Addressing the Health Equity Concerns Surrounding Obesity
By Matt Phillion
In many ways, treating patients for obesity remains an outlier: The vast majority of health plans do not cover weight loss drugs, leaving groups of patients without access to the care they need. And with studies showing that lower-income households are 68% less likely to have health insurance, groups with the highest occurrence rate of diabetes are often left without care. This includes access to medications for treating obesity, like GLP-1 agonists.
There are many factors contributing to this inequality in care, notes Jenny Yu, MD, chief health officer for Healthline Media.
“Everything from lack of insurance to lack of access to providers—whether you’re rural or urban, there are pockets where we have these medical deserts,” she says. “There’s not enough providers, not enough systems, not enough clinics.”
The numbers aren’t getting better, either: The attrition rate for providers leaving healthcare increased along with burnout during the COVID-19 pandemic, and there simply are not enough of these highly trained professionals to keep up with the turnover.
It’s not just the lack of care opportunities, though, Yu points out. It also has a lot to do with how the healthcare industry thinks about obesity.
“When we talk about obesity medicine and general management, we have to think about it as a recurring, chronic condition,” says Yu. “That’s where our messaging has not been consistent. We don’t think of obesity in this way. When we only think about it in a way that puts shame or blame on the individual, or think of it only in terms of aesthetics or lifestyle, we aren’t going to be able to get things covered like medications like GLP-1.”
This puts patients who are already in a disadvantaged position even further behind. “They’re not going to get those medications in a way that can really help them in terms of changing their entire path of their obesity care,” says Yu.
Everyone—healthcare systems, pharmacies, providers, governments—must think about obesity as a chronic condition that has the implications of other chronic conditions, Yu says.
“We need to think and talk about that in a way that allows insurance payments, not just looking for medication as a magic bullet or a single shot to solve all problems. We need to think about it from the perspective of how we help people along their entire journey, including lifestyle changes and behavioral changes, that can lead to a healthy outcome,” she says. “There are lots of opportunities in terms of education from the patient, provider, and system standpoints. How can we engage with patients in those ways, particularly in terms of access and reshaping the conversation?”
Begin with a multipronged approach
Changing perceptions of obesity is difficult, but possible if all the stakeholders work together, Yu says. “It takes time to get everyone to address it in a concerted effort, but otherwise it’s confusing: The patient is hearing mixed messages about the latest wonder drug for weight management and it’s unclear how they get it or how they qualify for it,” she says. “That confusion then creates more mistrust with the person engaging with their providers.”
There must be responsibility and accountability on the industry side, looking at new drugs as tools in the toolbox, not one-click fixes. “We know that human beings are complex and multifaceted, and to help change someone’s behavior is not just one thing,” she says. “Culturally we want convenience, we want to take this one thing that makes our lives better, but we need to have a better sort of conversation that is not shaming or judgmental, but rather helps people understand there are lifestyle behaviors that have cumulative effects.”
It’s an ongoing, complicated conversation that takes all parts of the healthcare journey to get the patient to where they need to be. “Whether it’s sleep management, movement, nutrition—all the things we think about in terms of helping someone with preventive care to get to a state of owning and empowering their health—it is easier said than done,” says Yu. “But we can say, ‘Hey, we’re not striving for perfection, but we do need to understand the behaviors that ultimately add up and affect our risk for disease states.’ ”
Equity in messaging
Part of the disparity in treating obesity comes from simply not understanding how to meaningfully reach all groups on the topic. “It’s important to create messaging and editorial content that feels like it’s speaking to people, to lead with empathy first,” says Yu. “We want to make sure people are getting messages they can understand.”
Populations who sense they are being left behind by the healthcare landscape can find it difficult to place trust in healthcare providers. As such, all stakeholders must exert a concerted effort to make sure their messaging is heard at a level that can drive policy change. “This is whether it’s reshaping the conversation from just talking about obesity in a chronic condition way to really putting in an infrastructure that allows people to have access to these medications,” says Yu.
It’s a multidisciplinary approach. Clinicians need to know the challenges patients have in accessing care, but the industry also needs whole-health integrated programming (and the resources and funds to implement it) that allows patients access to the medications they need to get started before helping them understand accompanying lifestyle changes and how obesity impacts overall health.
Barriers to success
The first challenge for changing the conversation about obesity to lessen inequity is where the patient begins their journey. What is their entry point into the healthcare system?
“When we had primary care doctors who felt like a family doctor, who knew everything about you that could affect your health, those conversations were easier to have,” says Yu. “You had a relationship that had trust.”
Familiarity is a missing step now, but also, Yu notes, the industry still struggles with cultural competency. “We use the [body mass index (BMI)] as a way to set criteria for how we use medications, but that’s an index used for research for a very different purpose,” she says. “And different ethnic groups are impacted in different ways, so BMI is not actually indicative of overall health. A patient could be from one ethnic group, very petite but have a bad cardio state, whereas other patients may have a very high BMI but be in better shape. Using BMI as a criteria is an inequity in terms of eligibility.”
Many academic institutions are teaching cultural sensitivity and awareness to help improve outcomes, but these advances haven’t spread everywhere, and their lack can be apparent in areas where patients have limited choices of care providers.
“There are curriculums in place for medical students and trainees to really talk about cultural competency, but studies have found that there’s a gap between physicians who have been out of training for a while. They’re seasoned in their clinical practice mastery for diagnostics but may not have the same training for cultural competency,” says Yu. “It’s important to make sure the folks who have been out of training for a while get this continuing education so they can have meaningful conversations with their patients that are relatable.”
Examining the issue of care access and healthcare deserts, virtual care can assist patients who otherwise face inequities based on geography.
“I think we should have some of these hub-and-spoke models, using digital toolkits and remote monitoring to be able to triage patients better so they can get better access to more specialized treatment centers when they need it,” says Yu. “One of the silver linings of COVID was it gave us a perspective into what was bubbling underneath in terms of these pockets where there is not enough access. And now we’re in a position where we can enable virtual care, while also getting those high-risk patients taken care of.”
The good news, Yu notes, is that the industry is thinking about these challenges in new ways. “It’s at the forefront of our minds, so we’re thinking about solutions to these problems and can begin to innovate,” says Yu.
She notes that the industry is in a position to merge past lessons with new technology and options to help make care more equal and accessible. “When we had that hometown primary care doctor who knew everything about you and made house calls, they didn’t have all the potential resources we have now,” says Yu. “There are learnings we can apply from history in new ways to deliver empathetic care with technology to help close those gaps.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.