Introduction

Joe Kim (CCO): Thank you so much for your willingness to join us for this interview and to share your experiences about providing obesity care. Before we start, briefly tell us about your practice.

Natalie Orbach (MedStar Family Choice): I am a PA. Have been for 25 years. I work in an internal medicine office. It is a private office with one other doctor providing care. We see only adults over the age of 18. Our practice has been around for about 35 or 40 years. I have been here for 20 of those years. Most of our patients are long-term patients who have referred their family and friends to us. It is a really nice practice.

Joe Kim: I know that a few years ago we had the opportunity to work together on an obesity quality improvement program, and one of the areas of focus was around tailoring and customizing obesity care for your patients. What does that mean? Tell us about your process. How do you tailor the obesity care that is offered and provided to your patients?

Natalie Orbach: The first thing is I always ask patients about their weight. The one thing is I do not typically ask, are you happy with it as much as how stable is it? That usually gets the conversation going. Certainly, with our patients with higher BMI where we should be addressing these issues for health reasons. I try to understand, where they are at thinking about their weight, before we even jump into, "Hey, we need to do something about this." We talk about goals of care in terms of so much not my goals as much as what are their goals. It is establishing realistic goals. If a patient says to me, "Oh, I want to be 120 pounds." The question I ask is, "Well, when was the last time you weighed 120 pounds?" That we can be realistic about setting up our plans for achieving their goals. I always set goals small, so I personalize it to each patient. I have no rhyme or reason of the way I do it except it is really very individualized to the patient, the age of the patient, the motivation of the patient. I really try to keep it as very individualized as I can. The first thing we always do is talk about what the goals are.

Joe Kim: Regarding the way that you bring this topic up, would you find that it is easy to do with new patients? Do you find that you usually wait to establish care before you bring up the topic of obesity care? How and when would you say that you normally bring it up with your patient population?

Natalie Orbach: Great question because I do not know that there is one way to do it. I think most of my patients that are very well established, we have had these conversations. It is very easy to bring it up. Again, I usually approach the subject of, "How stable is your weight in terms of over the last few years?" Do we want to make any plans to change that, especially in our obese patients. I met a new patient actually within the last week. That was how I approached it with her and I said, "I am just meeting you today and tell me about the stability of your weight over the last few years." That got the conversation going right there with no problem. because she said, "Well, it is not been. I really want to talk about that. I just did not know when to bring it up to you because we are meeting each other for the first time." It was just really a very nice in for having that conversation.

Joe Kim: That is great to hear. Let us talk about these specific different interventions and modalities of care that go into an obesity care plan. Starting with the topic of nutrition, how do you bring this up? How do you address and talk about nutrition with your patients?

Natalie Orbach: This is another one that is very individualized to each patient, and I do tailor it to each patient. We talk about how they are currently eating. We start there with, "Well, tell me what you had for breakfast. Tell me what you are planning for dinner or lunch." We talk about where they are at right now and if they are skipping meals or they are choosing fast foods or microwaveable meals or what they are doing and how many calories. We get a sense of that. and then I try to not necessarily change people's habits right away with nutrition because that is a hard one to do. I cannot tell you to just now stop going to fast food restaurants if that is your lifestyle. A patient might say to me, "Well, Natalie, my schedule is so busy. I am running the kids all over the place. We are stopping in Chick-fil-A. We are going here. We are going there." I usually say, "You do not need to get an extra value meal. You can get a kid's meal." We talk about how can we eat less calories, eat a little bit better with what we are currently able to do. That is really how I approach that. I really try to individualize it to what they are currently doing. We talk about cutting meals in half. We talk about using smaller plates. We talk about, simple recipes. I am a big cook. I cook a lot at home. I talk about some of the simple things I do with my busy schedule. Yeah, I get home. I do not want to be spending 3 hours cooking a meal, so what do I do? I share some of those things that I do, so as to try to offer better healthy habits.

Joe Kim: How about when it comes to either nutrition interventions, referrals, either programs that are available commercially, when and how would you say you refer patients to those resources?

Natalie Orbach: I offer that from the very beginning in terms of if somebody wants to see a dietician or a nutritionist, we have a program here in Maryland that is called CoreLife, which is a program that is often covered by insurance. It is a really nice resource and patients go and they meet with the dietician's nutritionist and work on calorie counting and making better meal plans. I do actually offer that from the very beginning as an option for patients if they feel like they are struggling with balancing the meals. I have a lot of also literature types of things on nutrition that I give to patients that make it really easy. Where sometimes simple is better because when we make it too complicated, no one has time for that. I try to keep it simple. I show the divided plate with a small portion of protein, small portion of starches and the larger vegetables. We talk about what all those things are.

