Access and Use of Medical Care among Obese Persons
1107 Mace Avenue, Baltimore, MD 21224-3361. Fax: 410-605-7913; E-mail: kevin@grecc.Umaryland.edu.
The prevalence of obesity and severe obesity is growing rapidly, along with obesity-related comorbidities and mortality. Given the increased health risks associated with obesity, it is vital that obese persons have adequate access to, and make consistent use of, medical care services. Assuming obese persons have access to medical care that is comparable to non-obese persons, one would expect to observe greater use of medical services among obese persons. In this article we briefly review empirical evidence of the access to and use of medical care among obese persons. Although certain subgroups that tend to have disproportionately high prevalences of obesity (i.e., low socioeconomic status, minority groups) have reduced access to care, no studies have specifically examined whether or not obese persons have the same access to health care as do their lean counterparts. With respect to use of health care services, however, obesity has been consistently linked with greater rates of utilization and increased health care expenditures. Both the increased use and cost appear to be largely a function of treating obesity-associated comorbidities such as diabetes and hypertension. We conclude that, although it is clear that obesity is associated with both greater use and cost of medical care, the relationship between obesity and access to medical care has not been determined.
The prevalence of obesity and severe obesity continue to increase rapidly (1, 2) implying that both obesity-associated comorbidity and mortality will rise accordingly (3, 4). Given the increased health risks associated with obesity, it is vital that obese persons have adequate access to, and make consistent use of, medical care services. Assuming obese persons have access to medical care that is comparable to non-obese persons, one would expect to observe greater use of medical services among obese persons. In this article, we briefly review the literature to examine whether this is the case. We also highlight some of the ways to improve the quality of medical care provided to obese persons.
Obesity and Access to Medical Care
Access to medical care varies greatly within subgroups of the population. To our knowledge, however, no studies have specifically examined access to medical care among obese persons. However, we offer a brief synopsis of access to medical care in two selected population subgroups—low socioeconomic status (SES) individuals and minority groups. These two groups were chosen, because there is extensive literature on their access to care and because the prevalence of obesity among these populations is disproportionately high. However, we must emphasize that it would be illogical to conclude that, because both SES and minority status tend to associate with obesity, these variables can serve as a proxy for investigating the obesity-access to care relationship. Nonetheless, these two groups provide at least crude data with which to generate hypotheses regarding the obesity-access association.
There is a clear relationship between SES (whether measured by income, education, or occupational status) and health (5). Specifically, SES is directly related to increased medical risk factors (i.e., hypertension, cholesterol, and diabetes) (6, 7), greater psychological distress (i.e., depression, hopelessness, hostility, conflict, and stress) (8, 9), and reduced social support (6, 9). In addition, the prevalence of health-compromising behaviors such as smoking, physical inactivity, and consuming a high fat diet is inversely related to SES (6, 10). Low SES is also associated with less health knowledge (11) and reduced access to medical care.
Among minority groups, the prevalence of obesity and related health consequences is also disproportionately high (1, 12). Compounding the effects of lower education and income, minority groups also tend to live in urban and rural environments where they are confronted by numerous health and psychosocial challenges not faced by other groups (13). As such, physicians who treat low SES and minority patients must often address the complex psychosocial problems these patients face before medical issues can be adequately treated. These patients may require more frequent and longer office visits; however, they are also the group most likely to miss scheduled appointments (14, 15), in part, due to higher rates of psychological distress and social stress.
It is also important to note that nearly 20% of adults 18 to 64 years of age have no health insurance coverage (16), and the proportion of uninsured persons is significantly higher among minority groups (17). Moreover, even if insured, providers tend to receive lower reimbursements from Medicaid and even private insurance for services rendered to these patient groups (5).
In sum, it is clear that both low SES and minority status are associated with reduced access to medical care. As we have suggested, the mechanisms by which these sociodemographic variables impact on access are likely to be complex and multifaceted (e.g., psychological distress, poor health habits, lack of insurance, and the proximity, availability, and quality of resources). Although it is appealing to propose that, because obesity relates strongly to both SES and minority status, it must also be associated with reduced access. However, the question of whether access to medical care differs as a function of weight status remains to be investigated directly.
Obesity and Use of Medical Care
According to the 1997 National Ambulatory Medical Care Survey (NAMCS), the average person residing in the United States visits a physician as an outpatient three times per year (18). Visiting rates are higher for women compared with men, and for whites compared with non-whites (18). Unfortunately, the NAMCS recording form does not explicitly collect information on body weight, so it is impossible, with these data, to determine whether overweight/obese persons visit physicians more frequently than do non-overweight/non-obese persons. However, several published studies have investigated the association between body mass index (BMI, kg/m2) and use of medical services.
In a survey of over 17,000 members of a large health maintenance organization (HMO), where the financial barriers to access to care are essentially removed, BMI was associated with more frequent outpatient visits (19). Specifically, compared with lean and normal weight respondents (i.e., BMI < 25), those with BMI values between 30 and 34.9 reported a 17% higher rate of visits, and those with BMI ≥ 35 experienced a 24% higher rate. The association between BMI and outpatient visits was strongest for respondents under the age of 60 years. BMI was also associated with increased inpatient days, outpatient and inpatient costs, and total cost. The elevated costs, relative to respondents with BMI < 25, appeared to be due largely to treating three major obesity-related comorbidities: hypertension, coronary heart disease, and diabetes.
