Patient Experience

The negative effect of fat bias on health outcomes

May 3, 2022 7:34 pm

Cardiologist and epidemiologist Dr. Christopher Labos discusses weight bias in healthcare, including what health indicators to focus on instead of weight and how to help patients who are at risk improve their health outcomes without explicit or implicit fat shaming.

Mentioned in this episode:

Christopher Labos: So we shouldn’t blame people for the fact that, you know, their specific weight loss interventions didn’t work. Sometimes interventions don’t work. Frankly, most weight loss interventions have very little science behind them and don’t work.

Erika Grotto: The challenge of weight bias in healthcare, today on HFMA’s Voices in Healthcare Finance podcast. Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today, we’re talking about weight bias with Dr. Christopher Labos, a Montreal-based cardiologist and epidemiologist. If you’ve enjoyed our other content on bias and deferred care, you’re really going to find this one interesting. Later, we’ll be talking about HFMA’s new international membership, but before we get to all that, let’s find out what’s happening in healthcare finance news. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.

Nick Hut: Hey, everybody. We thought we’d try to hit on a few topics in this segment since, as is so often the case with healthcare policy, there’s a lot in the news. First, as some people may be aware, particularly those whose organizations have been affected, there’s no longer any money in the COVID-19 uninsured program, meaning for uninsured and self-pay patients, providers are on the hook for covering the cost of vaccine administration. They can’t bill individuals for those costs based on the rules for the federal vaccine program, which supplies free vaccines. A recent agreement in the Senate to provide more money for the overall federal effort against COVID-19 did not include money for that uninsured fund. Shawn, what’s your analysis of this news?

Shawn Stack: Yeah, Nick, I think that’s true. I think now that those funds have expired, especially for the CDC vaccine program, I encourage everyone to review their list of participation requirements under that CDC vaccine program. But yeah, you’re correct. If the provider wants to participate in that program, you know, it gets a little sticky if you want to recoup some of those costs from those patients. And most likely, in most cases, you’re not going to be able to. Over in the uninsured fund, that also expired. If the cost of care due to COVID-19 from an uninsured program is not covered by the uninsured fund and there’s no other applicable funds to apply to the costs of that care, then balance billing can occur, just as long as you didn’t seek funds from that uninsured fund.

Hut: Yeah, that’s a great clarification. Another point we’re making is that providers are allowed to bill self-pay patients for testing and treatment costs.

Stack: Correct.

Hut: Those costs likewise had been covered by the uninsured program, but now that the program seems to be defunct, providers could bill for those costs as they see fit. Now, we wanted to touch briefly on labor trends. Hospitals and health systems added 5,100 jobs in March, according to the data. That’s a robust number, and if we get another, say, two or three months like that, it’ll be a pretty good indication that the sector is getting back to something a lot closer to normal than the last two years have been. But the job tally is still about 100,000 behind pre-pandemic levels, and it just remains to be seen whether the workforce can ever return to the “before times,” so to speak, in terms of numbers. Shawn, how do you see this situation?

Stack: Yeah, talking to a lot of our members, they’re taking the opportunity to do a lot of creative recruitment, retention through employee benefits that speak most to those employees, retention of their current staff, recruitment possibly bringing back staff that have left and now want to come back. We’ve seen a lot of creative aspects in that recruitment and retention arm of HR at different facilities. Another thing that hospitals are really stressed about right now and really searching for a good way to express, this increase in wages that they’ve been paying for the last two years—you know, whether it’s through employees that are under the umbrella of the hospital or contract services—is, as they file and work on their cost reports for 2020 and those roll out, that wage index update is most likely not going to hit most providers until 2024. So that’s quite a bit of a 2-3 year lag, at least, for some depending on when their cost reports fall. And it’s going to be interesting to see what comes out in the rule this year, to see if there’s going to be a 5% cap on losses as CBSAs shift around the country in areas where COVID hit first, and some of that volume’s gonna show on this first year’s cost report. But it’ll be interesting to see how these CBSAs wage out since they’re budget neutral over the next couple of years.