Joe Kim: What has been your experience when it comes to patients who have tried some of the commercial, either meal replacement plans or some of the commercial dieting plans? Does that come up in your conversations?

Natalie Orbach: I have encouraged some of those programs when patients have used them before and been successful with them. I am going to tell you, it is not the my go-to in terms of recommending because they are expensive. Nutrisystem is one that can be very costly, but yet very helpful. I have a patient who is using that currently and being very successful with it, but she's done it before and it works for her. I do recommend some of these, these box meals that get delivered to people's homes, the HelloFresh and things like that. because I tell them it makes it really easy because you do not have to go shopping for anything. You do not have to think about it. The directions are all there on a little card, and they are very portioned out meals. I do talk about those products. Sometimes if somebody really says, "I do not know how to cook, I do not know what to do, but I want to eat healthier." I have encouraged some of those programs. Again, they are not cheap programs to encourage people to do. I am always trying to stay within things that are reasonable for everyone.

Joe Kim: Let us talk physical activity and getting patients to move more. How do you address the topic of physical activity with patients as well as set realistic expectations with them?

Natalie Orbach: I always start with, again, like I do with nutrition is where are you at? What are you doing currently? If you are doing nothing, besides going to work every day or taking care of the grandkids or whatever it might be, I usually say, "Let us give 1 day. You can give me 1 day out of the week that you take a walk for 15 minutes." I start slow and I usually try to add over the weeks more into their exercise, them exercising. Probably the most popular thing I hear all the time is patients will say, "I am going to join the gym. I am going to, I am going to join a gym. I have been thinking about it." I always say, "Stop thinking about it. We are not going to do it. Let us think about ways we can just exercise without having to go somewhere else or another expense or another commitment somewhere." I typically, I encourage things like, there is a program called ClassPass.

ClassPass is an internet subscription that allows them to find a class whether it is Pilates or yoga or Zumba or a mix fit or whatever you like, even cycling, or a day at the gym. Where they can go when they have time so they are not committed to a monthly expense of something they might not be doing. ClassPass is a big one. I encourage, especially for busy people because they can just say, "Oh, there is a class in this neighborhood." I am going to go. They can find it close to work. I usually start with where they are at and I try to encourage at least 1 day and then we increase depending on what they are currently doing. Patients who are already actively working out. I have some patients that are like, "I am going to the gym 3 days a week. I do not see anything happening." I usually say, "What are you doing in the gym? Tell me what your workout looks like." Then we find modifications. We talk about if somebody's only doing cardio, then I say, "Let us add a little weight training in there. No, you are not going to build big heavy muscles. We are going to just do a little bit more resistance training." We talk about some things they can do. I have been known to get on the floor in my office and show them some things to do.

We talk about easy things that are safe. That is the other thing is just also patients with limitations in their joints and pain. You want to find things. It has to be very tailored to that. I usually talk about that when I know the patient well and I say, "If your knees are bad, we are not going to be doing squats and lunges. You are going to be doing the stationary bike or the recumbent bikes." We find things and so that is how it is. It is very individualized because we have a good conversation about what they are doing. Simple things that I tell patients they can do in everyday life that they do not realize sometimes is, I say, "Park your car at the end of my parking lot. I want you to walk from the car all the way up to the office. Take the first flight of stairs and then get off and take the elevator up to the third floor for me." What you are doing is getting a few more steps in a little bit more activity than what you may have done at all during the day. It is just also finding how I can build it into their everyday life.

Joe Kim: Changes in their lifestyle and these incremental improvements. Obviously, there have been a number of patients who might say, for example, "The more I exercise or move the hungrier I get. I eat more." Do you find patients sort of bringing that up and saying, "This is an issue for me and so what can I do about it?"

Natalie Orbach: I do. I have a lot of patients that will say, "When I am exercising, of course then I eat. I am hungrier." We talk about how many calories they are eating on that average day and then how much we need to add in because what is their exercise regimens like? If they are really doing a lot of exercise, I want to make sure that they are getting the right amount of calories. We talk about their calorie, counts and we do it roughly. Most people do not want to sit there trying to calculate their calories every day because it becomes a full-time job trying to calculate these things. We get rough estimates about what people are doing based on what they are logging or they are telling me they are eating. What I have done is we either adjust that so that they are less hungry. The other thing I do is I encourage protein snacks or bars or meals, even simple things like I say, apple and peanut butter, or peanut butter crackers. Things like that or a peanut butter sandwich after your workout because just for the protein to heal the muscles, but also to give them a little bit of fullness. We just talk about that and increasing proteins if they are really working out a lot more because takes a lot longer to burn those so people stay full more.

Joe Kim: How about other interventions, whether it is evaluation for surgery or addressing maybe some mental health concerns? How do you incorporate those conversations as well as appropriate referrals if they are warranted?

