DENVER — With the demand for anti-obesity drugs continuing to soar and the provision of supportive care that is essential with their use lacking, the need for professional, highly skilled practices specializing in obesity medicine has never been higher, said an expert offering key recommendations for launching such a practice at the Obesity Medicine 2024 meeting.
"There's more access than ever, but patients should be receiving more access to quality care," said Ethan Lazarus, MD, past president of the Obesity Medicine Association (OMA) in speaking on launching an obesity medicine practice at the meeting.
"We need to think beyond just prescribing medications to actually taking care of people," added Lazarus, who is a physician and owner of the Clinical Nutrition Center, in Greenwood Village, Colorado, in comments to Medscape Medical News.
He emphasized that those considering addressing that need, either in launching a stand-alone obesity medicine practice or expanding an existing primary care practice to include an obesity medicine component, should first and foremost be prepared to have achieved comprehensive competency in the field.
"This includes everything from having a full understanding of the differences between all of the medications, including the latest [glucagon-like peptide 1] GLP-1 drugs, as well as details of pathophysiological, surgical, and neurobiological aspects of obesity, including conducting proper assessments, tests, and follow-up," Lazarus said in his talk.
A key source for such information is the recently published "Comprehensive Care of Obesity," authored by Angela Fitch, MD, the immediate past president of the (OMA), Lazarus recommended.
Weight-Friendly Office Environment
Of essential considerations in getting started is the environment of the office, itself, and the need to provide a setting sensitive to the unique patient population, with a comfortable, welcoming, and judgement-free environment for patients seeking treatment for weight loss.
Lazarus underscored that his practice's waiting room is free of the typical waiting room magazines graced with ultrathin models or pictures on the wall promoting Botox treatments or other types of body-enhancement marketing.
Also of profound importance is providing a weighing process that is private and respectful of the patient — that means not placing the scale in an open space such as in a hallway (as is not uncommon) and training staff to be highly sensitive to how they converse with patients.
"I have seen so many patients who are upset about the way they were weighed at their healthcare providers' office, even due to statements that may have been well-intended," Lazarus said. "You've got to train your staff on how to do a weighing."
Previous research showed that as many as 20% of patients who perceive being stigmatized by their current healthcare provider will avoid future appointments or seek out another provider.
Staff should be aware of language that is used — Lazarus said his practice refrains from using the words "obese" or "morbidly obese" in conversing with patients; instead, he discusses patients' body mass index (BMI).
"I will say, for instance, 'your body mass index is not in the healthy range — why don't we talk about strategies to achieve a healthier BMI?'"
"I have not had one patient get mad at me for using that language."
Body Composition Scale
In terms of a scale, while a scale accommodating all weights and sizes is a basic requirement, Lazarus underscores the benefits of a professional body composition scale, providing details beyond weight, including BMI, body fat, muscle mass, and body water, in addition to various other metrics.
Such scales require a bit of an investment, and insurance typically doesn't reimburse for body composition scale tests.
Nevertheless, "most of us moving into obesity medicine as a full-time practice are investing in a body comp scale," he said, noting that the benefits can be multifactorial.
"We use them to motivate patients, to be able to show them that they have lost fat can really be motivating," he said. "Being able to show patients that they're building muscle, for instance, is very encouraging."
While a core of Lazarus' practice has been a 20-week intensive lifestyle treatment intervention, consisting of weekly visits, he noted that preferences appear to be shifting toward biweekly or monthly visits, and his practice now also offers a biweekly option for 20 weeks as well.
Under that option, patients typically see the dietician three times in a row and then meet with the medical provider for a fourth visit.
A Key Caveat: Burdensome GLP-1 Issues
Lazarus' practice also offers an à la carte model, but he cautioned that a key caveat with that model is it can be a popular choice for patients whose main objective is only to obtain a GLP-1 prescription without much additional care.
In the current climate of drug shortages and access issues, that can wind up leading to substantial extra work and time for a practice.
"These types of patients will, for example, come in once every few months, and all they want is a GLP 1 prescription, and in between visits, we will receive [multiple] messages because they can't get the drug anymore and have to transfer to another pharmacy and then we wind up having to do multiple additional prior authorizations," Lazarus said.
"It's really hurting our practice, from a business perspective."
For those establishing new practices, Lazarus underscored that systems need to be in place for billing, prior authorization support, and phone calls surrounding the GLP-1 issues.
