the other part was a healthy weight for kids is that we would like, the ultimate goal is to get them back below the 95th percentile. We would like to get them there, which is what the definition of obesity in kids for, and that lines up with about a BMI of 30 in adulthood if you follow the curves through and we, with our weight loss during the program if they're losing more than a pound a week or more than two pounds a week, we actually look at them very closely to make sure that they're not doing something that's unhealthful to try and control their weight. So they're not starving themselves, they haven't started doing purging or anything like that. And I wanted to thank Chris Gardner because the purpose of today was to provide some inter-institutional exchanges and as an example, I think McKayla Cairnan's thought about maintenance early and teaching tools of maintenance, either it's something we're thinking about based on your discussion or it might be something that even if we use later a lot of the psychological tools that you've introduced to the group and that your research has shown to be effective may be things we would adopt in our program. Thank you and thank Chris for encouraging this exchange. All right. I got a quick one for Abby and Tom and Tom you probably know more about this than I do just in terms of the reimbursement issue. I just joined TOS fairly recently, the Obesity Society TOS and it wasn't there a debate recently that as a group, as a society they decided to classify obesity as a disease, not a condition. Is that just a shallow gesture since we have the president of SBM here as a professional society if you ruled obesity as a disease, not a condition? Are those the kinds of steps that could move this forward in terms of being reimbursable and being assigned a code? Didn't TOS officially do that? Does that sound familiar to you? Yeah, it's always been a big... Well, TOS has always been dominated by the clinical side and by clinicians and stuff too so I think it's moving towards that. I think that's the strategy that occurred with alcohol and alcoholism and things. If you can get things to find more traditionally as diseases then they're more likely to be reimbursed but I don't know... It hasn't seemed to have much of an impact I think even despite... The insurance companies that we've talked to I've talked to a lot of medical directors of insurance companies over the years and I get the feeling that they're just with this epidemic because it's more than two-thirds of adults are overweight in this country and it's growing around the world and almost 20% of kids are classified as obese they're worried about opening the floodgates and they think that they're just going to get killed. Yeah, and I would just add to that it medicalizes a sociological, sociocultural public health problem so I understand in the short term with the reimbursement how that makes sense I'm not sure given that the determinants go so far beyond medical issues I mean their cultural, environmental big picture public health issues I don't think I would be in favor of making something a disease so that it could simply be reimbursed and I'm not sure the people who are overweight I'm not sure how people would feel about that it's an interesting thing when your population 80% of your population is diseased I don't know, I mean I think it's a big it's an interesting question but I think we'd have to think beyond the reimbursement issues That's why they elect wise leaders like you to be the president of SBM Thanks Other thoughts? Somehow we're actually almost right on time we're about 10 minutes further than we said we would be at the beginning of the day but we thank our panel group for this afternoon The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University Please visit us at med.stanford.edu