The latest breaking news....
Confidence rises in weight-loss surgery
Every year, about 250,000 people in the United States undergo surgery to lose weight, paying — or having their insurance companies pay — tens of thousands of dollars for procedures that essentially restrict how much food they can take in.
But are the surgeries safe? Do they work? And can they help treat diabetes, hypertension and other conditions caused or made worse by obesity?
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New research on morbid obesity from A. Berarducci and co-authors summarized
According to a study from the United States, "The objectives of this study were to determine the incidence of and associated risks for falls and fractures after gastric bypass surgery for morbid obesity and to determine the clinical signs of bone loss.
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Bariatric Surgery and Diabetes
Dramatic changes in type 2 diabetes
If you’ve been considering bariatric surgery for obesity, you probably already know about its many potential life-transforming benefits. If the surgery also improves your type 2 diabetes, just imagine the additional impact on your health and your life!
The evidence in support of bariatric surgery for type 2 diabetes continues to mount. Various studies have shown:
||77% of patients with resolved diabetes. In these patients, diabetes completely disappeared or treatment (medicines, insulin) was no longer needed. In studies measuring for “resolution or improvement,” the number rose to 86% of patients.
||Rapid results. For some patients, diabetes disappeared almost immediately, within days of surgery. Others saw blood sugar levels begin to fall soon after surgery, becoming completely normal within a year.
||92% reduction in deaths from diabetes-related causes.
Note that different types of bariatric procedures had different degrees of impact. Gastric bypass surgery resolved diabetes in 34% of patients, whereas gastric band procedures resolved it in 73%.
A chance to live better, live longer
By eliminating or improving your diabetes through bariatric surgery, you may:
||Reduce your risk of serious complications, including:
||Congestive heart failure
||High blood pressure
||Cut the costs (and the hassles) of diabetes medications:
||Reduced or eliminated need for diabetes medicines
||No more need for insulin injections
||Have more energy
||Be healthier overall
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Weight-Loss Surgery: A Cure for Diabetes?
BACKGROUND: According to the American Diabetes Association, the most common form of diabetes is type 2 diabetes. A person suffering from the condition does not produce enough insulin, which is required for the body to turn glucose into energy. Insulin moves glucose from the blood into cells, but if glucose builds up, cells may be starved for energy. Type 2 diabetes can also affect the eyes, kidneys, nerves and heart. Obesity is one of the major risk factors for the disease. Excess weight and physical inactivity both contribute to insulin resistance. The International Obesity Task Force (IOTF) found approximately 58 percent of diabetes worldwide is due to a BMI above 21 kg/m2. In western countries, that figure jumps to about 90 percent of type 2 diabetes cases.
SURGICAL WEIGHT LOSS: Bariatric Surgery has become a mainstream procedure for obese individuals who have not been able to lose weight through diet and exercise. The treatment works by changing the anatomy of the digestive system, reducing the amount of food the stomach can hold. The most common bariatric surgery is gastric bypass. In 2005, roughly 140,000 Americans sought the procedure, which has been performed since the 1950s. Many surgeons prefer this surgery because they say it’s safer and has fewer complications.
AN UNEXPECTED SIDE EFFECT: While the procedure can help patients lose weight, it may also help reduce the incidence of diabetes. Studies have shown about 80 percent of diabetics go into complete remission following the operation. Some patients have seen results just days after the procedure, even before losing a significant amount of weight. Francesco Rubino, M.D., chief of gastrointestinal metabolic surgery at the New York Presbyterian Weill Cornell Medical Center in New York, N.Y., sought to find out the cause of this phenomenon. After performing bypass on diabetic rats, he discovered when the top of the small intestine is disconnected, the duodenum, diabetes disappears. When the duodenum is reattached, the disease returns. He concluded that preventing food from traveling through the duodenum can reverse diabetes, independent from weight loss. Clinical trials are currently taking place in Sao Paulo, Brazil on diabetics who are not obese to find out if the procedure is safe and effective for those individuals. Currently people with diabetes who are not obese cannot get bariatric surgery; only morbidly obese patients can. Morbidly obese people are typically 100 pounds overweight.
In addition to diabetes, bariatric surgery offers other health benefits to patients as well. Some experts estimate that roughly 100,000 people in the United States die every year from cancer due to their weight. Researchers at McGill University in Montreal found those who undergo bariatric surgery have about an 85 percent reduction in the risk of breast cancer and a 70 percent reduction in the risk of colon cancer.
FOR MORE INFORMATION, PLEASE CONTACT:
Tampa General Hospital
Ellen Fiss, Public Relations Manager
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Coverage Decision Memorandum for Bariatric Surgery for Treatment of Co-morbidities Associated with Morbid Obesity
21 February 2006
The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.
CMS has determined that covered bariatric surgery procedures are reasonable and necessary only when performed at facilities that are: (1) certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements in effect on February 15, 2006).
A list of approved facilities and their approval dates will be listed and maintained on the CMS Coverage Web site at www.cms.hhs.gov/center/coverage.asp, and will be published in the Federal Register.
The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary; therefore, the following are non-covered for all Medicare beneficiaries:
a. open vertical banded gastroplasty;
b. laparoscopic vertical banded gastroplasty;
c. open sleeve gastrectomy;
d. laparoscopic sleeve gastrectomy; and
e. open adjustable gastric banding.
The two non-coverage determinations in the National Coverage Determination Manual (NCDM) remain unchanged
- Gastric Balloon (NCDM Section 100.11) and Intestinal Bypass (NCDM Section 100.8).
Modification of the current policy on obesity, found in section 40.5 of the NCDM, will include a reference to the covered surgical procedures and will merge the obesity policy with the final bariatric surgery policy. The modified obesity policy will read as follows (emphasis added to the new language within the policy):
Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI > 35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity.
Treatments for obesity alone remain non-covered.
