More obesity surgeries receive insurance coverage
Some extremely overweight Idahoans have new hope of slimming down as the state's two largest health insurers cover more weight-loss operations.
Blue Cross of Idaho and Regence BlueShield of Idaho in January 2007 added adjustable gastric banding to other weight-loss surgeries they already cover. In the gastric banding operation, a doctor makes two tiny incisions and slips a small ring over the upper part of a patient's stomach so the patient will feel full without eating much.
Weight-loss surgery is gaining momentum nationwide as Americans get heavier and suffer more weight-related health troubles. Adjustable gastric banding, gastric bypass and other bariatric surgeries are a growth industry nationwide and are just starting to take off in Idaho.
About six of every 10 Idahoans are overweight, a record high, according to state Health and Welfare Department statistics for 2005, the most recent available. One in four Idahoans is obese. The operations are not a magic bullet. Many patients must undergo a psychological evaluation before the surgery and eat right and exercise to keep the weight off.
"Being overweight can lead to serious health conditions and complicate existing conditions," Karen Early, director of corporate communications for Blue Cross, said in an e-mail. "And that's why we decided to offer coverage - because for some people, losing weight is important enough to consider surgery," Early said.
So far, the coverage is limited mainly to workers insured through large companies that have specifically added bariatric surgery to their policies. Unless patients are willing to pay for the procedures themselves, they must call their insurers or physicians to see if they have the benefit. Most don't, at least not yet.
At Regence, about 6,000 customers have the benefit and fewer than 10 have sought to use it, Regence spokeswoman Georganne Benjamin said. At Blue Cross, Early said 125 members had undergone the surgery since the company began paying for it.
The surgery must be medically necessary, meaning patients must first try to lose weight in less drastic ways, including diet and exercise. So far, Regence has agreed with every patient: The less-drastic methods weren't working. "We have not experienced any member who has the benefit, but doesn't meet the medical necessity criteria requesting treatment," Benjamin said in an e-mail.
Coverage may vary widely, Early said at Blue Cross. Some policies may cap payments at $5,000. Others may cover bariatric surgery the same as any other kind of operation. Employers choose who qualifies for surgery. A generally accepted standard requires patients to be morbidly obese - 80 pounds overweight for women or 100 pounds for men, or with a body mass index of 40 or more. Patients who are not that heavy might qualify if they have two or more ailments, such as high blood pressure and sleep apnea, that sometimes go along with lots of extra pounds.
"Anyone considering this surgery should do some research and make an informed decision, along with their physician, to determine if it is right for them," Early said.
Even if you have coverage, Blue Cross and Regence have standards your doctor and hospital must meet before the companies will cover your operation.
The standards are set by the Blue Cross and Blue Shield Association. The program is called Blue Distinction Centers for Bariatric Surgery. (See sidebar on right for details.)
The standards take into account the number and results of surgeries for a hospital. More is better for getting certification. The idea is practice makes perfect. By April 2007, no Idaho hospital yet met the Blue Distinction standards, but approved facilities were open in Bend, Ore., Portland, Seattle and Salt Lake City.
In recent years, several agencies, not just the Blues, have created standards of excellence for bariatric surgery. Blue Cross and Regence believe Blue Distinction is best, but some health providers consider the issue open to debate.
One of the agencies is the American Society for Bariatric Surgery. In Idaho, one doctor and one hospital, Dr. William Christian Oakley and the Bariatric Surgery Center of Idaho at St. Luke's Boise Regional Medical Center, meet the standards.
Oakley has little patience for most health insurers. "The insurance industry has been trying to find excuses for years about why they won't cover bariatric surgery," he said. Their efforts confuse patients about the benefits of the surgeries, he said. Fact is, the surgery works, he said, and it saves money in the long run for treatment of weight-related conditions such as high blood pressure, sleep apnea and diabetes.
Dr. Robert M. Cahn, who performs LAP-BAND adjustable gastric banding surgeries, said he plans to seek certification from yet another agency, the American College of Surgeons. "They've been around a lot longer than the ASBS," he said.
Certification is a loaded issue for some doctors and hospitals. Health insurance coverage hinges on it, but the standards can be frustrating to meet - because of the volume of surgeries required for certification. Many certifying agencies require hospitals and doctors to perform more than 100 procedures a year, but without insurance coverage, many patients may go without treatment, making it hard to do enough surgeries to qualify.
Cahn was critical of that requirement, which is based on the notion that patients are safer in the hands of doctors who do more operations. "There's no data to show it improves patient safety," he said.
This is what a few area hospitals are doing to get more health insurance companies to cover their weight-loss surgeries:
Mercy Medical Center in Nampa was working on certification in spring 2007. The Roux-en-Y gastric bypass is the surgery performed there. Dr. Jim Valentine at the Idaho Center for Weight Loss Surgery has performed more than 330 of the procedures at Mercy over the past five years, spokesman Ken Taylor said.
Saint Alphonsus Regional Medical Center in Boise hopes for certification from the American Society for Bariatric Surgery in 2007, said Sherry McClendon, business manager for surgical services. The hospital hopes for accreditation from Blue Cross and Regence, too. The cost of the surgery, $19,500, may drop a bit.