By the same token, an analysis of population-based data from 16,000 respondents, both insured and under/non-insured, of the 1987 National Medical Expenditure Survey found an association between BMI and the likelihood of using health care services in the previous year, even after controlling for age (20). Moreover, the association between BMI and health care use was stronger for men than women, and for whites than non-whites. With respect to health care expenditures, a 1-unit increase in BMI in those in the intermediate BMI category (defined as a BMI of 22 to 35 and 22 to 31 for women and men, respectively) was associated with a 7% increase in expenditures for women, and a 16% increase for men. Finally, when hypertension and diabetes were included in the model, no association between BMI, number of visits, or health care expenditures were observed, suggesting that the association between BMI and medical use is largely a function of the relationship between BMI and comorbidities.
In another study investigating health care utilization among women in a primary care setting, Sansone et al. (21) found that, as compared to non-obese women, obesity was associated with a greater number of diagnoses, contacts with the facility, total number of prescriptions, and number of different physicians seen. However, after controlling for the number of diagnoses, BMI remained associated only with the number of different physicians seen.
An analysis of data from the 1992 National Health Interview Survey also revealed that, among women, BMI was associated with the number of physician visits in the previous year (22). That is, for every 1-unit increase in BMI there was, on average, a 0.06-unit increase in physician visits. However, despite the positive association between BMI and physician visits, BMI was negatively associated with preventive health behaviors such as obtaining breast examinations, Pap smears, or gynecological examination within the previous 3 years (see Reference (23) for a review of the literature pertaining to the association between obesity and the use of preventive health care services).
Cross-sectional survey data from the 1994 Canadian National Population Health Survey also found that having a BMI of ≥ 27 was associated with increased physician visits, after controlling for the effects of age, sex, marital status, income, level of physical activity, and even smoking status (24). Moreover, compared to non-obese respondents, obese respondents were more likely to have been prescribed medication(s) (e.g., antihypertensives, antidepressants, pain relievers, oral diabetes medications) and to have sought mental health services. In contrast, obese persons had fewer hospital admissions than non-obese persons in the previous year. Similar associations between obesity and health care utilization have also been observed in Germany (25) and Sweden (26).
In sum, obesity has been consistently linked with greater utilization of medical services and with increased health care expenditures. Both the increased use and cost appear to be largely a function of treating obesity-associated comorbidities such as diabetes and hypertension. Indeed, the association between obesity and health care utilization becomes weaker, if not eliminated completely, when obesity-related comorbidities are added to the statistical models. Recent econometric studies (27, 28) confirm that the health and economic consequences of obesity are substantial and imply that sustained modest weight reduction among obese persons would yield substantial health and economic benefits.
How Can We Improve the Medical Care of Obese Persons?
Because obesity is a chronic refractory disease that puts people at increased risk of a variety of comorbidities, it seems appropriate to both conceptualize and treat obesity within a chronic care model (29). This model proposes that obese persons require consistent and timely medical care to identify and evaluate health risks and treat them accordingly. That is, we can improve the care provided to obese persons, and thereby reduce their health risks considerably, if physicians take a proactive approach to their treatment. This would involve assisting obese persons to evaluate their health risks and devising a plan of action to address these risks. Although part of the treatment could be to assist the obese patient in procuring a modest weight reduction, another important component of the treatment is to help the patient remain healthy in spite of their elevated body weight. For instance, it has been shown that even modest changes in diet and physical activity (30) can have a significant impact on cardiovascular risk factors independent of whether or not the person loses weight.
Recent studies (e.g., Reference (31)) suggest that physicians express high concern for their obese patients, but variable interest in taking a leading role in treating the obesity. This reluctance has been attributed to a lack of knowledge regarding effective treatment strategies, negative stereotypes regarding the motivation and ability of obese persons to change behavior, reduced awareness of resources available, low confidence in counseling and behavior change skills, as well as discouragement from the relatively poor outcomes in clinical studies (31). Conceptualizing obesity from within the chronic care model outlined by Hill (29) may empower physicians to participate more actively to ensure that their obese patients are not only given timely treatment for their obesity-related comorbidities but also the opportunity and resources to address their weight (if the patient wishes to do so) as well.
Based on our review of the relatively sparse literature on these important topics, we offer the following conclusions:
- 1) Although certain subgroups that tend to have high prevalences of obesity (i.e., low SES, minority groups) have reduced access to care, it is not known whether weight status is an independent risk factor for reduced access. Therefore, research is needed to investigate directly the issue of access to medical care among obese persons, particularly as it relates to routine services (e.g., physical examinations, screening tests).
- 2) Obese persons tend to use medical services with greater frequency than do non-obese persons and the costs of the services rendered to obese persons tend to be higher. Both the increased use and cost of medical services are largely a function of treating obesity-related diseases such as hypertension and diabetes.
- 3) Physicians would benefit from training to enhance skills in the identification, treatment, and counseling of their obese patients.
- 4) Conceptualizing obesity as a chronic disease may empower physicians to work more actively with their obese patients in an effort to establish goals and develop strategies to more successfully manage both the obesity and its associated comorbidities.