Hut: Yes. Most definitely that bears watching. I believe in the hospice proposed rule and the inpatient psychiatric facility proposed rule, CMS did include a cap on the amount by which the wage index could decrease. So that’s an indication of what may be in store like you mentioned.

Stack: Yeah, Nick, that’s what we’re thinking. And that cap is not temporary. That’s a permanent cap they wrote into both of those rules. We’re expecting the same on the IPOP side, but we’ll wait and see what happens there.

Hut: No doubt. And finally, healthcare stakeholders need to be aware of the impending end of the COVID-19 public health emergency. Right now, it’s set for April 16. We think it’s gonna be extended for 90 days because of the lack of notice today about the expiration. HHS, by all rights, can’t really just end the whole thing out of nowhere. It could, but it wouldn’t be very helpful for anybody who’s involved with healthcare. Whenever it ends, whether that’s July, whenever, one issue is gonna be a huge volume of people potentially dropping out of Medicaid coverage. That’s because the public health emergency has included a continuous enrollment provision in which states have been prohibited from disenrolling individuals. And according to data, a record 85 million people are now enrolled in Medicaid, and that’s an increase of 19% since the pandemic began. And now, states are having to figure out what to do with all those additional millions of people in terms of eligibility determinations. So what are we looking at here, Shawn, and what, if anything can providers be doing?

Stack: I mean, I think that what we’re looking at here is not a uniform transition after the pandemic, after the public health emergency. I think you’re right. I think we’re going to see the PHE period end in July most likely, unless another variant comes along that wreaks havoc on the healthcare system. So I think July’s the date we’re gonna see PHE end. But I think the Medicaid enrollment and regarding disenrollment, we’re gonna start seeing the sheer, in the fall, after July, start to trend off in some states. I think it’s going to be very state-to-state specific on how they handle this ramp, whether they try to seek waivers to extend funding based on the situations in their own state.

Hut: Well, that’s great perspective, Shawn. And for coverage of all these stories and more, you can go to

Grotto: If you’re a regular listener of this podcast, you know that a key focus of ours has been health equity and deferred care. Study after study—and I’ll link a few in the show notes—has shown that when people don’t feel welcome and understood by their healthcare providers, they don’t come back until they’re too sick to ignore their conditions. We’ve discussed race on the podcast. We’ve discussed the challenges faced by people who are transgender. But today’s topic is a little tricky because the characteristic we’re discussing is directly tied to health. We’re talking about weight bias, and it took me a long time to find the right guest for this, because I wanted to appropriately balance inclusivity and real health outcomes. And then I found Dr. Christopher Labos, a Montreal-based cardiologist and epidemiologist and one of the hosts of a podcast called The Body of Evidence. It’s a great podcast, by the way. We discussed how healthcare organizations can promote better health while at the same time making patients feel welcome and comfortable.

I actually found you through an article you wrote called “Can you be obese but still be healthy?” and the answer seems to be, “Yes, but that doesn’t mean that you always will be.” And you mention that people whose BMI would put them in the obese category are more likely to develop heart disease, heart failure, more likely to have a stroke.

Labos: Yes

Grotto: So objectively, I can see why a physician might look at a patient who is obese and worry about what can happen down the road. But the way that concern manifests itself in exam rooms is not always so great.

Labos: Right.

Grotto: What kind of damage can be done when a patient is continuously told to lose weight? The physician might look at them and say, “You should be losing weight,” but if they’re sitting in front of you and saying, “I have an ear infection” or “I have a broken leg” or something that has nothing to do with their weight, do you still want to grab that opportunity to talk to them and intervene? Or, what’s the strategy?