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Study shows deaths more likely for men, older patients in obesity surgery
Nancy McVicar (Health Writer), 19 October 2005
Bariatric surgical procedures, such as gastric bypass surgery, to achieve sustained weight loss have increased dramatically in the past five years, but research published today shows a higher risk of death in the months afterward than was previously known.
Writing in the Journal of the American Medical Association, researchers said the overall death rate during the first year after such stomach surgeries is as high as 7.5 percent. It said men, older patients and patients of surgeons less experienced in the surgeries are most at risk.
The data were from a review of more than 16,000 patients, with an average age of 48, who were covered by Medicare.
Dr. Patricia Byers, director of bariatric surgery at the University of Miami Miller School of Medicine, said she hopes insurers will not use the information in the study as a reason not to cover the procedures.
"I'm just very concerned this data is going to be taken the wrong way," Byers said. "It's a very big operation on very sick people. It needs to be compared to other similar operations, such as a kidney transplant."
Morbid obesity has increased dramatically in the past decade. The number of people with a body mass index, or BMI, of higher than 40 -- a ratio of height to weight -- quadrupled to 1 in 50 between 1986 and 2000. The number or people with a BMI of 50 quintupled to 1 in 400.
Morbidly obese people considering the surgery need to approach it with the right frame of mind and know the risks and benefits, Byers said. They should have the surgery only after diet and exercise fail to shed the weight, and keep it off."A 40-year-old man with a BMI of 40, his life on average will be shortened by 16 years," if he doesn't lose the weight, Byers said.
Byers and Dr. Michel Murr, director of bariatric surgery at the University of South Florida and Tampa General Hospital, have studied 25 older patients who had the procedures at their hospitals and found a much lower complication rate than the JAMA study.
Murr will testify on the need for insurers to cover bariatric surgeries today in Tallahassee before the Florida Senate Health Committee, but he said he understands insurers concerns about quality of the procedures.
"Not everybody [is allowed to do] liver transplants. We need to concentrate bariatric surgeries in certain centers where we can track the outcomes," Murr said.
Surgical procedures to induce weight loss have escalated from 13,365 in 1998, to an estimated 102,794 in 2003.
"If our observed rate of growth continues, there will be approximately 130,000 bariatric procedures in 2005, and as many as 218,000 in 2010," the authors said. "The cost to the U.S. health care system will be substantial.
In an editorial in the same issue, doctors said bariatric surgery is a potentially life-saving intervention in the right patients and in the right surgeons' hands, but the studies indicate that "experience and technique count." And despite the problems reported by researchers, "bariatric surgery today remains a fundamental therapy for morbidly obese patients."
Drs. Bruce Wolfe of Oregon Health & Science University and John Morton, of Stanford University said the research should be seen as an opportunity to improve surgery techniques and an excuse by insurers to avoid covering the procedures for people who need them.
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More Obese Seniors Choose Gastric-Bypass
Mitch Stacy (Associated Press Writer), 21 September 2005
With 360 pounds hanging on his 5-foot-7 frame, Robert Stratiff was in sad shape.
He had heart problems, poor circulation, wasted knees and sleep apnea that kept him awake most nights. Miserable at age 69, he knew he wasn't long for the world unless he did something drastic. And soon.
So in February 2002, the Colonial Heights, Va., resident had gastric-bypass surgery to lose weight, with Medicare picking up the cost. Because he couldn't eat as much, the weight dropped off faster than he could believe. Exercising got easier.
Now the retired Army colonel who flew helicopters in Vietnam is down to a svelte 170 pounds and swims a mile in the pool four or five times a week to keep fit. He's since had heart bypass surgery and a knee rebuilt. All the other medical problems disappeared with the pounds.
"I knew I was not going to make it if I didn't have that done," Stratiff, now 73, said of the weight-loss surgery. "My health was on a toboggan anyway, and it would have gone down hill quicker. I wouldn't have lived."
Medical advancements are helping Americans live longer, but a fast-food culture and sedentary lifestyles are making us fatter than ever. People who are morbidly obese — at least 100 pounds overweight — are increasingly opting for some form of gastric bypass surgery as a last resort.
That includes seniors like Stratiff who are seeking to improve their health and quality of life for the years they have left.
Recent research suggests seniors can benefit from weight-loss surgery as much as younger people and maybe more. One study, from Columbia University's Center for Obesity Surgery in New York, found that patients over 60 got the same benefits from the surgery and had a comparable rate of postoperative complications as younger people.
A soon-to-be published study of 27 gastric-bypass patients 65 and older who had surgery at the University of South Florida and the University of Miami also showed the procedure produced good results and improved quality of life with about the same rate of mortality and complications as seniors who have heart-bypass and hip replacement surgery. That's a mortality rate of about 2 percent to 4 percent, double the death rate for younger gastric-bypass patients.
"We know it corrects the diabetes, it corrects the hypertension, it takes away the sleep apnea, it fixes the heartburn reflux, it makes their knees and joints last longer," said Dr. Michel Murr, a bariatric surgeon at the University of South Florida who has performed nearly 1,000 of the procedures. "All of this is medicine."
One of his patients, Sandra Ainbinder of Myakka City near Sarasota, said she weighed a little over 400 pounds when she chose to have the surgery last year at age 68. She'd lost weight on any number of diets but always gained it back plus more. She was sick, embarrassed and rarely left the house because she could barely walk.
She was rejected by one surgeon because of her age before being accepted by the University of South Florida doctors, with Medicare paying for the surgery.
"It's not a pleasant thing to go through," Ainbinder said. "It's a serious piece of surgery. If there was any other way to do it, I would have done it. But I felt I had to. I was going to die if I didn't do this."
Sixteen months later, Ainbinder is down to 259 and is still losing. Many of her medical conditions either improved or went away. She's got more energy and is looking forward to exercising more after knee-replacement surgery.
