PREAMBLE
Many health insurers/HMOs have disease management programs. This is where the HMO takes proactive steps to prevent treatable diseases (e.g. asthma, diabetes, hypertension) from becoming high-cost nightmares. The HMO pays higher costs up front (costs of having nurses make house calls;
costs of giving patients internet access so they can communicate with doctors; costs of keeping after the patient to make sure he/she takes his/her medicine, etc.), but the HMO hopes to SAVE money in the long run.
I have not yet seen a obesity management program, but this is my idea for one.
This is PURELY OPTIONAL to the patient. Even extremely fat people are free to choose whether to participate. The HMO will try to reward them for participating, but the patient is free to live his/her [hereafter, "his"] life the way he/she [hereafter, "he"] wants.
This program is only for extremely obese people (people who weigh at least 2 times their prescribed body weight).
AMBLE
I'm only 20 pounds overweight, and even I find it hard to give up food or start on a diet. Eating is a major source of enjoyment for me, and I'm loath to give it up. In fact, the only things I would be willing to give up food for (by "food" I obviously mean tasty, abundant, fulfilling food) are money, sex, or possibly friendship. Now, I'm not going to suggest that HMOs hire gorgeous guys/girls to go over and have sex with the enrollee as a reward for his losing weight. However, such an idea would be within the philosophy of this approach. For this is to be a *drive-driven* obesity management program.
The only other two drives that are possibly primal enough to compare with the drive to eat are wealth and friendship. Personal desires, such as staying healthy or looking attractive, are not primal drives. Most attempts to control obesity by appealing to these seemingly important motives have failed.
MONEY
I am not just talking about the HMO waiving premiums for program enrollees; I am literally suggesting that cash be given, for free, to the enrollee every week that he continues to make satisfactory weight loss.
Give a chronically extremely obese person money every week and he will begin to look forward to spending it and buying special things (or even saving it to buy a house). This will take his mind off eating. Money naturally makes the enrollee less stressed and internally happier, and this may reduce long-term costs, too.
The structure of the cash flows must be well thought out. A constant cash stipend every week will eventually become a bore to the enrollee. Once the excitement of money goes away, the primal drive of food will overpower it again and the patient will relapse. An increasing stipend would be better for retaining the interest of the enrollee, and would give the enrollee a feeling of "investment" in the program; he would know that if he dropped out and reentered it, he would be back down to the tiny initial payment again.
Even a linear increase in cash payment could get boring; what I really advise is for the cash flows to be exponential. Now, I don't mean one dollar the first day, two dollars the second day, four dollars the third day, etc. We're not going to make any million-dollar payments here. But a mild curve, increasing by 1% per week, would take the edge off inflation and also keep the enrollee's mind guessing. All good things, when trying to make money more interesting than food.
ENFORCEMENT
The second prong of the obesity management program is enforcement. The enrollee will be assigned a companion who will live with him 24 hours a day. This "case manager" is a friend, a counselor, and, at times, a warden. Cravings can be unpredictable. The case manager's job is to keep the enrollee from going off his diet at all costs. Part of this will be easy -- the friendlier the CMer is and the more fun the two people have together, the less time the enrollee will have to be alone and eat out of boredom or loneliness. However, the CMer's second job is to be alert to the enrollee's attempts to "cheat" on his diet. The CMer must sleep lightly, to prevent midnight fridge raids. At times the CMer may have to use force to keep his client away from harmful food. CMers are trained for these possibilities and they recognize that this is their best way to help the enrollee, who has voluntarily entered this program.
FRIENDSHIP
The case worker must be sociable and be a companion and a friend to the enrollee, or else the program's goals are undermined. Should there be complaints or communication problems, the enrollee may have to choose a different case worker. All attempts will be made to find one who hits it off well with the patient.
CONDITIONS
The program continues in full force as long as satisfactory weight-loss progress is made (or maintenance, once a target weight is reached). However, the HMO will not spend money it deems to be futile. If the enrollee has problems with too many social workers, the HMO will conclude that he is bitter and mean and will no longer provide expensive help to him. A strict limit of 1 relapse and reinstatement will be allowed. If the obese person goes off his diet a second time, no further effort is made to enroll this patient.
POSTAMBLE
Obesity is a very difficult condition to reverse. I believe that only a drive-driven approach has a reasonable chance to beat it.
While all disease management programs involve cash outlays at the beginning, to be regained years later, the approach given here involves an extremely deep cash investment which may or may not ever yield savings to the HMO in the long run. While the social benefits are indisputable -- the enrollee will be healthier; a friendship will be made; a job will be created -- it is unlikely that any HMO today would be willing to make such a radical commitment. One problem with my system is that the HMO will only recoup whatever money the program does product if the customer remains a member of that particular HMO for many, many years into the future. In practice, HMOs are usually made available by employers, and when an enrollee quits one job for another, his HMO membership will often have to be switched, too. HMOs will be reluctant to invest such heavy funding into a program whose savings will most likely accrue to someone else.
One structural solution would be to create independent obesity management "vendors", and to have volunteering HMOs pay fixed funds into these programs. Benefits are that the centralized programs could more easily administer the obesity management objectives, as well as more easily do the hiring and credentialing of case managers. However, *all* HMOs and health insurers would have to participate; otherwise there would be the same incentive problem, and nonparticipating HMOs would be able to charge cheaper premium rates and attract the lion's share of the health market.
Thank you for your consideration.