Insurers limit obesity surgery

Weight-loss surgery once was considered a rare measure of last resort. Now, tens of thousands of obese people a year are turning to such procedures, often out of frustration with more traditional attempts to shed excess pounds.

Faced with the daunting task of paying for all those surgeries -- estimated at more than $3 billion last year -- a growing list of insurers around the country are canceling coverage of the controversial procedures. In recent weeks, Kentucky-based Humana Inc. stopped covering the surgery and Blue Cross and Blue Shield of Florida announced it will do the same beginning in January. A number of other insurers have also walked away from paying for such operations in the past year, including UnitedHealthcare, the nation’s biggest health insurer.

Employers and the self-employed can continue financing the procedures by paying higher premiums, but benefits experts say the majority of them aren’t doing so.

“We are concerned about the overuse of this procedure, especially considering the lack of assurance that it’s both safe and effective in the long run,” says Barry Schwartz, vice president of care at Florida’s Blue Cross. Schwartz estimates his company would spend more than $200 million in the next few years if it didn’t change course.

According to the American Society for Bariatric Surgery, the number of weight-loss operations jumped to more than 100,000 last year, up from 16,000 in the early 1990s.

The insurance industry’s recent change of heart is leaving many morbidly obese people at a loss for what to do now. At 5 feet, 6 inches tall and 550 pounds, Richard Sepeda, 32, suffers a litany of problems more appropriate for someone twice his age: high blood pressure, diabetes, bum knees already propped up by recent reconstructive surgery.

Worse, he says, is the emotional toll. His latest round of depression in December was his most severe yet. “I wonder what it would be like to be normal and live a normal life,” says Sepeda, a Lockhart, Texas, police dispatcher.

Although Sepeda wants gastric bypass surgery, his insurance won’t cover it and he can’t afford to pay for the $30,000 surgery on his own. He has hired a lawyer to appeal the decision but if he loses, which he acknowledges is likely, he and his wife, Marilyn, may sell the house they bought three years ago to pay for the surgery. “I have to do something or I am going to end up dying before I’m 40,” he says.

Much of the recent growth in bariatric surgery, paradoxically, has come largely because of insurers’ willingness to cover it, as well as high-profile post-operative endorsements from celebrities such as Al Roker of the “Today” show and Randy Jackson of “American Idol” fame.

Even a small number of insurers stopping coverage is a blow to the industry, which is booming so rapidly some hospitals are dedicating operating rooms to bariatric operations.

The long-term stakes are enormous: Almost two-thirds of adults in the United States are overweight, and 30% are obese, according to a study by the national Centers for Disease Control and Prevention in Atlanta. What’s more, the number of morbidly obese people, defined as anyone 150 pounds or more overweight, is growing even faster. They grew from 1 in 2,000 Americans in 1986 to 1 in 400 by 2000, according to a study by the Santa Monica-based think tank Rand Corp. The typical man in that category now weighs 373 pounds and is 5 feet, 10 inches tall.

In the most common type of bariatric surgery, a surgeon attaches the patient’s small intestine directly to a pouch that has been created in the stomach. Food then bypasses part of the small intestine, which reduces the body’s absorption of calories and nutrients. In a newer option, used about 15% of the time, a silicone band is placed around the top of the stomach to restrict the amount of food it can hold.

Both options have risks. About 2% of patients die during or shortly after gastric bypass surgery, from complications including pulmonary embolisms and leakage in the intestines; about half that rate die during banding surgery, researchers say. Even those who come out fine can suffer long-term problems such as higher rates of anemia and metabolic bone diseases caused by the loss of vitamin absorption.

Patients can regain the weight by overeating (they turn to high-calorie liquids like milkshakes) or not exercising enough, which doctors say is essential. Further, some physicians believe that the banding procedure doesn’t work as well in the long run as gastric bypass, though they don’t know why.

According to the National Institutes of Health, which set up widely used clinical recommendations in 1991, the surgery should be considered only for those with a body-mass index (a mathematical formula based on height and weight) above 40 -- or about 100 pounds overweight. Slightly less obese people can qualify as long as they have life-threatening complications such as high blood pressure or coronary disease.

Susan Pisano, spokeswoman for America’s Health Insurance Plans, the health insurance trade group, says that companies pulling back on coverage are simply being realistic. They can’t possibly afford to pay for even a small percentage of obese Americans eligible for the treatment, she says. (Under the NIH standards, it’s estimated that 20 million people around the country are candidates for weight-loss surgery.)

She adds that many insurers are growing increasingly worried that some smaller hospitals and doctors have recently started performing the surgeries even though they are not qualified or don’t have the appropriate equipment to treat the severely obese. One worry is that few small hospitals have items like oversized CT scans that are necessary to look at the abdomen in case of post-operative complications; typical machines can’t handle patients over 300 pounds.

And, says Pisano: “Some of the newer surgeons doing this have only taken one weekend class, taught on cadavers or pigs, before they start operating. It’s scary.”

To help deal with that issue, the American Society of Bariatric Surgery recently began a program through which it will soon visit and review facilities around the country to see if they meet the society’s safety standards. Blue Cross of California has started a similar plan for its enrollees.

In the meantime, advocates for the obese say they are preparing for a long brawl.

Walter Lindstrom Jr. of the Obesity Law and Advocacy Center in San Diego says that many groups are lobbying state governments and pushing laws similar to those in Maryland and Indiana that require insurers to pay for weight-loss surgery.

Lindstrom says many patients are also starting to sue insurers who turn them down. Some are using the argument that obesity is a genetic condition that can’t be cured by behavior alone. “We are going to fight this with everything we’ve got,” he says.