"I should be able to join the human race, and I'm looking forward to be being able to walk down the block," she said.
The American Society for Bariatric Surgery, based in Gainesville, Fla., said 140,000 people in the United States had some sort of weight-loss surgery last year, most of them gastric bypass — reducing the size of the stomach to limit food intake. The number has grown by about 50 percent a year since 1998.
Doctors estimate that elderly people make up 1 percent to 2 percent of the total, but they expect that percentage to keep growing as Americans live longer and grow larger.
A study last year in the Journal of the American Geriatric Society estimated that obesity in those age 60 and older will increase from 32 percent in 2000 to 37 percent in 2010. Men ages 65 to 74 and women 55 to 64 are the age groups with the highest prevalence of being overweight and obese.
Many private insurance companies cover bariatric surgery, finding it cheaper than long-term treatment of obesity-related health problems, such as diabetes and high blood pressure. Cost of the surgery starts at about $20,000.
Still, the inherent risks in what is indisputably a major operation keep some surgeons from performing the procedure on older people.
Armed with the recent studies showing that the surgery is safe and effective for many seniors, the society for bariatric surgery is trying to make it easier for older people to get it. Earlier this year, the group petitioned Medicare to develop uniform coverage guidelines and include other types of operations, including less-invasive keyhole surgery that require only small incisions in the stomach wall.
Medicare coverage of weight-loss surgery currently is decided from region to region. "It's kind of a crap shoot," said Dr. Harvey Sugerman, a past president of the society.
Weight-loss surgery has pitfalls for patients of any age. Recovery can be slow and uncomfortable, and a drastic and permanent change of diet is necessary. Stratiff, for instance, said he hasn't had a French fry since before his operation. He gets sick if he eats anything with too much sugar.
Still, he has no regrets.
"I never look back on the decision and second-guess it," he said. "It was the best thing for me to do. It was the only thing for me to do."
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The fifth hurricane: Florida’s crisis of access to medical care
Dr. Michel Murr, SOARD Volume 1, Issue 3, Pages 382-384 (May 2005)
Restricting access to bariatric surgery will have a devastating effect on patients with clinically severe obesity. Florida’s share of the 300,000 annual deaths from obesity is far greater than the deaths associated with global outbreaks of the West Nile virus, severe acute respiratory syndrome (SARS), bird flu, and all 4 hurricanes that struck Florida in 2004 added together. Yet the hoped-for public outcry against major Florida health insurers who terminated patients’ access to bariatric surgery was limited to a few newspaper articles and miscellaneous media headlines.
Florida-based insurance companies announced that they will terminate coverage of bariatric surgery starting in January 2005 because, as a senior-ranking administrator stated, “gastric bypass is extremely risky and of questionable benefit.” These claims are unfounded and conflict sharply with the recently published scientific data supporting the safety and long-term efficacy of bariatric surgery. Of even greater concern, these insurers’ position contradicts the recent conclusion of an expert panel convened by The Centers for Medicare & Medicaid Services (CMS) in November 2004 . The Medical Coverage Advisory Committee (MCAC) expert panel, comprising physicians, surgeons, insurance executives, and health policy experts, concluded that bariatric surgery is safe and effective. We believe that the major driving force for terminating patients’ access to bariatric surgery is based heavily on insurance companies’ financial considerations.
Nevertheless, Florida health insurers have faced explosive growth in the utilization of bariatric surgery, a 10-fold increase over the last 5 years (7000 gastric bypass procedures in Florida in 2003). The 3-year trailing costs (an insurance industry benchmark) were many standard deviations higher than insurance executives had budgeted for. In addition, the acceleration of and opportunity for bariatric surgery brought to the field some enterprising physicians and hospitals that lacked appropriate training and ultimately jeopardized safe, effective, and comprehensive patient care. This dizzying influx of untrained and inexperienced bariatric surgery providers left the health insurance community with the opinion that many programs were the equivalent of simple street peddlers. Poor patient selection, poorly executed procedures, poorly equipped hospitals, and poor patient follow-up resulted in an exponential increase in serious complications and patient deaths in startup programs. These poor outcomes gave insurers credible ammunition supporting their decision to terminate patients’ access to bariatric surgery. Dramatically publicized complications and patient deaths have reached a sympathetic public ear that has been demanding physician and hospital accountability, continuous quality improvement, and a reduction in preventable medical errors. The Centers of Excellence program developed by the American Society for Bariatric Surgery (ASBS) through the Surgical Review Corporation, which became functional in June 2004, should address this issue of quality bariatric surgical care.
Our response to this crisis has been tepid because we concluded, based on our misconceptions of health care utilization and public policy, that health insurers will regain their sanity and reinstate coverage for bariatric surgery once they become aware of the benefits of bariatric surgery and the rising costs of nonoperative treatment for obesity. To educate these insurers on the benefits of bariatric surgery for clinical severe obesity, I met with several local insurers’ medical directors. My efforts, as well as the efforts of Dr Harvey Sugerman, President of the ASBS, who met with Dr. Barry Schwartz from Blue Cross Blue Shield of Florida, led nowhere, however.
A series of local meetings and industry-supported dinners followed between May and December 2004 (Figs. 1 and 2). The many surgeons who attended the meetings were supportive of pursuing legislative action and grass-roots movements. But the mechanisms for executing these decisions were nonexistent. The ASBS was busy with the upcoming annual meeting, the growing controversy of our new journal, and the critically important CMS meeting. Action by our partner, the American Obesity Association, did not materialize. My visit with Dr. Harvey Sugerman to Florida Secretary of Health Dr. John O. Agwunobi in August 2004 was intended to educate the Secretary about the benefits of bariatric surgery and ask for assistance in reinstating access to bariatric surgery. At the conclusion of our meeting, Dr. Sugerman and I concluded that the Secretary provided us with an education in politics. We learned that science alone does not yield policy and that we needed to take a different approach to be effective. Under these conditions, I sought the help of Mr. Vincent Zeringue, a well-known health care consultant with national experience in the area of cardiovascular technology.
