WLS and Insurance

[Guest guest]

Seven Rational Reasons

To Require Universal Insurance Coverage of

Weight Loss Surgery (WLS)

so that morbid obesity need not be a death sentence for millions

without resources

by Glenn Goldberg, J.D., R.C., VBG WLS 10.24.02 360/195

1. Americans are suffering from an epidemic of obesity that

devastates countless lives and families with incalculable suffering

and expense, and then kills people prematurely. Obesity is also a

causative factor in many other costly and debilitating medical

conditions.

According to the 12.08.03 issue of Newsweek, more than 65% of

Americans are overweight or obese, a rate that has doubled in the

last 20 years. Obesity rates vary from about 14% in Colorado to

almost 26% in Mississippi. Morbid (i.e. life-threatening) obesity is

often defined as weighing 100 pounds or more over a person's ideal

weight.

Newsweek also reported that the incidence of diabetes increased 27%

in the last five years. The Centers for Disease Control and

Prevention estimate that 17 million American adults have already

been diagnosed with diabetes, and 12 million adults are developing

the disease. Morbidly obese individuals are at particularly high

risk for diabetes.

In the July, 2003 issue of ObesityHelp magazine, www.obesityhelp.com

founder Klein estimated that the average costs associated with

morbid obesity (e.g. medications, hospitalizations, etc.) are about

$6,000 a year. At this rate, a Weight Loss Surgery can pay for

itself in about four years, and start generating significant savings

in five years!

More than 10 million Americans, 4.7 percent of the population, are

medically eligible for Weight Loss Surgery, according to the

National Institute of Diabetes and Digestive and Kidney Diseases of

the National Institutes of Health. More than 100,000 very overweight

people are expected to undergo Weight Loss Surgery this year, double

the number that had WLS in 2001, but largely because of insurance

exclusions for the procedure, that represents only 1% of the number

of people who are medically eligible.

Morbid obesity is an independent risk factor for premature death,

with the risk rising as a person's BMI (body mass index) increases.

A BMI greater than 40 -- or greater than 35 with associated medical

problems -- means that a person has clinically severe or morbid

obesity, which is associated with diabetes, heart disease, high

blood pressure, high cholesterol, heartburn, gallstones, arthritis,

urinary stress incontinence, infertility, and some types of cancer.

People with a BMI of 30 have a relative risk of dying early that is

1.3 times greater than normal weight individuals. By the time the

BMI reaches 40, the risk is almost 3 times as great. At 50, the risk

of dying prematurely multiplies exponentially.

2. Mandating insurance coverage for WLS is the fair, equitable and

right thing to do, because obesity is a disease. The disease of

morbid obesity need not and should not be a death sentence for so

many individuals without insurance coverage or resources.

Weight Loss Surgery is a medical (not a moral) condition requiring a

medical intervention (not moral judgments.) Smokers aren't denied

insurance coverage for appropriate surgical treatment when they

develop lung cancer, and patients with heart disease are covered for

indicated surgery regardless of their lifestyles. This raises

fundamental issues of fairness and discrimination in health care

policy on the basis of weight and appearance. Classifying obesity as

a disease would not only lessen the severe social stigmas associated

with the condition; it would also immediately remove presently

insurmountable economic and regulatory hurdles to prevention and

treatment. Declaring obesity as a " disease'' could open up insurance

coverage to the estimated 10 million Americans who need treatment

for their morbid obesity.

" For ages, obesity has been regarded as a personal moral failing, a

behavioral issue that's easily fixed by people who have sufficient

willpower to do so,'' says Downey, executive director of the

American Obesity Association. " The modern scientific understanding

of obesity is that it is a complex disease in its own right.'' That

understanding has led many major medical authorities, including the

National Institutes of Health and the World Health Organization, to

conclude that obesity should be classified as a disease.

3. Mandatory WLS coverage at equitable compensation rates would

encourage and help the American Society of Bariatric Surgeons (ASBS)

to elevate their training, research and quality assurance programs.

Hundreds of doctors have jumped into the bariatric field recently

and started to advertise their availability as WLS surgeons, even

though they may not have the expertise and experience required to

perform the procedures safely and effectively. Universal WLS

coverage, and the increased resources that would generate, will

encourage the most highly qualified bariatric surgeons to impose

stringent ASBS certification requirements that will protect patient

safety and promote quality medical treatment and care.

4. WLS is proven effective and reasonably safe (especially compared

to alternatives).

Numerous studies suggest that Weight Loss Surgery is the ONLY

treatment that reliably produces significant and sustained weight

loss. According to Dr. Bruce Wolfe, a bariatric surgeon and

Professor of Surgery at the University of CA at , " Morbid

obesity is life-threatening, and surgery is the only treatment that

works. " Surgical treatment for clinically severe obesity has been

endorsed by the National Institutes of Health, the World Health

Organization, Shape-Up America, the American Heart Association, the

American Dietetic Association, and the American Obesity Association.

WISH Bariatric Centers have reported that their patients lose as

much as 70 percent of their excess weight within one to two years

after surgery. Other studies show that more than 92% of American WLS

patients achieve and maintain long-term weight loss.