Labos: So I think there’s a couple of points here. We can’t deny the reality that obesity is a risk factor for not just cardiovascular problems but also cancer-related issues. Obesity does increase the risk of certain cancers, specifically breast cancer. So obesity is definitely a risk factor in the same way that high blood pressure is a risk factor, diabetes is a risk factor, cholesterol is a risk factor. And so we have to treat it as one problem amongst many that can affect people. I think the difference and the reason why we sometimes get into issues when people do not do this properly is that you don’t tell somebody with cancer, “Stop having cancer.” We don’t tell somebody with diabetes, “Stop having diabetes.” We treat the problem. Now, you don’t necessarily have to treat it with medications. There are sometimes non-pharmacological options, right? Certain exercises can work in certain conditions. But the point is, you treat the problem, you don’t just tell somebody, “Stop being sick.” Which is unfortunately how a lot of people approach the problem of obesity. They tell people, “Lose weight.” Well, that’s all well and good, but let’s remember, most people have tried to lose weight multiple times over the course of their life and it usually hasn’t gone well. That’s why they are suffering with this problem now. So you can’t just raise the problem and tell people to go fix it themselves. You have to provide a solution. Now that solution could be dietary counseling. It could be helping them adopt an exercise routine. But we should also acknowledge that if diet and exercise were easy, people would do them. They don’t because they are hard, and one of the aspects that we often don’t talk about is medications. And there are medications that can treat obesity. This field has advanced quite a bit in the past 10-15 years, and so you have medications like semaglutide, which is a diabetes medication but can help people lose weight. And these are not either/or propositions, so I think when we approach the issue of obesity with a patient, you don’t want to fat shame people. You don’t want to make people feel bad about the fact that they have this problem in the same way that you wouldn’t make somebody want to feel about having cancer. It’s a disease they have. It’s not their fault to a large extent. It’s a complex interplay of societal factors and genetics that lead to this. So you want to identify it as a problem without making somebody feel as if it’s their fault that they got sick because it’s often not. And then give them a path to victory. Give them a solution. And maybe it will work, or maybe it won’t, just like some therapies work and some therapies don’t. But we have to treat it in a more scientific way rather than be sometimes an unfortunately dismissive attitude of, well, you just have to eat less and exercise. If that was the solution to obesity, obesity wouldn’t exist as a problem.

Grotto: There’s this societal assumption that people who are overweight or obese must have terrible eating habits and must never exercise, which isn’t always the case.

Labos: No, and there’s a lot of factors. Genetics plays a major part in it in the same way, like, why are some people able to drink a glass of alcohol at dinner and be fine and why do some people become alcoholics? Why do some people become addicted to cigarettes and other people not? Some people smoke a little bit when they’re teenagers and then for whatever reason decided to stop smoking and never had a problem with it. Genetics plays a major factor. And our society has evolved in unfortunate ways. We all live a more sedentary lifestyle than our ancestors did even 100 years ago. We are more urban than we were 100 years ago. We are more sedentary than we were 100 years ago. We have access to a virtually inexhaustible supply of food, which we did not have 100 years ago. So there are a lot of factors that are contributing to the fact that the average weight of the population on a broad scale is going up. And so it’s not an individual’s fault. There are complex things that are playing into it. And another big one also is the economics of eating healthy. If you’ve been grocery shopping recently, you know food is getting very expensive, and especially fruits and vegetables are getting expensive. The reason why junk food is so appealing is, one, it tastes good—right, let’s not pretend that junk food doesn’t taste good, that’s how they get you to buy it. But it’s also cheaper, and so if you are of limited economic means and you have a limited budget, well, you’re gonna gravitate more toward unhealthy options because that’s what you can afford. So it’s very easy to say make healthy choices. Often we don’t give people the tools that they need to make those choices, and the challenges that they face, if we can’t get rid of them, we’re not going to see success in getting people to adopt healthier lifestyles.

Grotto: I like that you got into the food issue because that can be an issue for people no matter what their weight is, right? We’re kind of working too with the assumption that fat=unhealthy and thin=healthy, which is also not necessarily true, which I want to get into. But I want to talk about the food for a minute. There are some health systems that I’ve heard of that are doing prescriptions for food or have food programs for people. This is speaking to the epidemiologist side of you. What’s the solution here? I’m gonna ask you to solve the whole problem right now.

Labos: Yeah. OK.