Our obvious goal was to reinstate Floridians’ access to bariatric surgery. After several meetings with Mr. Zeringue, we decided that we would make elected and appointed officials, as well as the general public, aware of Florida’s current crisis as it related to obesity and obesity management. Through personal contacts and interaction with patients in our bariatric program, we secured appointments with both state and national elected and appointed officials. Florida Representative Sandra Murman was instrumental in crystallizing our needs, agenda, and strategy. Within 2 days of meeting with Representative Murman (Fig. 3), we obtained appointments with key Florida lawmakers in Tallahassee. We were surprised, but pleased, to learn that these Florida lawmakers knew about the obesity crisis and that some were aware of Florida insurers’ retraction of coverage for bariatric surgery. At the conclusion of our day in Tallahassee, one thing was crystal clear: Mandating coverage for bariatric surgery was not an option at this time, given the current legislative and political landscape in Florida.
Based on our findings and the many feedback discussions that followed our visit, we realized that there may be other, better options for reinstating access to bariatric surgery than legislation mandating coverage. Many lawmakers have agreed to help us initiate and maintain constructive talks with Florida insurance companies and, as necessary, mediate our differences. The purpose of these tripartite meetings would be to bring about a comprehensive solution to the crisis of access to care and to implement practical solutions that address concerns about quality assurance in bariatric surgery. Toward that end, we are taking the following steps:
||Build a coalition of physicians and concerned entities under the umbrella of the ASBS.
||Retain a Florida-registered lobbyist to represent the interests of the coalition.
||Develop a memorandum of understanding to (a) reinstate patient access to bariatric surgery and the addition of coverage for secondary prevention services, and (b) outline a credible credentialing process to ensure quality care in Florida-based bariatric centers through the ASBS Centers of Excellence program.
||Arrange for meetings between the coalition, high-ranking insurance executives, and Florida legislators to implement item 3.
||Blueprint this strategy and lessons learned for other states.
This advocacy endeavor is significant and will not be easy. Our task—to obtain coverage and payment for secondary prevention services and reinstate coverage for bariatric surgery—is enormous, but corresponds with our responsibility to our vulnerable patients. We have a historic opportunity to lead in the fight against the obesity epidemic and further our knowledge. Along with this great opportunity comes the great responsibility to ensure quality care and safe and effective long-term care for obesity and its related comorbidities. We must hold ourselves accountable in making such difficult decisions to eliminate substandard medical practice and regulate ourselves; otherwise, the “fifth hurricane” will ravage Florida and the rest of the nation.
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Florida Insurance Companies Deny Coverage for Bariatric Surgery
Susan Hemmingway Johnson (Tampa Tribune), 3 March 2005
As the calendar rushed toward 2005, University of South Florida surgeon Michel Murr worked extra hours so he could operate on obese patients at Tampa General Hospital. Weekends weren't normal times for the gastric bypass surgeries intended to help patients lose weight, but Murr faced a deadline: When the clock passed midnight Dec. 31, many patients wouldn't be able to afford the surgery if their health coverage was through BlueCross BlueShield of Florida.
BlueCross, which serves more than 6 million people in Florida, is one of the
largest health insurers in the state. On Jan. 1, it stopped covering obesity surgery. ``I wasn't sleeping at night,'' recalled Murr, who was concerned patients were going to be shut out of their best chance for losing hundreds of
BlueCross' decision is part of a national trend. Although the popularity of obesity surgery has soared, insurers are eliminating coverage of the procedures, which can cost $25,000 or more. In Florida, Cigna, United Healthcare and Humana dropped obesity surgery from standard coverage last year or earlier. The companies will tailor certain policies to include the coverage when employers want to offer the benefit. Spokesman Mark Wright said BlueCross will do that, too. For insurers, offering the coverage was becoming risky. ``It was a business decision,'' said Roger Rollman, United Healthcare spokesman. ``If you put everything that people could conceivably want in a benefit package, there's no way on earth that anyone could afford that package.''
Along with increased cost, health insurers cite concerns about safety as a reason for exclusion. The booming obesity-surgery business - fueled by celebrity testimonials and television commercials - has attracted more surgeons who have less experience and training. ``The risk to our members was really considerable,'' said BlueCross of Florida Vice President Barry Schwartz, adding that insurance companies could be swept into malpractice lawsuits.
BlueCross announced 11 months ahead of time that it would stop coverage. In a February 2004 announcement, the company labeled gastric bypass surgery ``an extremely risky procedure that is of questionable benefit.'' ``The situation was getting progressively worse,'' Schwartz said. ``The number of [operations] was going up very quickly. ... There was advertising all over the place.''
Fear For The Future
Caught in the middle are patients such as Anna Brown, 50, an administrative nurse at a Pasco County hospital. Brown weighs 368 pounds. Insured by BlueCross through her husband's job, she learned of the company's decision in June and tried to make the end-of- the-year deadline. To combat a weight problem dating to age 14, she has tried dozens of diets, including a hospital-supervised liquid fast in the 1980s. Her weight-aggravated problems include loss of a kidney and a bad back that requires frequent injections for pain.
The process to qualify for obesity surgery can be lengthy.
BlueCross required Brown to undergo a doctor-supervised diet for six months.
She needed to be seen by internists, psychologists and other specialists to be approved as a good candidate at the University of South Florida-Tampa General Hospital bariatric surgery program. After passing requirements at Tampa General, she was able to see Murr on Dec. 10. Her insurance request landed at Blue Cross on Dec. 22 but wasn't reviewed before Jan. 1, she said. Brown isn't sure what she will do but may decide to have surgery where she can pay on an installment plan. She worries whether her family can afford the payments and fears for her future. ``Medically, if I don't [have the surgery], I'll be lucky if I live another five or 10 years,'' she said.