Natalie Orbach: I have referred a lot of people for surgical intervention through the years, and usually it is a conversation we have when we have been really working hard and with close follow-up and we have done all the things we have talked about and the patient is really committed to a program, but we are not getting the results they are necessarily looking, or they are finding themselves just really struggling. It does come up as an option. I have a few programs in the area that I refer to that I think are very good programs. A lot of times I might encourage a patient to go. I say, "Just go meet them." Let us hear what it is all about because some of these programs have 3 to 6 months that you have to follow more regimented dietary restrictions. They end up starting to lose weight with some of these other modalities that these programs offer. Many of them might get through these programs and not even decide to do surgery. I always tell them, "You are not committed if you do the program, so it is okay. We can just get some information."

I have some patients that come in the door and the first thing they want to do is talk about going for some bariatric surgery and I am open to it because that is their goal. We talk about other things they have tried because usually we have tried and failed other means of losing weight in order to support their decision to do a surgical procedure. Now in terms of mental health, so I think mental health plays a huge role in some of our patients with obesity. Certainly, if they are eating for stress or that is their go-to for comfort, whatever it might be, we do talk about it but that is usually in the conversation when we are talking about what is going on with their eating habits. Patients are pretty forthcoming and they will say, "I have just been really stressed out and that is what is been going on. I am definitely looking for the cookies and the, and the ice creams or definitely like my fast food restaurants because it just makes me feel better." When I hear those things, that is when I know we might need to talk with a therapist just to sort that out.

Joe Kim: When it comes to referring patients for mental health, professionals, 2 different mental health professionals, do you find that it is relatively easy to allow them to make those appointments and get access? Is it more that they need a support group or how would you say it has been getting them to see mental health if they need it or to get other mental health needs met?

Natalie Orbach: I think depending on which way I direct them is usually what is going on. If I have a very situational type of problem that is leading to us not being able to stick with a program of weight loss and they are struggling, a lot of times I will have the patients call their EAPs at work if they have them available because I think that is easier access. Plus it does not create a financial burden on them because these are free access to patients. Other times I refer them out. We have some groups that we work with and getting whatever mental health services they need, I usually start with therapists as opposed to just referring out to a psychiatrist because of course some of the psychiatric medications when we begin to use them they are not as helpful when people are losing weight. Oftentimes, it really is very dependent on why I am sending them for mental health services. I have a lot of resources.

Joe Kim: Let us talk now about medications. I am sure some of your patients come in asking for medications. What has it been like for you to talk with patients about the role of anti-obesity medications as well as helping them get access to these?

Natalie Orbach: This is a great topic. One of my favorites actually, because it is a conversation I probably have at least once a day, maybe more than that, but it is a conversation I have a lot because patients are all coming in asking for them by name, certainly by any name that they are familiar with. With the GLP-1 inhibitors as well as some of the others that are out there the phentermine/topiramate combinations. This is a conversation I had very early on when we are talking about our goals of weight loss. Typically, we talk about nutrition, we talk about exercise, but then we do talk about the medications that are available. Some patients come in right as their visit and they say, "My friend is on this and this is what I am thinking." We talk about the medications. We talk about all the options. I talk about the injectables as well as all the orals available. We talk about what is going to be the best for that patient because not every patient can tolerate all of these things. We talk about dosing regimens of them.

I am very, very familiar with all of them and is very, very familiar with all of the insurance companies in our area that cover them. Also, with all of the extra programs that are available for patients to get access. I have used a lot of these medications, and I have been continuing to use them and getting patients access to them by just being creative about what is available. There is a lot of coupon programs. There is these direct cash programs and again, it is very tailored to the patient. If I have a patient that is better suited with phentermine and a little topiramate, then I will do that, because maybe they want to lose 10 pounds, 15 pounds because the class reunion is coming up.

Then we know that we can achieve those goals. Most of my patients, the injectable drugs, the GLP-1 inhibitors have definitely been the very popular medications and they are definitely expensive drugs, but again, the companies that make these drugs have offered incredible, cash saving programs to make them way more available and affordable. One comment I will make though because there are a lot of these compounded versions of these medications available in our area. That is always a question that comes to me from patients about whether or not I feel they are safe and is it an option for them? I am a bit discouraging of it because I do not know what this compounded version is. I am usually trying to be a little more creative about how we can get the actual medications.

Joe Kim: It sounds like with your patient population and just being really familiar with insurance coverage, that it is extremely helpful just in terms of even knowing how to guide the conversation. In terms of the work that it takes to fill out things like the prior authorization forms or even submitting for some of these other assistance programs, is that work that you do yourself? Do you have other people within the group who assists with that? What is your process?

