In Health Law, a Boon for Diet Clinics

Dr. Michael Kaplan looked across his desk at a woman who had sought out his Long Island Weight Loss Institute and asked the question he often poses to new patients: “Where do you think you go wrong with food?”

The 38-year-old patient was about 20 pounds overweight and, as she described it, desperate. Weight Watchers, nutritionists — she had tried them all in vain. A physician like Dr. Kaplan, she reasoned, might be the only one left who could help her. “I’m really tired of it,” the woman said one recent afternoon, declining to give her name to a reporter. “I feel like something is off with me.”

Dr. Kaplan, a leader in the medical weight-loss industry, nodded sympathetically, interjecting questions that ranged from what she typically ate for breakfast (protein shake) to whether she felt depressed (sometimes). By the end of the 50-minute session, the woman had chosen Dr. Kaplan’s most expensive weight-loss plan: $1,199 for six weeks’ worth of meal-replacement products, counseling and vitamin supplements.

Then he delivered some good news: Her insurance would probably reimburse her for at least a small portion of the bill, thanks to a provision in the federal health care law that requires insurers to pay for nutrition and obesity screening.

The news was pleasing to the patient. But it has also created a financial opportunity for a corner of the diet industry that has often operated on the fringe of the medical establishment: for-profit diet clinics overseen by doctors.

“It’s really a game changer,” said John LaRosa, research director at Marketdata Enterprises, who has studied the weight-loss industry for more than 20 years.

Mr. LaRosa estimates that medical weight-loss programs, which include those run by hospitals as well as clinics, bring in $1 billion annually and that the market will grow about 5 percent a year through 2019.

The prospects are so lucrative that in March, Mr. LaRosa sponsored a seminar advising entrepreneurs how to open their own weight-loss clinics to take advantage of the new stream of insurance coverage.

And Dr. Kaplan recently started a consulting business to teach primary-care doctors how to bill insurers for obesity treatments.

“We’ve been in a rapid expansion mode as a result of the insurance companies covering obesity treatment,” Dr. Kaplan said. He estimated that a doctor could earn as much as $3,000 more a year for each obese patient, according to promotional materials for his new company, Obesity Management Systems.

But the prospect of rapid growth in the diet-clinic industry, fed by insurance payments, has exposed deep philosophical differences on the best ways to help patients lose weight.

Obesity specialists at major medical centers say the proprietors of diet clinics often employ unproven tactics — like vitamin injections, costly supplements and extreme diet plans — that lure customers but do not lead to lasting results. Diet-clinic owners contend that they are filling a needed role because the mainstream medical establishment pays little attention to patients’ struggles with weight.

Meanwhile, Americans keep piling on the pounds. In 2013, the American Medical Association classified obesity — defined as having a body mass index of 30 or higher — as a disease, and solving the obesity epidemic came to be viewed as one of the nation’s most pressing public health challenges. Beyond the federal requirement that insurers cover obesity screening, many states go further, requiring coverage that ranges from basic counseling to weight-loss surgery.

Sustained weight loss is notoriously difficult to achieve. Lasting results require long-term care and follow-up, said Michael D. Jensen, the director of the obesity treatment research program at Mayo Clinic in Rochester, Minn., who has studied the effectiveness of weight-loss programs.

“It just takes most people so long to make permanent changes in eating or activity habits,” he said. “There’s always this search for the quick fix, and usually you can find somebody who’s willing to sell it to you.”

Dr. Pieter A. Cohen, a primary-care doctor at the Cambridge Health Alliance in Massachusetts and an assistant professor at Harvard Medical School, said several of his patients had used such clinics, only to return to him in frustration. “My clinical experience is that at least nine out of 10 patients who do these kinds of diets don’t just regain the weight, but go up again,” he said.

Few clinics follow patients long enough to demonstrate their programs’ effectiveness, although they point to individual success stories and say they do offer comprehensive behavioral counseling. Some are trying to improve treatment standards by employing doctors with backgrounds in obesity and certified nutritionists, while recommending only evidence-based treatments. And they say they offer real options to patients who have been shunned by mainstream medical providers.

“Doctors — even my own doctor — they would just say, ‘Stay under X calories and get lots of sleep and get lots of water,’ ” said Cris Cawley, chief executive of Thinique, a small medical weight-loss chain based in Texas. “But that’s really difficult.”

But often the clinics are overseen by doctors who have left other practices they found unprofitable. In many cases, the physician oversight amounts to little more than reading patients’ charts from afar, while the real weight-loss counseling is left to assistants with little training in the field.

