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At a time when government figures show 27% of Americans are obese, its no surprise that the publics and the insurance industrys awareness of “bariatric surgery,” or gastric bypass surgery, has grown.

The treatment is potentially effective, sometimes dangerous and definitely expensive.

For brokers and agents helping companies find the right match of health care against a picture of rising health care costs, here is a quick primer on the insurance issues surrounding this treatment.

For the industry, the most urgent need is to look for cost-effective answers with good outcomes, because obesity has far-reaching implications.

Questions about the cost and popularity of bariatric surgery for morbid obesity gained steam in mid-2004 following an announcement by Medicare officials that the program will consider covering obesity itself as a disease, rather than covering only so-called “co-morbidities.” Major “co-morbidities” include hypertension, heart disease, type-2 diabetes, sleep apnea, stroke and a range of cancers.

The bariatric surgery issue has many facets:

Results of clinical trials measuring the short-term and long-term outcomes of bariatric surgeries vary depending on the type of surgery completed, the experience of the surgeon and hospital or other facility, how “sick” the candidates are before surgery, the impact and compliance of post-surgical behaviors, and the general risk of surgery for morbidly obese patients. Good results with one study have not always carried over to the next.

Mortality rates for these procedures are between 1% to 3%. According to a study published in the Journal of the American College of Surgeons, the risk of death within 30 days after gastric bypass surgery was nearly 5 times greater if the surgeon had performed fewer than 20 procedures. In addition, about 20% of all bariatric surgery patients require follow-up procedures to treat complications. Despite the risks, experts support the results of evidence-based studies, reaffirm the need for informed consent and acknowledge that the risks for these individuals may be worth it in the long run.

Even though Medicare decisions on coverage usually have helped lead the industry toward universal reimbursement, many third-party payers are hesitating due to the extreme costs associated with complications for this high-risk population. Some 140,000 bariatric procedures will be performed in 2004, according to an article that appeared in the Journal of the American Medical Association. Multiply that number by an average cost of $25,000 (with no complications), and these 140,000 procedures will cost a jaw-dropping $3.5 billion.

While self-insured employers may choose to cover the procedures, fully insured employers cannot choose, thereby creating an adverse selection by obese employees to secure reimbursement for the surgery. While the treatment likely will decrease long-term direct health care costs, the cost burden can be amortized over 3.5 years, according to a recent study in the journal, Obesity Surgery. Unfortunately, many employees change jobs before companies can realize these health and financial gains.

All surgeries are not created equal. The Roux-en-Y gastric bypass, which costs about $25,000, has come to be known as the “gold standard” for its longevity with appropriate candidates. Because cost is a factor, new procedures are entering the arena, including laparoscopic methods that reduce hospital length of stay, physician time and the recovery period. The “mini gastric bypass,” costing just $17,000, produces results with major weight loss, and requires less operating and recovery time. Unfortunately, there is not yet enough evidence to ensure this procedures safety or to confirm favorable outcomes.

So, what does the future hold? The American Society of Bariatric Surgeons has begun a process for identifying and credentialing “Centers of Excellence” for bariatric surgery. Its goal is to establish guidelines for a procedure never before regulated; investigate, evaluate and examine candidates for certification to provide these services; participate in education and research in the field; and provide data management for outcomes. This effort offers a great deal of promise. Additionally, more research is needed and will continue now that information about long-term outcomes is more accessible.

In the interim, health insurers are looking at their options: Eliminate coverage, increase out-of-pocket costs or offer selective reimbursement only for procedures consistent with good outcomes.

It is clear that health care providers need to do the research and develop comprehensive programs of care for obesity patients before they are in the operating room. The successful programs are out there, as are the experienced physicians. Rarely before has the phrase “buyer beware” had as much financial impact as it does here.

, R.N., is market research analyst for the group life, accident & health reinsurance operation at ING Re, Minneapolis. She can be reached at Kathleen.thiesen@ing-re.com.


Reproduced from National Underwriter Edition, January 6, 2005. Copyright 2005 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.