Grotto: No, but what do you think is the way forward when access to healthy food is an issue?

Labos: The problem is the price differential—or one of the problems is the price differential, OK? So we either need to find a way to make unhealthy food more expensive or to make healthy food less expensive. That’s the only way you’re gonna solve the issue of a price differential. And neither one is really more valid than another. They are both going to accomplish the same thing. They involve different aspects and different types of legislation. The way you make junk food more expensive is a sugar tax, or some variant of that. And you know, when you mention it, people are like, “Argh, this is a sin tax.” I’m like, well, let’s not forget, the government does this for all kinds of things. They have a tax on tobacco products. They have a tax on alcohol. We have a tax on gasoline, which encourages people to use public transportation, or not use their cards, right? So the government does this type of thing all the time, and sugar taxes have been shown to work. In jurisdictions where they have been put into place, sugar consumption goes down. And even if it’s limited to, you know, drinking soda, which is a major source of how we North Americans consume sugar, it makes a difference. So we can get people to consume less sugar, which is a major contributor to obesity and many other metabolic problems like diabetes, etc., by making it more expensive and therefore less appealing. And in the same way that tobacco taxes have led to decreasing smoking rates, sugar taxes are going to decreases in sugar consumption. The other alternative is to make fresh food or healthy food less expensive through some sort of voucher program or subsidy program, and there are many different versions of this that exist in Canada and the United States. And they help when you give people the option or the means to go to a grocery store through vouchers or coupons or some program and get healthy food. That works as well. And so, there is a rather extensive body of evidence on this issue, and whether you want to go with the sugar tax or the food voucher program, to give these terms shorthand, really depends on how you want to approach it. There are advantages and disadvantages to both. A sugar tax is, from what I understand, a little bit easier to implement because you just have to apply the tax, you don’t have to create the infrastructure for managing a program which you have to do with a voucher program. But it’s about acknowledging that there are reasons why people make unhealthy food choices and removing the impediments that are there in place. And so if one of the reasons is price differential, which it is, you’ve got to eliminate the price differential, and those are the two options that you have at your disposal.

Grotto: Are there things that individual healthcare organizations can do? I mean, certainly from a public policy standpoint, you can advocate for whatever it is you want to. But, you know, if you’re working in a hospital and health system and you say, “I want to help my patients with this,” are there things that they can do on that level?

Labos: Well, there certainly are. I mean, here’s the thing. On a very basic level, if you want people to be better informed about healthy eating, you have to connect them with a nutritionist or a dietician or somebody who’s going to give them advice. I mean, the criticism is often leveled against physicians. Physicians don’t know anything about nutrition. They don’t get any education in nutrition, which is not true. You get all kinds of education. The problem is, as a physician, you often have limited time with patients, and you can’t get into a one-hour discussion about which type of fruit is best. That’s not an efficient use of your time. So if you work in a system where you can have somebody provide dietary counseling to patients, that’s going to help, and patients are really going to like it. One of the main issues where I am is that if you’re being seen by an endocrinologist for diabetes, you often do have access to a dietary counselor, but not for any other disease, and that’s just, you know, the vagaries of how the system is set up. So if you can give people access to this, that’s a good resource that’s going to help. If you can create a program where somebody can advise patients as part of an exercise routine—because one of the big problems with exercise is the issue of motivation. You can tell people, go buy a gym membership. Most people are not going to show up. So you need some sort of structured program, you need some sort of an incentive program in place. And there was, relatively recently a study that came out, this large mega-study about different incentives about what makes people stick with an exercise program in a gym. And some things work and some things don’t. In general, giving people an incentive or having something that draws them back into a gym like a free audiobook or something that they can only listen to or watch while they’re exercising, it makes them come back. So within your healthcare system, if you can have some sort of allied healthcare professional like physiotherapy or a kinesiologist or somebody who can advise patients on how to exercise and have regular follow-ups with them to keep them on a program, that will help. So we can create these things. The limiting step is often resources and insurance coverage. If it’s not something that’s covered by their basic insurance plan or covered by governmental insurance, it’s very hard to ask people to pay for these things out of pocket, because it can become very expensive. So there’s a lot we can do. We just need the resources in place to make it happen.