During the past two years, more insurers started putting up barriers to
obesity-surgery coverage, said Chris Salvino, a weight-loss surgeon who
founded The Wish Center chain eight years ago. The Illinois-based company has clinics in seven states, including one in Tampa. Patients would be told they had to be under doctor-supervised diets for months, only to complete the requirement and learn the rules had again changed, Salvino said. Insurance companies in some markets dropped coverage earlier. In metropolitan Seattle, 75 percent of patients pay out of pocket, he said. Wish Center clinics offer installment plans for self-paying patients. Loan terms can be stretched to seven years, depending on the client's credit rating. Interest rates range from 9.9 percent to 15.9 percent. Salvino predicted some insurers will return to offering coverage but only at comprehensive centers that specialize in weight-loss surgery.
``There have been so many doctors jumping in [and offering weight-loss
surgery] and there are no standards,'' Salvino said. ``Any surgeon in the
United States can do weight- loss surgery.''
More experienced surgeons have lower mortality rates, according to a report
issued in November for the Centers for Medicare and Medicaid Services. Obesity surgery can be covered under Medicare if it is performed to relieve serious medical problems aggravated by weight. Citing comparisons with control groups, the report concluded there is evidence the surgery results in much greater weight loss for severely obese
patients and can resolve problems such as diabetes and hypertension. Insurance companies that refuse to cover obesity surgery are ignoring that evidence, Murr said. Their decision to drop coverage ``flies in the face of all the medical literature out there that supports the safety and efficacy [of obesity surgery],'' he said.
In Florida, Murr said, the mortality rate associated with obesity surgery is
less than 1 percent. He is completing research that will show mortality rates based on the number of operations performed by surgeons and where they took place in the state. The number of obesity surgeries in Florida has soared during the past 10 years, Murr said.
According to state hospital records, 70 people underwent obesity surgery in Florida in 1993. That number jumped to 7,000 in 2003. That rapid growth concerns surgeons such as David Echevarria, who started a comprehensive obesity surgery program at St. Joseph's Hospital in Tampa last year. ``Absolutely, in appropriately selected patients, [obesity surgery] is a life-saving maneuver,'' Echevarria said. ``I do believe that something needed to be done with regards to determining what facilities should or should not be providing the service.'' Scheduled weight-loss surgeries have slowed at St. Joseph's, Echevarria said, but he predicts the surgery won't disappear. ``It's a shame that the insurance companies just pulled themselves completely out ... especially because this is not a sham operation.''
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Why Doctors Have a Difficult Time Treating Obesity
Howard Markel, MD, PhD (Medscape Pediatrics), 3 March 2005
In many ways, Jake is a typical 16-year-old American boy. He enjoys playing video games, listening to rap music, and watching action-packed movies with his friends. And, like almost 20% of all American youth, Jake is overweight. In fact, at more than 300 pounds, there's no subtle way to describe Jake's physique. Doctors like me might use an obtuse clinical term such as "morbidly obese." His teenage buddies, far less polite, typically deride him by calling him "The Fat Man."
A few months ago, a social worker colleague asked me to see Jake. She had excellent reasons to be concerned. Not only was he physically huge, his health was dangerously compromised. At 195/100 mm Hg, Jake's blood pressure was alarmingly high; his cholesterol soared above the 300 mark; and his blood sugar levels placed him in a concerning category called "prediabetes."
Few today need to be reminded of the epidemic of expanding waistlines. Most alarming is the spread of this health problem to youngsters. Because eating habits are established early in life and most overweight children tend to remain that way when they become adults, many public health experts are predicting a huge increase in the incidence of obesity-related conditions. These will include atherosclerosis, heart attacks, hypertension and strokes, adult-onset diabetes mellitus, and even osteoarthritis, occurring as a result of carrying around all those extra pounds for so many years.
But even more disturbing than the plethora of fast food, soft drinks, and snacks that have invaded our children's schools and daily lives has been the relative inactivity of physicians in arresting this problem. The complaint of how little we doctors learn about nutrition, exercise, and healthy diets is, sadly, a valid one. The medical school where I teach offers only a few hours in the formal curriculum on these subjects, whereas there are weeks devoted to explaining the drugs we have available to treat hypertension and adult-onset diabetes. Even more time is allotted to the burgeoning number of after-the-fact surgical interventions for problems that could be prevented, or at least attenuated, simply by eating right and engaging regularly in physical activities.
At the clinic where I see Jake, we really don't offer any of the dietary counseling or nutrition classes that might help him. It's also very difficult finding the time to address the importance of cutting calories and eating healthy at the family level where obesity typically originates. I could, however, get him an appointment to see a surgeon to consider performing an expensive, and not entirely safe, stomach-stapling procedure simply by making a 2-minute phone call. This is hardly unique to my practice.
Perhaps the root of this problem lies in the fact that doctors, as a rule, like to succeed in their treatments. We gain great satisfaction from surgical procedures that quickly remove an offensive tumor, or prescribing pills that quickly arrest a medical condition. But most of us find treating obesity frustrating, if not outright hopeless. This problem is only exacerbated by the sad fact that most insurance companies rarely reimburse clinicians who are willing to spend the long hours it takes encouraging these kids to learn an entirely new approach to eating. As a result, many avoid treating patients with obesity entirely.
Jake and I decided that we would meet weekly for a weigh-in and a chat about his progress. At the close of our first visit, we consulted the Internet for a sensible and safe diet suggested by the American Heart Association. He also agreed to begin a program of regular exercise by walking at least a mile a day with the intention of increasing that amount over time. And I promised to supplement my own pitiful knowledge on the art of losing weight by studying some of the latest findings and textbooks on the subject. Most important, we made a pact to learn how to fight this remarkably stubborn health problem together.
