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Anti-fat surgery: Weighty dilemma Some insurers pulled away from covering
the RNY Gastric Bypass procedure
By DEBRA PRESSEY
© 2004 THE NEWS-GAZETTE
Published Online August 22, 2004
URBANA – With obesity continuing to climb to epidemic levels in the United
States and the dismal statistics on the long-term success of dieting, an Urbana
managed care company figures it stands a better chance of helping its members
quit smoking than seeing them shed their excess weight and keep it off.
So Health Alliance Medical Plans covers smoking cessation – but there's no
coverage for diet plans and health club memberships.
The question is, how will Health Alliance and other private health insurers
continue to cover the last resort option for the morbidly obese – a procedure
called gastric bypass surgery – in which the size of the stomach is restricted
so a person can't eat so much?
Some insurers have pulled away from covering the procedure, even as a recent
announcement from Medicare opens the door to the possibility of
government-funded anti-obesity treatments, such as surgery, in the future.
Dr. Robert Scully, chief medical officer for Health Alliance, said many
insurers are questioning the safety of the surgery, and some are balking at the
growing expense.
The number of people who have had the surgery has climbed in just two years
from 40,000 to 120,000 last year, according to Dr. Walter Pories, a North
Carolina-based surgeon and past president of the American Society for Bariatric
Surgery.
And with more than 23 million Americans currently considered morbidly obese,
defined as at least 100 pounds overweight, "we haven't even made a dent," he
said.
The charge for gastric bypass surgery runs about $25,000, setting the total
sticker price of the procedures in the United States last year in the
neighborhood of $3 billion. And experts project a substantial increase in the
number of surgeries this year.
The risks, which can include serious complications and a 1 percent death
rate, should be taken very seriously, Scully said.
"A lot of people are getting the impression that this surgery is no more
difficult than having your gallbladder out," Scully said. "It has significant
risk. People are taking it a bit too lightly."
The dilemma for insurers, he adds, is that despite its risks, gastric bypass
surgery can help achieve a significant weight loss for some patients.
Health Alliance currently covers one version of the surgery, called
Roux-en-Y, which includes a restriction of the stomach and some diversion of the
digestive stream so some nutrients can't be absorbed. Scully said this procedure
seems to achieve the greatest results with fewer complications than those that
include a more aggressive diversion of the digestive stream.
Gastric bypass surgery is also still covered by Blue Cross Blue Shield of
Illinois, though Blue Cross Blue Shield of Florida said it's dropping coverage
for the surgery at the end of the year because of the risk involved.
Louisville-based Humana Inc. stopped covering stomach bypass surgery earlier
this year in the plans it offers in most states – though the company said it
still offers employers the option to include it in individual plans if they want
to pay more.
"In our view, there has not been enough scientific study and evidence to show
that such procedures are safe and effective in reducing obesity in the long
term," said Mark Mathis, spokesman for Humana, a large publicly traded benefits
company with 600,000 health plan members in Illinois.
Health Alliance is in a review process right now to determine how – and if –
it will continue to cover gastric bypass surgery under its commercial plans,
Scully said.
Options include continuing to cover it, dropping coverage entirely or moving
coverage to a rider that employee groups could add to their coverage at
additional cost, he said.
For now, Health Alliance provides coverage of Roux-en-Y for members who meet
strict criteria that include:
– A record of having tried and failed a doctor's program of diet, exercise
and behavioral modification for six months.
– A body mass index (a ratio of height and weight) of 40 or above, or a body
mass index of 35 and above with serious medical problems that could be improved
by treatment for obesity.
Adults generally fall into the healthy weight range with a body mass index of
20 to 24.9. A BMI of 25-plus equals overweight, and 30-plus puts you in the
obese range.
So why wouldn't a managed care company cover the kinds of programs that might
help prevent that much weight gain?
Health Alliance says it offers its members lots of education about healthy
diet and exercise and focuses on the management of diseases associated with
obesity. But premium dollars have to be used for the care that provides members
the most for their money, and the fact is health club memberships and diet
programs don't ultimately pay off because people so often don't stick with them.
"The long-term data on that is so disappointing," Scully said. "Most people,
in the long run, don't sustain their weight loss."
Here are another health insurer's results from offering a diet program,
Scully said: After 12 months on the program, 35 percent of the participants
didn't lose any weight; 27 percent dropped less than 5 percent of their body
weight; 20 percent lost between 5 percent and 10 percent; and only 16 percent
lost greater than 10 percent.
Compare that to Health Alliance's recent smoking cessation program which
achieved a 29 percent quit rate for the first 12 months.
"Yes, if people really work at diet and exercise, you can make a difference,"
Scully said. "There's a lot that can be done, but it's very difficult."
Pories said diet and exercise seem to fail universally for people who exceed
100 pounds overweight, who are the very people for whom gastric bypass surgery
is intended. And long-term studies show the surgery has a substantial success
rate for maintaining weight loss, he said.
"With diets, people lose 10 or 20 pounds and gain it back within a year or
two," he said.
With evidence like that, Pories said, he doesn't know how any responsible
insurer wouldn't cover the surgery.
Champaign-based PersonalCare, part of Maryland-based Coventry Health Care,
won't say what its coverage position is on the surgery. The company says members
can call their customer service representatives and ask if they have coverage
under their own plans.
Bloomfield, Ct.-based Cigna HealthCare, which has about 410,000 members in
Illinois, discontinued coverage for the surgery earlier this year for its fully
insured plans in Florida, Arizona, Texas and North Carolina, and will be adding
more states to that list next year, according to company spokeswoman Amy
Turkington.
Self-insured plans, which are the majority of Cigna's business, still have
the option of adding coverage for the surgery, but the decision to drop it for
fully insured plans was driven by a market demand for more affordable premiums,
she said.
Blue Cross Blue Shield of Illinois covers weight loss surgery if it's
considered medically necessary, with the company's charges for it totaling $144
million last year, said company spokesman Tony Rau.
Specifically, that company says coverage for the surgery "may be considered"
for treatment of morbid obesity when all its criteria are met.
That includes a body mass index of 40, or a BMI of at least 35 with two or
more "co-morbid" conditions that include such things as hypertension, Type 2
diabetes and heart disease.
Patients must also show a documented five-year history of morbid obesity and
prove they failed a medically supervised weight loss program for a year within
the past two years of the request for coverage, the company said.
Meanwhile, Mathis, with Humana, said his company plans to monitor the Centers
for Medicare and Medicaid Services' upcoming evaluation of obesity-related
procedures.
Medicare last month announced it is removing language in its coverage issues
manual that had stated obesity isn't an illness. Because Medicare only covers
services that are medically necessary for illness and injury, the change
effectively removes a barrier for covering anti-obesity treatments – but only,
the government says, if medical evidence demonstrates the treatments are
effective in improving the health outcomes of Medicare beneficiaries.
The Centers for Medicare and Medicaid Services said the new policy has been
widely misinterpreted since the July announcement.
Medicare already covers anti-obesity surgeries for those who are both
morbidly obese and also threatened by conditions such as heart disease, and the
new stance will open the door to the possibility of coverage for those without
co-morbid conditions, an agency spokesman said.
But the new policy won't have an immediate impact on coverage.
The Centers for Medicare and Medicaid Services said it is waiting for a
formal request to be made from the public for coverage of an anti-obesity
treatment, such as surgery, and it would then take at least a year after that to
study the medical evidence about that treatment, reach a decision about covering
it on a national basis and make it available to Medicare recipients.
You can reach Debra Pressey at (217) 351-5229 or via e-mail at
dpressey@news-gazette.com.
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