Grotto: I was just thinking, when you started talking about that mega-study, I had this alarm go off in my brain going, I think I just listened to a podcast about that, and I realized it was yours. So I will point people to that episode if they’re interested in learning more about that study because it actually was pretty interesting. Let’s talk about the messaging a little bit around healthy eating, around exercise, and get into the, again, societal assumption that fat is unhealthy and thin is healthy. Do you want the goal to be weight loss, or do you want to talk about, let’s get your cholesterol down, let’s get this, let’s get, you know, the other things that might be going on in a patient?

Labos: So definitely the latter. The changing number on a scale should not necessarily be the end point. If you change your lifestyle habits—eat healthier, exercise more, you know, quit smoking, which is a huge one—you can change a lot of your metabolic parameters. So your blood pressure will go down. Your cholesterol will be lower. Your blood sugar may decrease. You may need less medication as a consequence of that. You may not lose a lot of weight. You will probably lose some visceral adiposity. So you will have less fat coating your internal organs. There’s two types of fat that we often talk about. So we talk about subdermal or subcutaneous adiposity, so fat that’s under the surface of the skin, and visceral adiposity, the stuff that’s deep in your belly that’s coating your organs, and it’s the second one that’s really more dangerous. The one that’s under the surface of your skin actually does serve a certain purpose. It’s insulation; it keeps you warm. But it’s really the visceral adiposity that we can measure that is associated with worse health outcomes. So you can actually have an impact on that by adopting a healthier lifestyle. But you may not lose that much weight. When you do these sorts of things, it’s important to remind patients, look, if you can eat more fruits and vegetables and walk for 30 minutes a day, you are healthier as a consequence even if the scale hasn’t budged.

Grotto: Have you listened to the podcast “Maintenance Phase”?

Labos: No, no.

Grotto: Have you heard of this podcast?

Labos: No.

Grotto: OK. “Maintenance Phase” talks about—they go into a lot of, like, junk science behind health fads, which are kind of fun. But they had an episode on The Biggest Loser and how dangerous it can be to try to lose weight so fast like that and some of the kind of behind-the-scenes awfulness on that show.

Labos: Yeah. Yeah.

Grotto: And this is something that I kinda see as one of the risks here of, “You have to lose weight.” OK, well, then I need to lose weight at any cost. It makes me feel kinda icky just thinking about the message about weight loss as a path to better health.

Labos: And one of the fascinating things about this whole issue is how we use language when we talk about weight. Because we say somebody has diabetes. We say somebody has high blood pressure. We say somebody has cancer. We say somebody has arthritis. But we say somebody is obese. Right? And the way we speak about it is different than the way we speak about other medical problems. And so I’ve been trying very hard to say “somebody who has obese” throughout this whole podcast, and I really hope I got it right. I do realize that sometimes I slip up and say it wrong, but how we use the word, how we talk about it, is important because we see obesity not as a medical problem to be addressed, but we see it as a defining characteristic of the individual in a way that we don’t attribute to any other disease or medical problem or risk factor. So part of it is also us becoming more mindful of the fact that this is a medical issue to be addressed, and when you’re a healthcare provider to try to address it in that same scientific way and to realize look, not every therapy works. If a cancer patient got started on chemotherapy and they didn’t improve, you wouldn’t blame the patient for the fact that the chemotherapy didn’t work. You wouldn’t blame somebody whose heart surgery went badly for whatever reason. So we shouldn’t blame people for the fact that their specific weight loss interventions didn’t work. Sometimes interventions don’t work. Frankly, most weight loss interventions have very little science behind them and don’t work. Most diets are frankly ineffective. You cannot stick with them and they don’t really produce good results. Some of them have some good short-term results, but there’s no real reason to prefer one over the other. So we can’t blame people for the fact that our interventions are ineffective. It’s hard to people to lose weight because, frankly, most things don’t work, and we should acknowledge that. And so that’s why we have to be, No. 1, constantly looking for things that do work, and when we identify things that do work, realize it, fund it, advocate for them to be covered by insurance and government insurance so that patients can be reimbursed for the therapies they need, and acknowledge that when we find something that does work, we should use it and not let our own bias and hesitations scare us away from things that are needed. So we can’t blame the patient. We just need to advise better therapies to treat this problem, the problem being obesity, which is something that increases your risk for multiple disease. So we need to treat it the way we treat everything else.

