North Carolina Blues covers medical visits related to obesity

BlueCross BlueShield of North Carolina, which figures it paid an extra $83 million in 2003 because more than half its members are overweight or obese, said in October it plans to start paying doctors to treat obesity on an outpatient basis.

The plan is designating clinics with bariatric surgeons who have more experience and better outcomes as "centers of excellence" to whom the plan will pay significantly more for the controversial and increasingly popular operation.

The decision to authorize reimbursement for obesity-related office visits was good news, doctors said, because while insurers typically reimburse doctors in connection with patients' comorbidities often associated with obesity, such as hypertension or heart disease, payment for evaluation and treatment of obesity itself is virtually unheard of.

"We deal with obesity on a daily basis, and I don't think it's any mystery that obesity is a crisis in America -- and North Carolina is certainly ahead of the curve" in overweight people, said John Mangum, MD, a family physician from Sanford, N.C. It will be especially useful to send patients to dieticians knowing that the visits will be covered, he added.

"Patients often have remarkable misconceptions about diets," he said. "I have patients who drink a two-liter bottle of [soda] every day, and they don't think that's anything unusual."

The Chapel Hill, N.C.-based Blues plan will cover up to four physician office visits annually for obesity starting in April 2005, said Don Bradley, MD, senior medical director. "If we expect physicians to be part of the solution, we should pay for their time," he said.

Two other new benefits for obese patients will be introduced in October 2005. The company will start to cover the weight-loss drugs Meridia and Xenical and will pay for patients to see licensed registered dieticians. Until now, the North Carolina Blues would pay for patients to see dieticians only for certain illnesses such as diabetes.

Health costs for overweight and obese patients in the Blues plan are one-third more than for those of normal weight, the company said.

The new obesity benefits will be available to 1.1 million of the plan's 3 million members. Members of a self-funded state benefits for government employees, run by the Blues, won't be getting the benefits because coverage for that plan is determined by the state.

The president of the Aurora, Colo.-based American Society of Bariatric Physicians said it was "wonderful that insurance companies are starting to look at this as a serious medical problem."

But G. Michael Steelman, MD, who practices bariatric medicine in Oklahoma City, said he did have some qualms about the new policies. Setting a limit of four patient visits per year for obesity seemed "pretty arbitrary," he said. He also questioned the decision to cover Meridia and Xenical but not some of the older weight-loss medications that work well for many people, even if fewer published studies exist to prove their effectiveness.

Paying for consultations by dieticians is laudable, Dr. Steelman said, so long as the dietician acts as part of a team giving advice to the patient and works closely with a doctor. "The front-line treatment should be by physicians," he said.

Blue Cross also has selected 12 bariatric surgeons in the state who it says have had the best records doing gastric bypass surgery, and has branded them as practicing in "centers of excellence." The professional fees for these surgeons have been raised by 30% to 50%, Dr. Bradley said, and their names are being featured on the company Web site to encourage patients to choose them.

Preauthorization requirements for these surgeons will be less onerous, he said. The intent is to cut costs over the long term by avoiding errors, complications and repeated surgeries.

Dr. Steelman said he strongly supported efforts to identify centers of excellence for bariatric surgery, which he said had attracted an influx of relatively inexperienced surgeons.

"Many [facilities] lack experience and don't have good follow-up systems, or may not screen patients in advance," he said. "Insurance companies need to be certain before they walk into this area that the surgeons are well-qualified and facilities can handle complications and that long-term care is provided by a full team."