Just when the U.S. government has declared obesity a public health crisis, insurers are growing more skeptical of drastic -- and expensive -- remedies like “stomach stapling” surgery.
Demand is skyrocketing for these bariatric surgeries, which shrink the stomach to help the obese lose weight. The number of procedures performed in the United States jumped to 103,000 last year from about 16,000 in the early 1990s, according to Dr. Robert Steinbrook, a national correspondent for The New England Journal of Medicine.
“The epidemic of obesity in the United States has spawned a second epidemic -- of bariatric surgery,” he wrote in the March 11 edition.
Mounting costs
Analysts say many factors are driving the frenzy, including a rise in obesity, the advent of less-invasive surgical techniques and publicity from celebrities like NBC television personality Al Roker and singer Carnie Wilson, whose surgery was broadcast over the Internet.
But as health insurers grapple with mounting medical costs, the $30,000 procedure is coming under close scrutiny. HMOs say the complication rate is high, and some are refusing to cover it at all.
“While everyone initially covered it, I think everyone is getting more diligent” about qualifying patients who really need it, said Mohit Ghose, spokesman for the trade group that represents most U.S. managed health plans.
The surgery is recommended for people who are “morbidly obese” -- generally defined as overweight by more than 100 pounds for men and 80 pounds for women. According to U.S. government data, 4.7 percent of Americans fall into that category.
But experts agree the risks of the surgery are grave --including excessive bleeding, blood clots, infection, ulcers, gastrointestinal leaks, respiratory failure and spleen injury.
'Questionable benefit'
Inamed Corp., maker of the banding device that squeezes the stomach so that a smaller portion is available to digest food, has factored more insurance coverage into its financial projections.But Blue Cross and Blue Shield of Florida, with 6 million members, will end coverage of bariatric surgeries next year, saying they are “risky” and “of questionable benefit.”
But Morgan Downey, executive director of the American Obesity Association patient advocacy group, said advice to diet and exercise is a “simplistic remedy,” although he acknowledged the dilemma for insurers.
“The irony is that they’re still paying for all the conditions that obesity causes,” Downey said. They include costly ailments like diabetes, hypertension, arthritis and heart disease.
Employers struggle
Corporate America is putting pressure on health plans to limit big-ticket procedures like bariatric surgeries, according to a recent survey by the nonpartisan Center for Studying Health System Change.
Nebraska’s Blue Cross decided most of its plans should stop covering the surgery beginning this year so they can keep costs down and compete more effectively, according to spokeswoman Celann LaGreca.
“It’s driven by what employers are willing to pay for,” she said.
UnitedHealth Group Inc, the No. 1 health insurer, and Coventry Health Care Inc. are rivals in Nebraska Blue Cross’ market, she said.
Coventry spokesman Dale Wolf would only say the company will cover the procedure if it is “medically necessary,” but would not elaborate. A UnitedHealth spokesperson did not comment.
William Popik, chief medical officer at Aetna Inc., said the surgery is often performed on patients who have not met criteria like the ability to stay on a diet for several months.
Employers are asking more questions about the legitimacy of paying for coverage for so many people, he said.
“I’m aware of people who have actually gained weight to get up to the morbid criteria to get the surgery,” Popik said, “and I’m concerned that people see it as a quick fix.”
While achieving weight loss may save the health care system money over the long term, individuals do not stay with one plan long enough for the insurer that pays for the surgery to benefit, said Dr. Alan Wittgrove, president of the American Society of Bariatric Surgery.
“An insurance company isn’t interested in saving another insurance company money several years down the road,” Wittgrove said. “They have to answer to their shareholders next quarter.”