Grotto: Now I’d like to back out of the exam room a little bit. Something that came up when I interviewed the executive director of the National Center for Transgender Equality. Rodrigo Heng-Lehtinen was his name. Some of the things that he brought up as solutions were things that can be done in the waiting room. He talked about paperwork not matching up—you know, your name and gender on your insurance card might not match your name and gender on your driver’s license, might not match your, you know, whatever. And I don’t know how it is in Canada, but here, it can be very difficult to get all your documents. It can be a very expensive, time-consuming process. So one of the things that he talked about was adding some fields in your electronic health record system where you can put in your preferred name and gender and that way, it’s all in front of the person when you get there so they don’t call one person’s name and someone who doesn’t necessarily match what you think somebody with that name would look like stands up and has to out themselves to the entire room.

Labos: Right.

Grotto: I couldn’t help thinking there might be some things that can be done just for this population too. When we’re talking about weight bias, some things that I saw come up in blogs are like chairs in the waiting room —

Labos: Yeah.

Grotto: — big enough to accommodate a patient comfortable. Finding the right size blood pressure cuff, which sounds like it could be —

Labos: Yeah.

Grotto: That can be embarrassing and also not great because you’re probably not going to get the right reading, I would guess.

Labos: That is a major cause of people being falsely labeled with high blood pressure. If you use a cuff that’s too small, it could give you an erroneous reading. So choosing the right cuff size is actually a major issue and something that we are supposed to teach medical students, like make sure you measure, because sometimes the numbers aren’t accurate and you end up treating a condition that’s just a consequence of measurement error.

Grotto: Are there other quick wins here, other things that are just so simple that you can just do today and make people feel more comfortable and, like, this is a place where they’re going to be welcome?

Labos: I think you just have to listen to the patients. And, I mean, patients will tell you, “It would be great if you could do this or do that.” I mean, a big thing too—I don’t know how common this is in various places, my patients, for whatever reason, love to be weighed when they come into the office for their regular visits. And I don’t know why.

Grotto: You have the only patients in the world who love that, I think.

Labos: Yeah. And I don’t understand. It is a certain segment of the population, and they tend to be on the older side. I think they just got used to this idea of, when you went to the doctor, the doctor would go in and weigh you because I guess when they grew up most people didn’t have scales at home. But they will specifically ask me this, because they see the scales, like, “Can I get weighed?” And I’m like, “If you like. It’s not really relevant to what we’re doing here today, but sure.” And some patients don’t. And I’ve heard some doctors like, “We have to weigh every patient,” and I’m like, “Why? How is that relevant to their arrythmia?” The only time when it becomes maybe useful is if you’re trying to see if they meet criteria to start weight loss medications where you have to see if they meet the criteria, so you need an accurate assessment of their height and weight. But apart from that, I personally don’t think it’s that useful to weigh the patient in the office. I realize that it bothers most people. It pleases some. I don’t understand either one, but I just let the patients decide. I tell the up-front staff, “If they don’t want to get weighed, it’s fine. It doesn’t matter to me. If it’s relevant for them, which is an exception, I will let you know, but otherwise, just let them be. Like, it’s fine.” And so I think it’s really just letting the patient tell you what they want. If you really do want to weigh somebody, a technique that I’ve often seen is just have them step on the scale backwards so they don’t see the number because some people just get anxiety having to look at the number. So you can record the information if it’s relevant to you. I know if somebody’s getting healthier. I have metabolic parameters I can look at that are, to me, I think frankly more important and more useful. So it’s really just being responsive to the patient and sometimes a very, very simple thing like, you know what, we’re not gonna weigh you, or we’re gonna weigh you backwards, like step on the scale backwards. Very simple things that really doesn’t change anything in the grand scheme of things. So just being open and responsive to that is a very simple thing to do.

