Designation as disease may help on insurance
July 17, 2004
BY PATRICIA ANSTETT
FREE PRESS MEDICAL WRITER
Now that the federal government has declared obesity a disease, more severely overweight Americans are likely to have their insurance pay for stomach-reduction surgery or some weight-loss programs in the year ahead.
The change in Medicare policy, announced Thursday by federal health officials, affects only those people who are morbidly obese -- those who weigh 100 pounds more than they should, or greater. From now on, the federal government will view their obesity as a disease, like cancer.
The new policy, which could pave the way for Medicare reimbursement for surgery or medically supervised weight loss programs, does not pertain to diet-watchers who are trying to drop a single clothes size or two. Those dieters will continue to have to pay out of pocket for weight-loss programs and gym memberships.
But for the severely obese, and those who typically have one or more diagnosed conditions like diabetes or high blood pressure, the eventual savings could be substantial.
Stomach-reducing bariatric surgery, for instance, costs as much $35,000.
Enrollment in hospital weight-loss programs, such as the area's largest one at Beaumont Hospital, which uses specially formulated shakes and nutrition bars, costs $500 a month, typically for a minimum of three months.
"The impact should be considerable," said Dr. Peter McCullough, chief of the division of nutrition and preventive medicine at Beaumont Hospital in Royal Oak.
Medicare recipients should not expect payment changes overnight. First, Medicare will conduct a careful review of the scientific research, most likely to start this fall, to determine whether certain weight-loss interventions like stomach-reduction surgery -- procedures made famous by TV weatherman Al Roker and singer Carnie Wilson -- are safe and effective.
That is likely to leave Medicare patients in a quandary for months.
How soon can they schedule surgery and expect reimbursement? And will Medicare pay for those who had surgery this year, like Millie Williams of Clinton Township.
Williams, 60, is appealing a recent decision by Medicare that refused to pay for the $35,000 operation she underwent in February at St. John Hospital and Medical Center in Detroit.
The surgery "saved my life," said Williams, whose weight has dropped from 401 1/2 pounds to 355. "I've been obese all my life, ever since I was a child," said Williams, a diabetic with high blood pressure. "I tried more diets than I care to mention. This has given me a new outlook."
Some plans already pay for certain types of stomach-reduction surgery or medically supervised weight loss programs if a person fits eligibility requirements and fails to lose weight after a year with a doctor's help.
In Michigan, the Health Alliance Plan, Blue Cross Blue Shield of Michigan and Blue Network, and M-Care, for example, all cover several types of the surgery.
HAP also pays for one-time-only enrollment in multi-disciplinary weight-loss programs offered by physicians, nutrition educators or psychologists for eligible members, said Liz Manasse, public relations coordinator at HAP.
HAP even gives discounts to members with obesity problems at some health clubs and gyms. Discounts vary, but are as much as 60 percent at some clubs, she said. HAP, like most other plans, requires that its members first be able to show that they have failed to lose weight after a year, with a doctor's help.
Another plan, M-CARE, pays for two types of stomach-reduction surgery and discounts on Weight Watcher's programs, M-CARE spokeswoman Sharon Morioka said.
Dr. Jeffrey Genaw, director of bariatric surgery at the Henry Ford Health System, said certain types of stomach-reduction surgery are effective, as shown in studies following patients for a decade or more.
Eighty-five percent of patients maintain substantial weight loss three years after surgery, Genaw said. Complications include deaths in 1 percent of cases after the surgery and a 5 percent combined risk of heart attack, pulmonary embolism, or clots, and bowel obstructions, he said.
"Bariatrics has become much safer than it was in the '70s and '80s."
Dr. Abdelkader Hawasli, director of laparoscopic and minimally invasive surgery at St. John, said that while effective, surgery "is not a pill. It levels the playing field. If a patient doesn't do what's needed to maintain weight, they shouldn't have surgery."
Some organizations and physicians oppose government policies to redefine obesity.
The Washington, D.C.-based Cato Institute, which favors restricting government involvement in health care, predicted any changes will lead to higher health costs for all Americans.
"By treating obesity as a 'disease,' the federal government added a slate of new entitlements to the Medicare program, all of which will be funded by U.S. taxpayers," the institute said in a prepared statement. "Americans who make healthy decisions about nutrition and exercise will soon be subsidizing those who don't, with diet programs (even the best of which fail at rates of 95 percent), diet drugs, and experimental procedures such as gastro-bypass surgery."
Contact PATRICIA ANSTETT at 313-222-5021 or [email protected].