About 2 months later, Jake's track record has been good, albeit not spectacular. He has managed to lose 11 pounds. He is sticking to the diet and exercise regimen I prescribed and remains determined to lose weight. As Jake admitted the other day, "this is really going to take a long time, isn't it?"
His social worker and I are committed to his weight loss goal as well. We only hope Jake's health insurance plan continues to support what I have come to label "nutritional cheerleading visits." These sessions, to be sure, are less exciting or definitive than open-heart surgery, but they just may save his life.
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N.C. Health Insurer to Offer Coverage for Weight Problems
Rob Stein (Washington Post Staff Writer), 13 October 2004
Alarmed by the obesity epidemic, North Carolina's largest health insurance company announced yesterday that it will offer more than 1 million of its members the most comprehensive package of benefits ever provided to prevent and treat weight problems.
Blue Cross and Blue Shield of North Carolina will begin paying for four visits to a doctor every year specifically to assess a patient's weight and provide treatment if necessary, nutritional counseling sessions with dieticians to help people stay thin or shed pounds, and two prescription diet drugs for those already overweight. Contrary to industry trends, the company will also continue to cover stomach surgery for the obese.
"This is the public health crisis of the 21st century," said Robert Greczyn Jr., president and chief executive. "Public health experts believe that, without a dramatic change, the coming generation will die at a younger age than our generation. We are going to do more about obesity. We want to walk the walk."
The decision was hailed by anti-obesity advocates as a groundbreaking step that will enable patients and doctors to take a more active role in preventing people from becoming overweight in the first place and treating them if they do.
"This is very positive," said Morgan Downey, executive director of the American Obesity Association, a Washington advocacy group. "It's very comprehensive and unprecedented in terms of covering people across their weight-spectrum needs."
The move will probably become a model for other insurers and private companies, which are becoming increasingly alarmed by the skyrocketing costs associated with obesity, experts said. More than two-thirds of Americans are overweight, including about a third who are obese.
"Other insurance companies and health plans and employers will be watching this very closely," said Helen Darling, president of the National Business Group on Health, a coalition of many of the country's largest companies. "If it proves to make a difference, then I think more employers will think about doing something like this, at least on a pilot basis and maybe more."
The North Carolina insurer is the first to significantly expand coverage for weight treatment since Medicare announced this summer that it was dropping a long-standing policy that did not recognize obesity as a disease. That decision was hailed as a watershed that would open the door for the federal program to cover obesity treatments, such as surgery, and that could prompt private insurers to follow suit for a variety of weight-loss treatments.
"Medicare opened the door for change last summer when the agency struck language that blocked the treatment of obesity as a stand-alone condition," Greczyn said. "At Blue Cross and Blue Shield of North Carolina, we are proud to step out front. We will treat obesity as a primary condition."
The company decided to launch the new package of benefits, called Health Lifestyle Choices, because half of its members are overweight or obese, triggering medical problems that cost the company more than $83 billion in 2003 alone, he said.
The package includes:
• Paying for four doctor's office visits each year and any related tests to determine whether a patient has a weight problem and to treat that patient if necessary, beginning on April 1, 2005.
• Paying for two prescription weight-loss drugs that have been approved by the Food and Drug Administration -- Meridia and Xenical -- when deemed medically necessary by a doctor, beginning on Oct. 1, 2005.
• Contracting with licensed dieticians to provide counseling to help patients maintain or lose weight, beginning on Oct. 1, 2005.
• Identifying 12 doctors in seven practices across the state who have demonstrated excellence in performing stomach surgery for obese patients, and continuing to pay for the operations. Patients will be encouraged, but not required, to use these doctors.
The new benefits will be available to about 1.1 million of the company's 3 million beneficiaries for whom the company can unilaterally decide to expand coverage, officials said. Other members could get the benefits if their employers opt to offer them.
The company has not calculated how much the program will cost, but officials said they expect that the added expense will be offset by savings associated with weight problems.
Rising costs -- combined with pressure from drug companies and medical-device makers to cover new treatments, and from government officials and public health advocates concerned about health consequences -- are prompting more insurers to pay for more coverage, experts said.
"All these factors are starting to converge," said Diane C. Robertson of ECRI, an independent health technology assessment company. "I think we're going to be seeing a lot more of this."
The move should remove a significant barrier to the treatment of many patients, doctors said.
"There are thousands of people who could benefit from treatment but are not seeking treatment because it's so expensive," said Kishore Gadde, an obesity expert at Duke University in Durham, N.C. "I know patients who have lost significant amounts of weight but couldn't afford to continue the treatment because it was so expensive."
Officials at several large Washington-area insurers said that they already cover many of the same kinds of care, but that they have no immediate plans to match the North Carolina package.
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Mass. panel issues new gastric surgery guidelines:ABC News question
Jennifer Peter (Associated Press Writer), 18 August 2004
BOSTON (AP) - Weight loss surgeries should be conducted only by
doctors who have been through a rigorous certification process in
facilities that perform at least 100 of these increasingly popular
procedures each year, according to a report issued Wednesday by a
panel of medical experts.
State Public Health Commissioner Christine Ferguson established
the panel earlier this year in response to several recent deaths
related to gastric bypass surgeries, whose prevalence in
Massachusetts has increased from 402 in 1998 to 2,761 in 2003.
The 69-page report is the first major product of the Betsy
Lehman Center for Patient Safety and Medical Error Reduction,
created by the state last year in memory of a Boston Globe
columnist who died in 1994 after a chemotherapy overdose at
Boston's Dana-Farber Cancer Institute.
The 24-member panel, made up of a range of obesity experts,
doctors, nurses and an ethicist, also recommended that hospitals
have specially equipped operating rooms, with extra wide operating
tables, extra long abdominal tools, and wider wheelchairs,
stretchers and walkers.
Other recommendations cover nursing care, the criteria for
selecting patients, pediatric obesity, pain management and areas
for future research.