While there are risks inherent in any surgery, the rates of death

(0.5 - 1%) or complications (5-8%) from Weight Loss Surgery are

comparable to those for most other major surgeries. The risks to the

health and life of a morbidly obese individual from NOT losing their

excess weight seem to be far greater than the risks of death or

complications from having WLS.

Bariatric surgery techniques and technologies have been refined and

improved, and they can save lives – if patients can afford to have

the surgery. The barriers created by insurance policy exclusions

prevent most patients who need surgery from having it. Consequently,

they effectively impose a death sentence upon millions of morbidly

obese Americans.

5. Weight Loss Surgery is extremely cost-effective. Denial of WLS

coverage today will exponentially multiply our nation's future

health care costs.

Dr. Kerr, director of health care management at

HYPERLINK " http://www.nytimes.com/redirect/marketwatch/redirect.ctx?

MW=http://custom.marketwatch.com/custom/nyt-com/html-

companyprofile.asp & symb=F " the Ford Motor Company, estimates that

obese workers cost employers $12 billion annually in medical bills,

reduced productivity, increased absenteeism and higher insurance

premiums. The National Institutes of Health reports that the annual

costs of treating obesity-related conditions -- including diabetes,

heart disease, osteoarthritis and breast and colon cancers -- are at

least $120 billion. (According to Frost & Sullivan, a consulting

firm, spending on bariatrics is now approaching $3 billion a year,

at an average cost of $25,000 for each procedure.)

According to an 8.29.03 article by Milt Freudenheim in the New York

Times, bariatric specialists say that the surgery reduces overall

health care costs in the long run. Patients with Type 2 diabetes,

which the National Institutes of Health said accounted for $98

billion of obesity-related costs, have normal sugar counts within a

few days after the stomach bypass procedure, without medication. A

recent study by the Blue Cross and Blue Shield Association confirmed

that " surgery is far more effective than diet and exercise in

treating morbidly obese patients, " according to Naomi Aronson,

executive director of the association's technology evaluation

center.

If Klein is right in his calculations, the financial " break

even " point for bariatric surgery may be as short as four years post-

op.

6. Insurance exclusions for WLS disproportionately hurts our poorest

and most vulnerable Americans.

Obesity is an especially acute concern for poor people (due in part

to government food subsidy policies that support and promote the

least nutritious, highest calorie foods.) Millions of low- and

middle-income people don't have and can't afford private insurance,

and Medicare and Medicaid -- the government's health care plans for

older/disabled and impoverished patients -- have been reluctant to

pay for bariatric procedures. At the University of California at

, for example, Medi-Cal patients face a 12-year wait for

bariatric surgery, according to Dr. Bruce M. Wolfe, a bariatric

surgeon there. Aggravating the dismal situation, Medi-Cal reimburses

for the procedure at less than a third of the hospital's

cost. " Basically [poor people] are not getting access to the care, "

he said. " They will suffer the consequences of untreated obesity. "

7. For many morbidly obese people, Weight Loss Surgery may be their

ONLY realistic hope for a long and healthy life.

Research has identified several genes (and their corresponding

hormones such as leptin) that seem to be at least partially

responsible for obesity. These genes help regulate appetite and

metabolism. We now have credible evidence that obesity is at least

partially biological in its origins, offsetting the prevalent

misconception that it is primarily a behavioral or psychological

disorder. Obesity is a disease which needs a cure, rather than a

character defect within the individual that warrants condemnation

and requires correction.

Perhaps because of their genetic endowment, people prone to obesity

seem to gain excessive weight easily, while finding it difficult or

impossible to lose it. That's why diets almost always fail and why

WLS is currently the only viable weight loss option for many

morbidly obese people, according to endocrinologist Cummings

of the Veterans Affairs Puget Sound Health Care System. Most people

can lose no more than 5-10% off their " natural " body weight by

exercising and eating wisely. Decades of diet studies show that more

than 90% of people who lose weight by dieting gain it all back

within 5 years. " There are exceptions, but when you are speaking of

general rules, the only people who are able to lose more than 10

percent of their body weight and keep it off are people who have had

gastric-bypass or other bariatric surgery, " according to Cummings.

Our community of Weight Loss Surgery patients and their families and

friends faces a difficult, but surmountable, challenge to create a

society where each person is judged by the quality of their

character, not their weight on the scale, and receives quality and

appropriate medical treatment for their medical needs. WE already

know that covering the costs of surgery is smart, saves money in the

long run, and contributes to our creating a nation that is

compassionate, caring and supportive to people struggling with

obesity. Our job now is to convince the rest of America that

Universal WLS Insurance Coverage – in both private and governmental

health insurance programs – is an idea whose time has finally come.

Each of us has a vital role to play in helping to encourage,

solidify and nail down what is presently merely an emerging trend.

If we educate and inform our circles and communities, and demand

action from our elected representatives, denial of insurance

coverage may soon become as outdated as our wardrobes after we've

used WLS to take off our excess weight.

I encourage you to become a WLS advocate on this issue in solidarity

with all those who are still suffering, and are without hope,

because they are blamed and judged for their excess weight, rather

than supported and assisted in their quest to regain their health.

In my next newsletter, the first of the new year, I will describe a

scenario whereby we can mobilize our community and realize this

dream.

Copyright, © 2003, Glenn Goldberg. All rights