Weighing The Risks

December 30, 2005
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GRAND RAPIDS — Obesity is not a stand-alone health condition. Arthritis, birth defects, cancer. Cardiovascular disease, diabetes, gallbladder disease. Heart disorders, hypertension, infertility. Liver disease, pancreatitis, sleep apnea, stroke. Those are just some of the dozens of health problems that scientists have linked to obesity.

That list is troubling news for overweight individuals. It is also troubling for health insurers.

A recent Emory University study showed the cost of treating conditions linked to obesity increased from $3.6 billion to $36.5 billion between 1987 and 2002. The study concluded that the best way to lower health care spending is to target the rise in risk factors — especially obesity.

In recent years, many insurance companies have begun to do just that. They have introduced wellness programs to encourage people to develop healthy lifestyle habits, such as eating well, exercising regularly and quitting smoking.

For some overweight individuals, these programs are successful. For others, bariatric (gastric bypass) surgery may be the best solution. But bariatric surgery is somewhat controversial among insurers, and also costly. Treatments range from $20,000 to $40,000, and insurance coverage is not guaranteed. Some insurers are concerned about complications that result in many patients being hospitalized in the year after surgery.

Locally, Spectrum Health and Michigan Medical Professional Corp. (MMPC) tout their certification as a Bariatric Surgery Center of Excellence by the American Society of Bariatric Surgeons. MMPC’s surgeons have performed more than 1,200 bariatric surgeries in the past two years. Studies suggest that a high level of experience, such as at Spectrum and MMPC, leads to fewer complications and better patient outcomes.

Blue Cross Blue Shield of Michigan is investing in research to see if that’s true. In 2005, the company began a collaborative project with the University of Michigan with the aim of improving bariatric surgery quality.

“The Michigan Blues have invited all Michigan hospitals performing bariatric surgery to share information on procedures and outcomes in a data registry,” read a company statement. “It will be used to help determine which practices produce the least risk, fewest complications and the best results while, at the same time, help reduce costs for the increasingly popular and expensive procedures.”

Through that collaboration, the participating insurers and hospitals hope to achieve better outcomes and to lower costs to customers. Further research will also allow insurers and patients to make more informed decisions about the safety and effectiveness of bariatric surgery.

“This is a very emotional topic for patients,” said Dr. John Fox, medical director for West Michigan’s largest local insurer, Priority Health. “Where we have challenges is when people are convinced that their only option is to have surgery. We understand that, but you also have to appreciate that this is a behavioral problem, most often. We are committed to providing the care that people need, but sometimes that isn’t surgery.”

To determine whether surgery is the correct solution for a patient’s problem, many insurers such as Priority Health and Blue Cross require patients to go through comprehensive, medically supervised weight-loss programs prior to surgery. Those programs are not simply used for screening purposes. They offer educational opportunities for all patients, including those who will go on to have bariatric surgery.

“The importance of the behavioral program is to give an intensive introduction to what it’s going to be like to be successful after the surgery,” said Fox. “It’s just like smoking. There are certain triggers that trigger your smoking behavior. There are certain triggers that trigger eating behavior. In fact, part of our program is that you have a psychological evaluation before surgery to make sure that there aren’t any underlying behavioral health issues or mental health issues that are going to reduce your likelihood of succeeding.”

Fox said that patients who successfully complete the behavioral health program and undergo surgery see a dramatic improvement in all of their related conditions (as in the list above).

Insurers like Priority Health have found that bariatric surgery is a good solution to some patients’ chronic obesity. Others aren’t convinced. Some insurers suggest that the risks associated with bariatric surgery are too high. Mark Mathis, a spokesman for Louisville, Ky.-based Humana Inc., said that his company does not cover bariatric surgery for a number of reasons.

“When evaluating any procedure, we examine two main criteria: whether a procedure is safe, and whether it is effective in treating the condition in question. With bariatric surgeries, there has not been enough study or enough clinical evidence to show that these procedures are both safe and effective in reducing obesity in the long-term. In fact, some reports show that gastric bypass patients have an alarmingly high rate of hospital re-admission.”

A report in the Journal of the American Medical Association showed that among a group of 60,000 California individuals who underwent the most common Roux-en-Y gastric bypass surgery, the rate of hospitalization in the year following the procedure was more than double the year prior. The report found that the hospitalizations leading up to the surgery tended to be related to health problems associated with obesity, such as joint pain or poor circulation. In the year after treatment, more hospitalizations were related to potential complications from the surgery, such as hernias.

Following that report, a story in the Wall Street Journal suggested that these types of complications have led insurers to cut back on their coverage of the treatment. The story also suggested that, because of increased demand for bariatric surgery, less-skilled surgeons may have entered the market, causing the overall quality of care to go down and risks to increase. That is one reason for the certification obtained by Spectrum Health and MMPC.    

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