"For many people, this surgery represents hope for the
future," Ferguson said in a statement. "The report and the
recommendations included in it increase the likelihood that they
will be able to pursue that hope in safety."
Weight loss surgeries should only be performed on well-informed,
motivate patients, who have a body mass index of at least 40 - 35
if they have other major obesity-related complications - and have
not been able to achieve long-term weight loss through other means,
the panel said.
Three patients died after obesity surgery in Massachusetts
during the past year. The most recent death occurred in January at
Beth Israel Deaconess Medical Center when Howard Reid, 37, of
Boston, went into cardiac arrest immediately after surgery.
Brigham and Women's Hospital in Boston suspended obesity surgery
last fall after Ann Marie Simonelli, 37, died in her hospital bed
following surgery. The hospital resumed surgeries in January after
an internal investigation found no deficiency in care.
A doctor from Brigham's was the chairman of the panel, while a
doctor from Beth Israel served as co-chairman.
Gastric Bypass Panel Recommendations, MA 8-4-04
For a Surgeon’s Accreditation:
- For provisional privileges: successful completion of 10 open cases proctored by a surgeon with full privileges for open weight loss surgery. For provisional privileges for surgeries other than “Lap Bands” the panel recommends successful completion of 25 laparoscopic cases proctored by a surgeon with full privileges for laparoscopic weight loss surgery.
- For full privileges for both open and laparoscopic procedures, review of the first 15 independently preformed cases by a committee, which should include the chief of surgery at the institution and an experienced weight loss surgeon.
For Facilities’ Accreditation:
- In order to reduce medical errors, the panel recommends that institutions have high volume surgeons (who perform 50-100 cases per year) and that institutions perform more than 100 cases per year.
- The panel recommends future research on both standardization of technical aspects of weight loss surgery, and compares the different types of procedures.
For Patient Selection:
- Recommends multidisciplinary evaluation and treatment focus on the different aspects of patient care, including behavioral and psychological care, such as support of necessary behavioral changes; nutritional care, such as monitoring of protein intake and adequate hydration; and medical care, such as identification and coordination of necessary preoperative testing and evaluation. The panel recommends that attention be focused on the contraindications to weight loss surgery, which may change depending on comorbidity, gender, age, and body mass index.
- For patient selection, the panel recommends use of the patient selection guidelines from the 1991 National Institutes of Health (NIH) Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity.
Body mass index ≥40 kg/m 2, or ≥35 kg/m 2
Major medical complications of obesity, such as cardiovascular disease, type 2 diabetes or sleep apnea.
A well-informed and motivated patient, a strong desire for substantial weight loss, failure of other non-surgical approaches to long-term weight loss and acceptable operative risks.
- The panel recommends future research on defining selection criteria, predicting complications and outcomes, identifying improved methods to assess outcomes, and collecting long-term data.
On Patient Education:
- Patients should be given information on alternatives to surgery and alternative forms of surgery, as well as other information, such as potential complications and common post-surgery psychological adjustment issues.
- Assessment of the patient’s understanding of the information provided should be part of the informed consent process.
- The panel recommends future research on different forms of patient education, assessing patient satisfaction with different approaches to informed consent, increasing the efficiency and the reliability of the informed consent process, and establishing a public repository of education materials and informed consent documents used by weight loss surgery programs in Massachusetts..
On Anesthesia and Pain Management:
- Adequate pre-anesthesia evaluation, including specific attention to signs and symptoms of sleep apnea, laboratory testing, appropriate induction techniques, and availability of additional anesthesia practitioners are crucial to safe weight loss surgery. The panel recommends adherence to the American Society of Anesthesiologists (ASA) guidelines for intraoperative monitoring and ASA Standards for Postanesthesia Care.
- The panel report emphasizes the need for effective and unimpaired communication between the anesthesia and surgical members of the care team. The recommendations also address equipment needs and sleep disorder issues.
- The panel recommends future research on pain management strategies, preoperative evaluation, improved monitoring devices particularly suited for use in WLS patients, and the impact of sleep-disordered breathing syndromes, among other topics.
- Protocol that should be followed by nurses participating in weight loss surgery care teams. Particular attention to patient confidentiality issues and issues related to the physical environment set out for the patient.
- Discharge planning and follow-up information are also emphasized in the report. The use of standardized order sets and/or clinical pathways are also recommended in order to reduce medical errors.
- The panel recommends future research on nursing knowledge and patient outcomes, teaching techniques, risk of injury to clinicians, and best practices for staff safety and pain management.
On Pediatric/Adolescent Care
- Recommendations on Tanner Growth charts and body mass index specifications.
- Other important variables include percentage of adult height attained, and the implications of possible effects of surgery on female patients’ reproductive systems.
- Recommends eligibility evaluations, including a workup for syndromic or genetic obesity for candidates suspected of these syndromes, and careful consideration on a case-by-case basis for proceeding with surgery in cases with such diagnoses.
- Evaluating the patient’s and their family members’ knowledge related to both surgery itself and sustained behavioral changes required post-surgery to achieve long-term success is important. In this area, the panel recommends both an interview and written examination prior to surgery.
- Evaluation of psychological maturity before surgery, and attention to psychological factors that could interfere with treatment.
- The procedures best suited for adolescents are the Roux-en-Y Gastric Bypass (RYGB) (for the best long-term results) and the laparoscopic adjustable gastric banding (for the lowest risk). A peer review process should be established for all programs offering weight loss surgery to adolescents.
- Future research on long-term medical and psychological outcomes in adolescents, effectiveness and complications of various procedures in the adolescent population, and the development of combined databases that include information on both adolescent and adult patients.
On Facility and Quality Assurance and Quality Improvement
- Specifies education programs that should be available to personnel caring for weight loss surgery patients.
