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Insurers Weigh Surgery Risks

Companies differ on whether to pay for procedures to help patients slim down.

June 27, 2005|Lisa Girion | Times Staff Writer

It's not unusual for doctors and insurance companies to clash over coverage. But when it comes to obesity surgery, insurance companies disagree even among themselves.

Worried about the safety and costs of stomach stapling and similar weight-loss operations, many insurers have tightened eligibility rules, and a few have stopped covering the procedures altogether.

These insurers say the risks of complications and death are too high. They also say that covering the procedures -- at an average cost of $25,000 -- would put more pressure on premiums.

Yet other insurers, looking at the same risk studies and similar costs, have reaffirmed their commitment to weight-loss surgery, saying it may be the only answer for some patients.

The procedures also can save money in the long run, these insurers say. Candidates for the surgery are at least 100 pounds overweight and already consume a disproportionate share of premium dollars through the treatment of diabetes and other weight-related conditions.

Who is right? Even insurers aren't sure.

Bob Greczyn, chief executive of Blue Cross and Blue Shield of North Carolina, decided to continue covering gastric bypass, the most commonly performed type of weight-loss surgery. But he isn't criticizing insurers that have stopped.

"You can make a legitimate decision not to cover something that's dangerous," Greczyn said. "What that leaves you with is people who are morbidly obese who don't have a lot of options. We set out to create a program that addressed patient safety concerns and create what we believe is a better outcome for patients who are morbidly obese and don't have a lot of other options."

For private insurers, weight-loss surgery is one highly visible component of spiraling obesity-related costs. Overall, insurers are spending at least $36.5 billion a year on obesity and related conditions, according to a study set to be posted today on the website of the journal Health Affairs. That is a tenfold increase in 15 years. Spending on obesity-related conditions, such as diabetes and heart disease, also is growing disproportionately, rising from 2% of all healthcare dollars in 1987 to 11.6% in 2002.

North Carolina mirrors the national trend. More than half of Blue Cross and Blue Shield's 3.2 million members are overweight or obese. These members cost 32% more to cover than others. In 2003 alone, the insurer figured it spent $83.1 million on weight-related medical problems.

Blue Cross and Blue Shield of North Carolina viewed weight-loss surgery as part of the solution and had been covering it for 18 years. But a few years ago, the insurer spotted an alarming trend in its claims data: Complications seemed to be rising faster than the number of procedures.

After analyzing the problem, the insurer concluded that an influx of inexperienced surgeons -- who, on average, have higher complication rates than veteran doctors -- was driving up the risk.

Other insurers came to the same conclusion, which led some to drop coverage.

But Don Bradley, executive medical director for the North Carolina insurer, remained convinced that, properly done, surgery to reduce the size of the stomach could be an effective way to help patients lose weight. Moreover, he said, studies have shown that when weight-loss surgery is successful, diabetes disappears in nearly 9 out of 10 cases.

"It doesn't get better -- it goes away," Bradley said. "We're ultimately reducing their disease burden for their whole life."

Experience also had shown that the benefits accrue to the bottom line. Pharmaceutical costs for the average patient in the first year after weight-loss surgery drop by 20% to 25%. As the pounds come off, patients take less insulin for diabetes and fewer drugs for high cholesterol, heart disease and other problems, Bradley said.

For him, a retreat from surgery was not an option.

"The real crime is to look and see the problem and not do something about it," Bradley said. "I believe that appropriately done -- and there is data to show this -- the surgery can be safe and effective. It can also be horrible. People end up in intensive care."

According to a Rand Corp. analysis of 150 studies, 1 in 5 weight-loss surgery patients has complications, most of them minor. However, when intestinal leaks, blood clots and other serious problems occur, patients can need additional surgery and spend months in the hospital.

Rand found a death rate of less than 1%, based on studies that relied on doctors' reports. However, insurance claims data show somewhat higher death rates -- between 2% and 3%, said Melinda Maggard, an author of the Rand study. By comparison, the death rate for cardiac bypass surgery is about 2.7%.

Bradley wanted to do everything in the North Carolina insurer's power to lower the risk. So he proposed an approach that already was common in cardiac care: Designate "centers of excellence" by identifying the surgeons and hospitals with the best support programs and outcome records. Then steer patients their way.

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