Why is use of the Medicare Intensive Behavioral Therapy for Obesity Benefit so low? Finding what works to promote wider dissemination.

肥胖是我们这个时代最普遍和最具挑战性的公共卫生问题之一。2011年11月 医疗保险和医疗补助服务中心（CMS）批准使用新的医疗保健公共 程序编码系统（HCPCS）为提供强化行为治疗的初级保健支付代码 肥胖患者的IBT治疗。尽管在医疗保险中肥胖症的普遍存在， 人口，使用这一福利已大大低于预期，这表明显着 这一福利利用不足。本探索性研究将追求以下目标：1）制定一个全面的 了解与使用和不使用Medicare IBT治疗肥胖相关的最紧迫问题 受益于初级保健，2）研究已成功实施的实践中使用的策略 根据IBT的肥胖医疗保险福利服务，并描述：a）这些特征 B）实施过程的关键要素， 成功的实践干预，c）患者使用IBT治疗肥胖症，包括继续接受 服务后，满足减肥要求的好处，和d）成本提供服务相对于 报销金额。为了实现目标1，我们将查询Medicare提供者使用和付款 数据：三个州的医生和其他供应商数据库：科罗拉多、密歇根和北卡罗来纳州， 确定所有由Medicare支付的提供IBT肥胖服务的提供者及其实践 在2012年至2014年的一年中，向10名或更多的受益人提供服务。我们将确定以下基层护理做法： 这些供应商和进行半结构化的电话采访的做法（多达100个 共计）。然后，我们将确定没有使用IBT优势的实践，与邮政编码匹配，实践规模（>5 提供者），以及家庭或内科医生使用该福利的做法，并对此进行类似的采访 组访谈将评估实践特征、使用、不使用和停止使用福利的原因， 涉及的过程和人员以及任何已知的患者结果。为了实现目标2，我们将有目的地 从目标1中选择36个符合IBT肥胖实施成功标准的实践，收集- 深入的信息，以了解他们的实施，病人的结果和成本。数据收集将包括 现场访谈和观察，以及EMR数据提取。归一化过程理论将用于 了解实施的重要因素。这些方法也将用于获取信息， 估计提供IBT服务的实践成本，并评估其在当前和 替代偿还金额。我们的研究结果具有直接的政策影响， 有效执行战略的可持续性，可从继续提供 IBT用于肥胖服务。本研究将通过确定这一领域的使用效益、使用原因 和停止使用，并确定在初级保健中有效实施IBT的潜在策略。

Obesity is one of the most prevalent and challenging public health issues of our time. In November 2011, the Centers for Medicare and Medicaid Services (CMS) approved the use of a new Healthcare Common Procedure Coding System (HCPCS) code for payment in primary care for providing Intensive Behavioral Therapy (IBT) treatment for obese patients. Despite the widespread prevalence of obesity in the Medicare population, use of this benefit has been substantially lower than expected suggesting significant underutilization of this benefit. This exploratory study will pursue the following aims: 1) To develop a thorough understanding of the most pressing issues related to the use and non-use of the Medicare IBT for obesity benefit in primary care, and 2) To study the strategies used in practices that have successfully implemented services in accordance with the IBT for obesity Medicare benefit and describe: a) characteristics of these practices and their environmental context, b) key elements of the implementation process that facilitate successful in-practice intervention, c) patients use of the IBT for obesity benefit, including continuing receipt of services after meeting the weight loss requirement of the benefit, and d) cost to provide the service relative to the reimbursement amount. To accomplish aim 1, we will query the Medicare Provider Utilization and Payment Data: Physician and Other Supplier database for three states: Colorado, Michigan, and North Carolina and identify all providers and their practices that have been paid by Medicare for delivering IBT for obesity services to 10 or more beneficiaries in a year between 2012 and 2014. We will identify the primary care practices of these providers and conduct semi-structured telephone interviews with the universe of practices (up to 100 total). We will then identify practices that are not using the IBT benefit, matched on zip code, practice size (>5 providers), and family or internal medicine to practices using the benefit and conduct similar interviews with this group. Interviews will assess practice characteristics, reasons for use, non-use and stopping use of the benefit, processes and personnel involved, and any known patient results. To accomplish aim 2, we will purposefully select 36 practices from aim 1 that meet our criteria for IBT for obesity implementation success to collect in- depth information to understand their implementation, patient outcomes and costs. Data gathering will include on-site interviews and observations, and EMR data extraction. Normalization process theory will be used to understand factors important to implementation. These methods will also be used to obtain information to estimate the cost to the practice of providing IBT services and assess its sustainability under current and alternative reimbursement amounts. Our findings have direct policy implications informing the dissemination and sustainability of effective implementation strategies that can be learned from practices continuing to deliver IBT for obesity services. This study will add to the field by determining the use of this benefit, reasons for use and discontinuation of use, and identify potential strategies for effective implementation of IBT in primary care.