Grotto: Something that I’ve noticed my doctor’s office does, which I appreciate because I’m an American and we don’t understand the metric system, is that they change it to kilograms.

Labos: Yeah.

Grotto: So if I want to know how much I weigh in pounds, I have to do math, which I’m not just not gonna do. But they do always weigh me.

Labos: They should start telling you how much you weigh in stones, if you really go back to the Middle Ages. You’re four—I don’t know what it is—you’re six and a half stone. I’m like, cool.

Grotto: This conversation has been so great. I have learned a lot. Dr. Christopher Labos, thank you so much.

Labos: My pleasure.

Grotto: Now it’s time to talk about an exciting development at HFMA: international membership. Now, I watch the statistics on podcast downloads, and I know that there are some of you listening from outside the United States. If you are one of those people and you’re not an HFMA member, listen on, because you’re going to want to hear this. And if you’re a member in the U.S., international membership has some opportunities for you too. Here’s Beth Brousil.


Beth Brousil: Hi, I’m Beth Brousil from HFMA’s Marketing department, and I’m joined today by Mary Mirabelli, HFMA’s senior vice president of strategy. Hi, Mary.

Mary Mirabelli: Hi, Beth. Great to be with you today.

Brousil: International membership is an exciting new direction for HFMA. Can you tell us how this came about?

Mirabelli: We got a lot of requests from folks. You know, it was really something people were asking us for, and that was coupled with our desire to support the international community and the global agenda to really improve health for all.

Brousil: That’s great. We know we get listeners from all over the world on this podcast. What should folks outside of the U.S. know about international membership?

Mirabelli: Well, we’ve created this. It includes access to all of the HFMA website content. It includes access to our revenue cycle KPIs, key performance indicators, our value-based health reports, and all of HFMA’s award-winning news stories and content. And we’ve packaged that up at a special introductory price. In addition to that, international members receive unlimited access to webinars, and we’ve curated those for our international audience. Also included is a complimentary course, Strategies to Prevent Claims Denials. International members also receive discounts on HFMA courses and certifications. Those certifications are the widely, widely regarded Certified Revenue Cycle Representative certification and the Certified Specialist Business Intelligence, which is all about analytics. And if anyone who’s listening is interested in more information on HFMA membership or international membership, they can listen to our latest webinar for international audiences, and that was titled, “An Update on Healthcare Finance and Revenue Cycle Management Trends.” And all you need to do is go to, or you can search for RCM trends on and magically, the webinar will appear. Just click “sign up now” to register at, and that’s the easy way to gain access to the webinar.

Brousil: That’s great. Let’s talk about our members in the U.S. for a minute. What should they know about international membership? For instance, what opportunities will have to share ideas with their colleagues from around the globe?

Mirabelli: I think what our members here in the U.S. need to know is that our international membership is just one part of the Association’s international strategy that really complements our focus on global cost-effectiveness of health. And so HFMA’s international strategy includes membership with the G-20’s health and development partnership with a particular focus on sustainable financing of health and healthcare. And then in addition to that, HFMA has joined the International Hospital Federation in its mission to improve the overall management of health, and we’re engaged with a number and variety of international speaking engagements. And right now, we are targeting content to our Middle East and Gulf Cooperation Council (GCC) audiences. And we’ve specifically created a catalogue that addresses their needs. One of the things we’re really excited about is we’ve developed a collaborative agreement with Knwbility, a GCC regional education company that offers access to a variety of revenue cycle membership coursework for certifications. And then finally, we’re in the process of inviting healthcare leaders around the world to join our inaugural International Advisory Council, so more to come on that as we build this respected and very knowledgeable group of health leaders.

