Bills come due for obesity operations

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Last update: March 25, 2006 – 10:29 PM

Bills come due for obesity operations

As insurers balk at paying for stomach-shrinking surgery, doctors

fear they are losing power to make medical decisions.

Phelps, Star Tribune

It's a new twist in the battle of the bulge.

So many overweight Minnesotans are seeking obesity surgery that

insurers struggling to control the cost of the procedure are getting

in disputes with health-care providers, who say the companies are

taking medical decisions away from doctors and their patients.

The most common obesity surgery is called gastric bypass, in which a

surgeon creates a small stomach pouch to restrict food intake. The

pouch is attached at one end of the esophagus and the small

intestine.

But some insurers are balking at paying for the procedure, which

averages about $18,000, unless patients first submit to supervised

diets, exercise programs and psychological evaluations. Doctors say

they worry some patients will die before getting approval for the

surgery.

But insurers are defending the prerequisites, noting that the

procedure carries some risk. Millions of dollars are at stake.

Blue Cross and Blue Shield of Minnesota, which saw bariatric

procedures grow by 108 percent between 2001 and 2005, spent nearly

$11 million on obesity surgery in the first 10 months of last year.

Medica, the state's second largest insurer behind Blue Cross,

covered claims for more than 1,000 of the procedures in each of the

last two years. At HealthPartners, the number of patients getting

the obesity procedure grew from just 78 in 2000 to 675 in both 2004

and 2005.

" We think utilization has reached a peak, but there is still a

significant demand, " said Dr. Karazija, Medica's medical

director of care management.

Obesity surgery is Blue Cross' fourth-costliest inpatient procedure,

trailing only joint replacement, major bowel complications and

angioplasty that includes a drug-eluting stent.

Hospitals are following the money. More offer bariatric programs

today than five years ago, and patients appear to be spreading the

business around.

The bariatric program at St. ph's Hospital in St. is less

than two years old. The hospital did 100 obesity procedures last

year and expects to double that this year. Fairview Southdale

Hospital in Edina began its bariatric program in 2003 and has done

500 surgeries.

As a result of the demand, insurers have cobbled together special

programs and some restrictions to determine whether individuals are

good candidates. Certain hospitals have been designated as preferred

providers based on their volume, experience and outcomes.

Medica added a pre-authorization requirement to its bariatric

coverage last fall, meaning doctors have to contact the insurer for

approval before scheduling surgery. Blue Cross released its list of

preferred hospitals for the surgery in January.

Different requirements

" Every insurance company has its own criteria and guidelines for who

qualifies for surgery. They're all different, " said Marie Brown,

surgery director for Fairview Southdale.

The latest insurance requirement, Brown said, is patient

participation in a physician-monitored diet and exercise program.

" This can't be Craig or Weight Watchers, " Brown said, naming

two popular consumer diet plans.

Some insurers, such as HealthPartners, require bariatric candidates

to participate in a six-month supervised weight loss program before

they can become eligible for surgery. Brown said some insurers

require patients to participate in the program for up to a year.

Janet Rudlong, manager of the bariatric program at Unity Hospital in

Fridley, objects to that. " There's no six-month weight-loss program

for hernia repair or knee replacement, she said. " Show me the

research that says six months of structured weight loss benefits the

patient. "

Reducing risks

But medical directors for insurance companies say the requirements

are critical to reducing risks associated with the surgery.

Medica's Karazija said his organization approves the procedure once

a patient meets the requirements. " We want to have a confidence

level that the patient made a good-faith effort through exercise and

diet, " he said.

Insurers also evaluate hospitals to determine where to send patients

for bariatric surgery.

Earlier this year, Blue Cross identified eight hospitals in

Minnesota and North Dakota it considered to be preferred providers

of bariatric procedures. The eight were picked for the relevant

experience of the medical staff, low readmission and complication

rates, and follow-up care.

Blue Cross patients do not have to use these facilities. " But the

incentive is that this is a big decision, " said Gold. " It's not a

cakewalk surgery. We want them to go to the best place possible. "

According to a Blue Cross study, complications occur in 30 percent

of bariatric surgeries, one in 12 patients is rehospitalized within

90 days, and 20 percent require follow-up surgery within five years.

The typical patient

Dr. Schwartz, director of the HealthEast Bariatric Center at

St. ph's Hospital, said his center's typical bariatric patient

is a 42-year-old woman who is 5-foot-5 and weighs 287 pounds. That

would give her a body-mass index of 48. An index of 40 is usually

the threshold for the surgery.

Potential bariatric patients have to go through an extensive pre-

surgery program that lasts several months and is designed to coach

the patient on the risks, benefits and uncertainties of the

procedure. Patients also receive post-surgery counseling.

Unity's Rudlong said two-thirds of Americas are overweight, but only

about 1 percent are being treated for chronic morbid obesity. " It's

a shame, " she said.

Schwartz, from HealthEast, agrees. " You get the money back that you

spend on surgery in three years, " he said. " There are tremendous

gains to be had in [reduced] health care costs. "

Phelps •

©2006 Star Tribune. All rights reserved.