"Many practices need dedicated staff members for these functions," he told Medscape Medical News. "They need to set budgets up to enable appropriate support staff and block time in provider schedules to deal with these issues."
To avoid losses, practices should "consider creative ways to monetize this function — such as with membership or access fees, prior authorization fees, etc.," he suggested.
In terms of educating patients on what to expect regarding potential hurdles in accessing the drugs, Lazarus suggested considering handouts describing the different medications, costs, availability, how to use them, side effects, reasons to call the office, and how to manage common side effects.
"Alternatively, consider suggesting video on provider websites," he noted.
Dispensing?
Lazarus' practice does dispense some older weight loss medications, such as metformin, with the benefit of providing convenience for patients.
However, he cautioned that this has caveats of its own in terms of costs and challenges in competing with the lower prices of high-volume retail pharmacies.
"If I were getting into this field now, I probably would not do office dispensing," he said in his talk. "I think it's too much liability for too little reward."
Exceptions of where dispensing would be important could include those in remote settings, for instance, where such services could be more beneficial to patients, Lazarus noted.
Food Sales
Contracting with food vendors of weight loss meal plans and products can be a convenient benefit for patients and income stream for the practice. He noted the importance of providing multiple brands, not just to offer choices but also to make sure to have other options if products from one company become unavailable.
Importantly, practices should never require that patients purchase any of the products, Lazarus underscored.
"It's an ethical issue," he said. "Under the AMA code of ethics, you may not require patients to purchase anything from you, so that's important to keep in mind."
Marketing: Is Your Website ADA Accessible?
While a well-designed website will be essential in promoting an obesity treatment practice and serving patients, Lazarus underscored a critical — and sometimes overlooked — consideration that the site must be compliant with requirements of the Americans with Disabilities Act (ADA).
The various requirements are detailed on the ADA's website.
Lazarus cautioned that legal teams regularly file suits against practices for having websites that fall short of the ADA requirements.
"Make sure your website is ADA accessible, with features for instance, for the visually impaired or other disabilities, or it may be just a matter of time before you end up getting sued," he warned.
Payment Models
Whereas few obesity-related services were reimbursable by insurance when Lazarus launched his practice about 20 years ago, the coverage landscape has changed dramatically since then, and many services in obesity medicine are now indeed covered, he said.
"It used to be that obesity practices were generally cash-based, but now, most can provide insurance-based billing practices," he said, noting that hybrid cash or insurance payment plans can also be offered.
Patient Retention
One thing that hasn't changed as much, however, is the ongoing issue of patient attrition, which Lazarus noted was among the key issues he had not anticipated when first opening his practice.
Clinicians need to consider "where are the patients coming from? What is the target population — Adults? Children? Men, Women?" he said.
Common solutions can include partnering with bariatric surgery programs, providing opportunities for cross-referrals and long-term management of patients post their weight loss surgery.
However, a quality core intensive lifestyle intervention program can be the most important driver of retention, as Lazarus discovered in an analysis of his own practice.
Lazarus's internal tracking data showed that 63% of those enrolled in the practice's 20-week intensive lifestyle treatment intervention remained active after 12 months vs only 40% of those who opted for the à la carte option program.
And more importantly, the retention translated to improved outcomes: Those in the 20-week intensive lifestyle intervention had an average weight loss over a year of 16% vs loss of only 11.5% among patients in the à la carte plan.
"One of the biggest issues facing a clinic is that you don't want to have to constantly be churning through new patients," Lazarus said.
"You want to get patients and you want them to stay, and we found that this [20-week] intervention was the best tool that we've done in my 20 years to improve retention," he said.
"And what's even better is that in addition to improving retention, it improved outcomes."
The results of Lazarus' analysis are supported by much larger, robust clinical trials demonstrating significant improvement in weight loss efforts with anti-obesity drugs when coupled with intensive lifestyle interventions, to the degree that the US Food and Drug Administration indications for GLP-1 drugs in the treatment of obesity in fact come with the stipulation that the drugs are prescribed in combination with intensive lifestyle interventions.
"Once a person has obesity, it is a disease like diabetes, and it deserves to be treated with all of the necessary tools — lifestyle intervention, structured healthy food plans, structured activity programs, and anti-obesity pharmacotherapy," Lazarus underscored.
Lazarus' disclosures included speaking or advisory board relationships with Novo Nordisk, Eli Lilly, Currax Pharmaceuticals, Boehringer Ingelheim, and Nestle.