Natalie Orbach: I do it all myself. Our medical assistants in our office do not do prior authorizations. Prior authorizations for these medications are very simple. They take button minutes. They really ask the standard questions of the things that we are already doing comprehensive weight management programs, exercise. They are asking about BMI. They are asking about comorbid conditions. This is just a very quick click, click, click through the boxes. You show proof of the BMI through the office note. Most of these insurance companies give an approval almost within minutes. Again, I am very familiar with which ones do approve it. Now, they all require prior authorization. Anytime I write this drug, I am getting a prior authorization and I already know that ahead of time. Even using the direct cash programs that we have been able to do, the patient assistance programs, again, very simple to use. It is done through our electronic record. We just send it off to the pharmacy. You alert the patient that they are going to be notified and the patient does their part on their end and it is mailed to their house. Actually, it does not take any time at all and at least not for me because it is very straightforward. They are all the same. When one comes over, you know exactly what it looks like.

Joe Kim: It sounds like with your electronic version and the way that it is been integrated into your health record, it seems like it is a streamlined process there. As you reflect back and think about this journey of providing obesity care and making improvements in that and using all these different modalities of treatment, what would you say have been some of the biggest challenges you have faced as you have provided obesity care for your patients?

Natalie Orbach: As easy as I made the prior authorization and these available programs to the direct cash programs sound, it is easy if people have the coverage and their cost is not prohibitive. That is probably the biggest challenge is because on average, these cash programs it is about $300 to $400 a month for medication. That is very expensive for a lot of our patients and it is not affordable. That is probably one of my biggest hurdles because then I am getting real creative about what else we can do and how to do it. One of the other hurdles is making sure that we are just getting our patients back in for follow-up. I set the standard as soon as I am seeing the patient and starting these medications, I say, "I want to see you every 6 weeks. This is how I want you in here so we can weigh you. I want to talk about where we are at. I want to make sure we are meeting your goals. If you come in in 6 weeks or you come in in 12 weeks and you are not meeting the goals you were hoping to achieve, then I need to figure out why not. We need to make some changes." That is sometimes difficult for patients too, is just being able to keep consistent in coming in. Sometimes that is a little bit of a hurdle.

Joe Kim: As you reflect also and talk to other clinicians about providing obesity care, what advice would you give to others who perhaps have not really done a lot of obesity care? Maybe they are thinking about it or they are perhaps developing an obesity care program within their practice, suggestions or advice for them to consider?

Natalie Orbach: One is familiarizing themselves with the obesity guidelines that are available to us because I think they are incredibly helpful with good guidance and even the diabetes care guidelines that come out every year are very good about discussing obesity treatments and availabilities. I think that the one thing I would say is do not be afraid to talk about it. Patients want to talk about it for sure. Patients are most of the time motivated and we do not turf everything to someone else. If it is talking about nutrition, if it is talking about exercise, we have to be able to start that. If I just have a patient come in the office and they talk about wanting to lose weight and my first referral is, "See the nutritionist." By the time they see a nutritionist, it is a few weeks down the road, we may have missed that window of opportunity to keep that patient moving through their goals and doing the things they want to do. I oftentimes say, "We do not have to know everything about nutrition. I am no expert, but you and I eat every day. We know some of the ways to eat that are good choices. We exercise."

It is just having some, giving some guidance I think is super important, when you had the patient's attention. If I got the patient's attention, let me go for it. Sometimes putting together simple handouts. For example, I created a handout that shows the titration. Shows when you should be calling me back about it. Shows when your follow up should be. Tells you about the side effects. Tells you how to deal with it. It is all the things I said to them, but now I put it in this nice little page for you that just reminds you of everything we talked about. I do this with simple things of measuring things. "Okay, if I tell you that you should eat, your protein should be the size of palm of your hand." I have a little handout that has those things to remind you. And these are simple things, take minutes for us to do them. Again, it really shows the patient that one, is you're committed to their success and I am invested in it so it helps.

Joe Kim: Those have been great tips and suggestions as we get ready to wrap up our interview and our conversation here, is there anything else in terms of any thoughts regarding obesity care or just ideas maybe even for the future of how you would aim and hope to do things differently?

Natalie Orbach: For myself and my practice, I would love to be able to get a support group or something of that nature, but not necessarily support group where we talk, just chatter, but more about where people are offering what they have done, how they have been successful. Even bringing in speakers to talk about exercise and nutrition and being able to do more of that. It is one of the things, I want to do, I just need to be able to put it together. Other things that I have done personally with patients, that I would like to probably find some way to do it at a bigger scale is sending those affirmative text messages saying, or just checking in. I would like to be able to do more of that sometimes just making sure, but at time is a lot of times our problem is just having enough time to do all these things. The other thing is just really, I wish we get more coverage for these things and more consistent coverage and affordability for these drugs, even though I feel like they are as good as they are right now, I think they could be better and it would just give people more access.