- equipment as extra wide operating tables and extra long abdominal instruments; wide wheelchairs, stretchers, walkers and examination tables; and special diagnostic and interventional equipment in operating rooms and other parts of hospitals. Doorways and elevators of sufficient size are also recommended. There should also be a blame-free atmosphere in place to encourage the reporting of adverse events, a focus on appropriate education regarding weight-based drug dosing, and an effective tracking and management of medication dispensing and administration.
- A statewide risk-adjusted weight loss surgery data registry should be developed, and subcommittees of hospitals’ medical staff credentialing committees should be established to credential emerging technologies. The panel recommends future research on collaboration with third party payers, and industry and simulation training.
On Insurance Coding and Reimbursement
- Full reimbursement for multidisciplinary care of weight loss surgery patients is important. The panel recommends that Current Procedural Terminology (CPT) codes be updated, and a standardized tiered data collection system be established. The panel also recommends consideration of the use of global fees.
- The Department of Public Health should also establish an advisory committee to examine and make recommendations about reimbursement policies for the treatment of moderate to severe obesity.
- Future research in a number of areas, including the cost effectiveness of different weight loss surgeries; identification and validation of outcome predictors; the effect of reimbursement policies on the quality of surgical therapies and on economic outcomes; and regional, cultural, and socioeconomic variation in utilization, outcomes, and patient satisfaction.
On Data Collection (Registries) and Future Considerations
- The panel recommends that the Department of Public Health establish an advisory committee to investigate the development of a mandatory, statewide data collection system for all institutions that perform weight loss surgery. Pre-operative, intra-operative, post-operative and long-term follow up data should all be collected.
- The panel recommends future research on the issue of data collection, including a pilot study on any proposed data collection system and a feasibility study to address the complexities and financial impact of such a system.
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Medicare Seeks Weight Loss Plans That Work
New York Times, 21 July 2004
The government is looking for the Holy Grail of weight loss programs: one that keeps the pounds off. Now willing to pay for a treatment that works, Medicare is shunning fad diets to focus on one of the more radical solutions, stomach bypass surgery.
Despite the claims of various diets and surgical procedures, most researchers agree that no approach to weight reduction has been proven to be effective over the long haul. In deleting Medicare's edict that obesity is not a disease, officials said they would consider paying for something, but only something that can be shown to work.
``The key piece of data that's not there is the long-term benefit of any of these particular therapies,'' said Steve E. Phurrough, director of coverage and analysis at the federal Centers for Medicare and Medicaid Services. ``That's what we're looking for.''
A Medicare advisory commission will take the first step in November when it considers the effectiveness of stomach-bypass surgery, which has soared in popularity over the past five years.
More than 100,000 morbidly obese people had the surgery in 2003, up from 25,000 in 1998, according to the American Society for Bariatric Surgery. Costing $30,000, the surgery is intended for people who are at least 100 pounds above their ideal body weight and who have failed at other attempts at weight loss.
Many insurance carriers have started to cover the procedure, finding it cheaper to pay for the surgery than long-term treatments of obesity-related health problems such as diabetes and high blood pressure.
One major insurer, however, Blue Cross and Blue Shield of Florida, which serves 6 million people, will stop paying for it next year.
``Gastric bypass surgery is an extremely risky procedure that is of questionable benefit to the patient,'' said Robert Forster, Florida Blue Cross' vice president and chief medical director. ``We are concerned at the growing numbers of these procedures while significant questions remain regarding quality of care, safety, efficacy and long-term consequences.''
Medicare has scheduled no other weight-loss treatments for review yet, but officials said they expect to get many requests from weight-loss programs, fitness centers and doctors.
Will Weight Watchers, Jenny Craig, Atkins and other programs win Medicare approval? Atkins' medical director, Dr. Stuart Trager, said he plans to find out.
``Clinical science shows that approaches like Atkins can work,'' Trager said of the low-carbohydrate diet that remains a subject of great debate among medical practitioners.
Some health plans subsidize gym memberships, but it is unlikely that Medicare would, despite the undeniable benefits of exercise.
Medicare often is a pacesetter in coverage decisions, followed closely by private insurers. But in the case of obesity, the agency will be catching up to health plans that already cover a variety of treatments. Medicare also lags behind the Internal Revenue Service, which designated obesity as a disease in April 2002.
The IRS allows eligible taxpayers who spend thousands of dollars because of obesity to deduct expenses for stomach-stapling surgery, approved weight-loss drugs and nutritional counseling.
Medicare's change of heart last week on weight loss was years in the making, prompted by the alarming rise in obesity as a killer of Americans. Now ranking just behind smoking, obesity claimed 400,000 lives in 2000, according to the Centers for Disease Control and Prevention.
The issue has been a self-described obsession of Health and Human Services Secretary Tommy Thompson, who regularly hands out pedometers and is known to scold overweight aides in public. ``The problem is growing as fast as our waistlines are in America,'' Thompson says at virtually every opportunity.
Perhaps as many as 7.4 million Medicare beneficiaries are obese, generally described as excess body fat of 30 pounds or more over ideal body weight.
Thompson and other top Medicare officials said they have no idea about the cost of any change in coverage. The amount will depend on any treatment that is accepted and how widely it is used.
Even without a new weight-loss benefit, cost pressures are building on Medicare. A new prescription drug benefit taking effect in 2006 will cost at least $400 billion and possibly much more over 10 years.
Taxpayers already foot the bill for $39 billion in medical costs related to obesity. Medicare and Medicaid programs now cover sicknesses caused by obesity, such as type 2 diabetes, cardiovascular disease, several types of cancer and gallbladder disease, according to the CDC. The government also pays for a limited array of treatments for illnesses that can lead to obesity, such as thyroid problems.
Officials have an array of questions to be answered before Medicare starts covering weight-loss programs. What is effective, and for whom? Can people 65 and older withstand the stress of stomach-reduction surgery? Just how obese must a person be to qualify for coverage?
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