Brousil: This sounds like a great step forward for the global cost effectiveness of health. Thanks for the update on international membership, Mary.

Mirabelli: You are welcome, Beth. Thank you.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is our director of content strategy. Our president and CEO is Joe Fifer. Our Annual Conference in Denver is coming up sooner than you think, and it’s going to be amazing. Check out the speaker lineup on our website,, and go ahead and register while you’re there. If you just can’t wait for more great HFMA content, hey, why not hit subscribe on our podcast and maybe tell a friend or colleague about an episode you enjoyed. And if you want to talk with us reach out. You can email our team at [email protected].

Brousil: I love anything that lets me talk into microphones.

Studies have shown that patients who feel they’ve been discriminated against because of their weight can suffer poor health outcomes and often delay or avoid care, but many still report fat-shaming in exam rooms as physicians insist that they must lose weight in order to be healthier. On a recent episode of the “Voices in Healthcare Finance” podcast, Christopher Labos, a Montreal-based cardiologist and epidemiologist, discussed how healthcare organizations can promote better health while helping patients feel welcome and comfortable.

Obesity as a risk factor

The classification of “obese” on the body mass index is not necessarily a signifier of poor health, Labos said. However, it can be a harbinger of future health issues such as heart disease, heart failure and cancer-related issues.

“Obesity is definitely a risk factor in the same way that high blood pressure is a risk factor, diabetes is a risk factor, cholesterol is a risk factor,” he said. However, the way the conversation around obesity as a risk factor often manifests itself in patient rooms is by fat-shaming, rather than by focusing on obesity as one piece of a person’s full health picture.

“You don’t tell somebody with cancer, ‘Stop having cancer.’ We don’t tell somebody with diabetes, ‘Stop having diabetes,’” he said. “You treat the problem. You don’t just tell somebody, ‘Stop being sick,’ which is unfortunately how a lot of people approach the problem of obesity.”

Identifying obesity as a problem and offering a solution by way of treatment, rather than dismissively telling a patient to lose weight can go a long way, he said.

“Give them a solution. And maybe it will work and maybe it won’t, just like some therapies work and some therapies don’t. But we have to treat it in a more scientific way than [saying], ‘You just have to eat less and exercise.’ If that was the solution to obesity, obesity wouldn’t be a problem,” he said.

Societal factors and food

Access to healthy food can be an issue for many people, Labos said. Junk food is inexpensive, so people of limited means often gravitate toward unhealthy foods because they’re more easily affordable than healthy options, he said. There are ways to change this reality, but they require government intervention such as a sugar tax to make junk food more expensive or vouchers and subsidies to make healthy food less expensive. But there are things individual healthcare organizations can do to help patients maintain healthier lifestyles.

“If you work in a system where you can have somebody provide dietary counseling to patients, that’s going to help, and patients are really going to like it,” Labos said. He also mentioned a recent mega-study that looked into incentives that got people to exercise more, discussed in detail in a recent episode of his podcast, “The Body of Evidence.”

“Giving people an incentive or having something that draws them back into a gym like a free audiobook or something that they can only listen to or watch while they’re exercising makes them come back,” he said.

Quick wins

Individuals — or even individual organizations — cannot solve systemic problems. However, there are things healthcare organizations can do to make patients feel more welcome in clinical settings. Ensuring that exam rooms are equipped with larger blood pressure cuffs can help patients avoid embarrassment and erroneous readings, Labos said. Another easy change is to stop insisting all patients be weighed on each visit because most of the time it’s not relevant to the visit.

“I personally don’t think it’s that useful to weigh the patient in the office,” he said. There are certain circumstances in which a patient’s weight is necessary, and in those cases, it can be helpful to have the patient stand backwards on the scale, so they don’t have to see the number. But that number on the scale should not be the focus most of the time, he said. It’s more useful to consider other health indicators such as blood pressure, cholesterol, etc.

“If you change your lifestyle habits, you can change a lot of your metabolic parameters,” he said. “You may not lose a lot of weight,” Labos added.


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