One recent job posting for a medical director of a Medi-Weightloss clinic in Connecticut described the position’s hours as “not very demanding” and said the doctor would mainly be reviewing patient records remotely.

“This may be the opportunity you have been looking for,” the posting said. “There are no set hours and you will have no emergency calls.”

Dr. Edward Zbella, the chief medical officer at Medi-Weightloss, which has 76 locations around the country, said the requirements for clinic medical directors vary greatly from state to state, and in some places — like Connecticut — they supervise the work of nurse practitioners or physician assistants, who are the ones seeing patients.

How each clinic will benefit from the new law depends on where they operate as well as their business model. Under the Affordable Care Act, basic obesity screening must be covered by insurance, and some obese patients may qualify for additional counseling. Twenty-three states require some type of coverage for nutritional and obesity therapy, which can include weight-loss programs. In 23 states, insurers must cover weight-loss surgery, according to an analysis in 2014 by the National Conference of State Legislatures.

Revenue has grown substantially at the three clinics in North Carolina where Medi-Weightloss recently began accepting insurance as an in-network provider, according to Edward Kaloust, the chief executive and founder, although he declined to provide specific figures.

But Dr. John Morton, chief of bariatric surgery at Stanford University School of Medicine, said diet clinics should not be the focus of expanded obesity coverage. “Those clinics exist all over the country, and my point about it is we need something better than that,” he said.

Even with attentive doctors at the helm, these clinics often employ techniques that are unproven and even some that have been discredited.

One example is the very-low-calorie diet, where patients eat as few as 800 calories a day, which leads to a rapid initial weight loss. Proponents, like the Medi-Weightloss clinic, say it gives patients an early increase in confidence that allows them to meet their goals. “A lot of people give up when you start out with a slow weight loss,” Dr. Zbella said. “It’s just not worth their while.”

Many clinics also sell patients a three- or six-month program that consists of some combination of diet supplements, nutritional counseling and medication. Many of the supplements, like injections of B-12 and other vitamins, are backed by little, if any, scientific evidence for promoting weight loss. A sign in the bathroom at Dr. Kaplan’s Long Island Weight Loss Institute advertises vitamin injections for $40, saying the procedure “naturally increases your metabolism and energy levels.”

Dr. Kaplan acknowledged that the treatments are not scientifically proven, but he said they do not hurt, and patients have come to expect them as an option.

But others say such tactics, like extreme diets and unproven supplements, are misleading at best and fraudulent at worst. Dr. Jensen, the Mayo Clinic obesity researcher, studied the effectiveness of weight-loss programs and found that patients who used short-term treatments were not able to keep the weight off.

“Essentially, if you didn’t have a year in the program, the results were horrible,” Dr. Jensen said. If a patient is hoping for long-term results, “a three- to six-month program is almost as effective as no program.”

Many clinics make a profit from selling products to patients, as well as prescription weight-loss drugs like phentermine, which is widely prescribed in diet clinics.

Some doctors include the cost of phentermine in their program fees. JumpstartMD, a group of medical weight-loss clinics based in California, charges $388 a month for a program that includes weekly counseling and medication, if the doctor prescribes it, according to Dr. Sean E. Bourke, the chief executive and a co-founder.

But selling medication at a for-profit clinic, whether as part of a package or on its own, still raises red flags for obesity specialists like Dr. Jensen.

“Clearly, if they’re making money off of it, that’s a conflict of interest,” he said.

Dr. Kaplan said that while he does prescribe weight-loss drugs, he does not sell them directly. And Dr. Bourke, Dr. Kaplan and others in the commercial weight-loss industry emphasized that medication was just one part of the plans they offered.

“The last thing that we want to be known for is just handing out pills to patients,” said Dr. Kaplan, who is a credentialed specialist in obesity. “The backbone of everything that I recommend that doctors do is lifestyle.”

And while his new consulting business is focused on helping doctors increase their profits, he said patients will benefit, too. “I think that what we’re doing will help get more providers to focus on obesity,” he said.

Back at his office, Dr. Kaplan’s 38-year-old patient stepped on a scale facing advertisements for Botox and other cosmetic procedures. Sounding slightly disappointed, Dr. Kaplan informed her that at 5-foot-7 and 170.5 pounds, she was not quite heavy enough to get insurance to pay for a larger chunk of the program’s $1,199 price tag.

But the patient didn’t seem to mind. “I didn’t even expect to cover anything,” she said. “So that’s fine.”

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