5 Points on Weight Loss Surgery, Obesity Coverage

Here are five points on insurance and Medicare coverage for weight loss surgery and obesity.

1. Medicare decision to cover obesity screening and treatment raises questions.
Medicare recently announced it would cover obesity screening and intensive behavioral therapy in patients who have a body mass index of 30 or more. Medicare coverage will include one face-to-face counseling visit each week for one month and one counseling visit every other week for five months. If the patient has lost at least 6.6 pounds during the initial six months, he or she is eligible for an additional six months of counseling. The plan stipulates treatment be done in a primary care setting.

This requirement has raised questions among physicians and the American Society of Bariatric Physicians. A recent survey of primary care physicians found 78 percent had no prior training in weight loss issues, and of those, 72 percent said no one in their office had weight-loss training. The 2007 Expert Committee on the Prevention, Assessment, and Treatment of Childhood Obesity as well as the Obesity Treatment Pyramid found the critical step between initial treatment and weight loss surgery is management by a comprehensive multi-disciplinary team of obesity experts. The ASBP urged Medicare to widen the definition of primary care physicians to include bariatric physicians and obesity medicine specialists.

2. Medicare coverage of weight loss surgery lowered the price and the risk of complications. Medicare decided to cover the less invasive weight-loss surgery called laparoscopic adjustable banding in 2006 after only reimbursing physicians for gastric bypass surgeries. A recent study found the price of the procedure has decreased while the safety has increased.

A team at the University of Washington analyzed data from CMS on Medicare recipients who underwent weight loss surgery in 2004-2008. After Medicare began covering the laparoscopic banding procedure, the prevalence increased to more than one-third of weight loss surgeries. Prior to 2006, no one in this group received the surgery.

Prior to the change, Medicare paid about $24,000 per procedure, but only $20,000 per procedure after. Safety also increased. Before 2006, 15 out of every 1,000 patients undergoing weight-loss surgery died within 90 days. After 2006, that number dropped to seven in 1,000. In addition, hospital readmissions decreased from 19 per 100 patients to 15 per 100 patients.

3. Georgia will cut funding for weight loss surgery. The state health insurance of Georgia will cut funding for weight loss surgery beginning in 2012 after facing a projected deficit of $815 million for the 2012 and 2013 fiscal years. The state estimates that 1,577 members had the surgery in the 2.5 years it was covered by the state's self-funded healthcare system. The surgeries cost the system $30.8 million — a little less than $20,000 per person. State officials said they might bring back coverage in the future but have added coverage for a wellness program.

The American Society for Metabolic and Bariatric Surgery says 44 states currently cover the surgery for state employees. Montana, Idaho, Kansas, Oklahoma, Louisiana and Pennsylvania do not. Missouri's state Consolidated Health Care Plan, which cut funding for the surgery in 2011, is bringing it back for 2012 after deciding the long-term benefits outweigh the short-term cost savings.

4. Prospective weight loss surgery patients are gaining weight to qualify. Due to insurance policies that limit weight loss surgery coverage to those with BMIs between 35 and 40, hopeful patients are gaining weight in order to qualify for the surgery. Earlier this year, the FDA approved Lap-Band surgery for patients with BMIs as low as 30 if they have at least one weight-related disease. FDA approval for heavy but healthy people still mandates a BMI of 40 or greater. The move made 27 million people eligible for surgery and incited experts to forecast an increase in lower BMI procedures.

However, insurance companies have not lowered their thresholds for covering those procedures, so that increase has not been realized. Almost 63,000 Lap-Band devices were implanted in 2009 in the U.S., according to the Agency for Healthcare Research and Quality. Less than one 1 percent of people eligible actually undergo weight loss surgery. Insurance companies still prefer people try less drastic methods, such as wellness programs, before undergoing potentially risky surgery.

5. CMS is considering coverage of laparoscopic sleeve gastrectomy. CMS is considering whether to provide Medicare coverage for laparoscopic sleeve gastrectomy, a procedure in which most of the stomach is removed and a surgeon shapes the remaining stomach into a tube. CMS closed a comment period on Oct. 31 in which it was requesting information to gauge whether there is adequate evidence for evaluating health outcomes of LSG for the indications listed in the current bariatric surgery for the treatment of morbid obesity National Coverage Determination.

Medicare currently covers three bariatric procedures: open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding and open and laparoscopic biliopancreatic diversion with duodenal switch. Beneficiaries must meet certain BMI, comorbidity and treatment requirements for coverage. A proposed decision memo is expected on March 30, 2012, and a National Coverage Analysis is expected on June 28, 2012.

Related Articles on Weight Loss Surgery:
Bariatric Surgery Mortality Rates Lower at Accredited Centers
Dr. Todd McCarty Performs First Natural Orifice Bariatric Surgery
10 Steps to Add a Gastric Lap-Banding Service Line to a Surgery Center

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