Insurers trim bariatric surgery coverage

Pressured by employers, health plans are looking at cutting coverage of gastric bypass surgery and other procedures perceived as being high-cost and low-benefit.

By Robert Kazel — Posted April 5, 2004

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As America grows fatter, some insurers' coverage of weight-loss surgery is becoming leaner.

BlueCross BlueShield plans in Florida and Nebraska are among those who recently announced they no longer would cover gastric bypass surgery. CIGNA Corp. has stopped coverage in four states and is looking to withdraw coverage in more states as contracts expire.

It's not just bariatric surgery being targeted. According to the Center for Studying Health System Change, insurers, under pressure from employers, are increasingly looking at eliminating coverage for procedures perceived as high-cost and unnecessary.

But bariatric surgery is a particularly high-profile and popular procedure. Nationwide, the estimated number of gastric bypass surgeries -- touted by celebrities such as singer Carnie Wilson, TV personality Al Roker and "American Idol" judge Randy Jackson -- climbed more than 500% between 1993 and 2003, from 16,800 operations to more than 103,000, says the American Society for Bariatric Surgery. This comes as the proportion of Americans with a body mass index of 40 or more -- at least 100 pounds overweight -- increased fourfold between 1986 and 2000, from one in 200 to one in 50. Insurers that pay for the surgery typically require a BMI of 40 or more for coverage, or 35 for patients with serious comorbid conditions.

But firms cutting coverage say they can't afford to keep paying for what they see as risky surgery, with a reported death rate of three out of 1,000 procedures, that is increasingly being done by less-qualified doctors.

"Everyone is looking at this thing as a cash cow," said Barry Schwartz, MD, vice president of care and network management for BlueCross and BlueShield of Florida. The Florida Blues spent $17 million to cover about 1,000 bariatric surgeries between May 2002 and April 2003, nearly double the amount spent for the like period in 2001-02. The plan will stop covering the surgery beginning January 2005.

Many physicians, especially primary care physicians and surgeons focused on obesity, say the insurance companies' decisions are wrongheaded. To some, it smacks of the kind of tightening of care that led state legislatures during the mid-1990s to require minimum coverage standards for procedures such as childbirth. Only Georgia, Indiana, Maryland and Virginia have laws requiring health plans to offer employers minimum coverage for morbid-obesity treatments, including bariatric surgery.

"Imagine if the insurance companies arbitrarily picked another disease and said if you have a heart attack," it's not covered, said American Obesity Assn. President Richard Atkinson, MD, an internist and endocrinologist in Washington, D.C. "What is it about obesity that these people have the gall to say they won't treat it as a disease?"

Cutting the fat

According to a March report from the Centers for Disease Control and Prevention, obesity may become the leading cause of mortality in the United States by 2005, with a death toll of 500,000 per year. Also, according to a study by the Rand Corp. released in March, one in five health care dollars spent by people ages 50 to 69 will be obesity-related by the year 2020, up 50% from 2000.

At this point, however, many employers and insurers aren't ready to trade short-term financial pain for possible long-term gain, especially with the likelihood a patient will change employers or plans before they benefit from any future cost or health benefit from the surgery.

Employers "are clearly looking for cost management," said Razia Hashmi, MD, MPH, medical director and vice president for coverage policy with CIGNA, which this year dropped coverage for weight-loss surgery in Arizona, Florida, North Carolina and Texas. A 2003 survey by Mercer Human Resources Consulting found that among companies with more than 500 workers and employer-sponsored health plans, 52% chose not to cover bariatric surgery.

Omaha-based BlueCross BlueShield of Nebraska excluded coverage of bariatric surgery as of last January. The only exception is self-funded group plans that choose to buy coverage as an add-on, said Timothy Ranney, MD, the insurer's senior vice president and medical director for health service programs.

"We're quite frankly just following the market," Dr. Ranney said.

Robert T. Marema, a Fort Lauderdale, Fla., bariatric surgeon, said coverage exclusions and insurers' tightening of patient eligibility and reimbursement have had a "massive" effect on his practice. He and his partners perform about five gastric bypasses a week now compared with about 30 a week two years ago, he said. Many patients who do have the surgery are financing it themselves, as Dr. Marema did when he underwent the procedure five years ago. Bariatric surgery typically costs between $20,000 and $40,000, plus much more for years of follow-up care, often handled by a primary care physician.

A victim of its popularity?

Bariatric surgery is not a specialty certified by the American Board of Surgery or other medical bodies. The level of training received by surgeons varies widely, from experiences in residencies or full-fledged, yearlong fellowships to weeklong mini-fellowships or brief preceptorships taught by experienced weight-loss surgeons, such as Dr. Marema. His U.S. Bariatric Management Institute teaches courses ranging from three days to two weeks for board-certified or board-eligible surgeons with laparoscopic backgrounds.

Insurance companies' qualms about the influx of surgeons into the bariatric field are not unfounded, said Harvey Sugerman, MD, a retired bariatric surgeon in Richmond, Va., and president-elect of the American Society for Bariatric Surgery. "But that's not a reason to globally block it for everybody."

Dr. Sugerman said his society is working to establish quality guidelines that hospitals and clinics can use to promote their physicians' adherence to high standards when doing gastric bypasses.

Meanwhile, Downers Grove, Ill.-based First Health announced in March that it is creating a subnetwork of surgeons with the highest level of expertise in bariatric surgery and the highest volume of cases. If patients choose their surgeons from this list, employers who choose to cover the surgery can receive discounts of 50%.

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Procedure gains popularity

The number of active surgeons in the American Society for Bariatric Surgery jumped from 168 in 1993 to 860 in 2003. From this, the society estimated the number of gastric bypass surgeries performed nationwide.

1993 16,800
1994 16,200
1995 18,100
1996 20,500
1997 23,100
1998 25,800
1999 28,800
2000 36,700
2001 47,200
2002 63,100
2003 103,200

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The skinny on weight-loss coverage

Although health plans typically say bariatric surgery is extreme and less drastic approaches to weight loss should be preferred, few insurers are willing to pay for products or services related to obesity treatment. The policy of Blue Cross and Blue Shield of Florida that will take effect in January 2004 is typical. It excludes:

  • Weight control/loss programs
  • Appetite suppressants and other medications
  • Dietary regimens
  • Food or food supplements
  • Exercise programs
  • Gastric bypasses, intestinal bypasses, gastric balloons, jaw wirings, jejunal bypasses, gastric shunts, and procedures that restrict the ability to assimilate food

Source: "Blue Cross and Blue Shield Endorsement: Exclusion of Coverage for Morbid Obesity Surgical Procedures"

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Stomach stapling school

Training for gastric bypass surgery ranges from a quick seminar to a yearlong fellowship. Courses taught by Robert Marema, MD, a Florida weight-loss surgeon who runs the U.S. Bariatric Management Institute, include:

Preceptorship (2 days) For surgeons who want to establish a bariatric surgery program or who have already started one, aimed at helping physicians and selected staff understand patient selection criteria, surgical guidelines and preoperative care.

Advanced surgeon training (3-5 days) Designed for surgeons with considerable laparoscopic expertise. Explores the use of equipment and instruments for gastric bypasses and allows participants to hone their skills through dry lab and cadaver lab exercises.

Physician's office staff training (1 week) Exploration of topics such as exercise and nutrition, insurance precertification, patient education, counseling and support programs.

On-site hospital training Instructors travel to the site where bariatric surgery is being performed for additional training of operating room nurses and staff, floor and ICU staff, and other employees.

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