Health plans don't cover weight loss surgery

WASHINGTON (AP) — Like 78 million other Americans, MaryJane Harrison is obese.

And like many critically overweight Americans, Harrison cannot afford to have weight loss surgery because her health insurance doesn't cover it. The financial burden makes it nearly impossible for her to follow the advice of three physicians who have prescribed the stomach-shrinking procedure for Harrison, who is four-feet, 10 inches and weighs 265 pounds.

Harrison's health insurance plan, provided by UnitedHealth, excludes coverage of any surgical procedures for weight loss. As a result, she and her family are trying to raise $15,000 to pay for the surgery that she thinks will save her life.

"I am now 53 and I don't think I'm going to live to be 55," says Harrison, 53, who lives outside of San Antonio and has tried for years to lose weight through dieting and exercise. . "When you feel your health deteriorating this fast, you know it."

UnitedHealth said it can't legally comment on Harrison's health plan unless she signs a privacy waiver. But Harrison declined to sign one due to concerns about how the company might use the information.

Harrison's case underscores a surprising trend: While the number of obese Americans persists at record levels, the number of patients undergoing weight loss surgery hasn't budged in a decade.

Last year, about 160,000 U.S. patients underwent weight loss surgery — roughly the same number as in 2004. That's only about 1 percent of the estimated 18 million adults who qualify nationwide for the surgery, according to the American Society for Metabolic and Bariatric Surgery.

"If we were talking about breast cancer, no one would be content with having only one percent of that population treated," says Dr. John Morton, professor of surgery at Stanford University. "Yet if you look at the impact of obesity on life expectancy, it's by far one of the most dangerous conditions we have in public health."

Surgeons blame a combination of factors for the stagnating numbers, including the economic downturn and a social stigma against resorting to surgery to treat weight problems. But insurance coverage is the largest hurdle, they say.

Nearly two-thirds of health plans sponsored by employers don't cover weight loss surgery, which can cost between $15,000 and $25,000. Those that do often mandate that patients meet a number of requirements, including special diets and psychological evaluations, before they can get the procedure covered.

And early signs indicate many of the same challenges seen in the private market have carried over to the new, state-run insurance exchanges that are part of the health care overhaul: Only 24 states require insurers to cover weight loss surgery for patients. And when the procedure is covered, many plans require patients to pay up to 50 percent of the cost out of pocket.

Insurers have said for years that bariatric surgery should only be used as a last resort, hence the many preliminary requirements and evaluations.

"All major surgeries are risky. This one is life altering, and if there is an approach that's less invasive and less risky for the patient, you want to try that one first," says, Susan Pisano, a spokeswoman for America's Health Insurance Plans, an insurance industry trade group.

But the insurance hurdles are pushing up against new medical guidelines urging doctors to more aggressively address obesity, including referring patients for surgery. Guidelines issued in November by the American Heart Association, the American College of Cardiology and the Obesity Society call on doctors to calculate a patient's body mass index — an estimate of body fat based on weight and height — each year, and recommend surgery for those who face the most serious health problems.

More than a third of U.S. adults are obese — defined as someone with a BMI of 30 or higher — and that's been the case since the middle of the last decade. Weight loss surgery is recommended for those with a BMI of 40 or those with a BMI of 35 who have other risk factors for heart disease such as diabetes or high blood pressure. A 5-foot-9 person would be obese at 203 pounds.

The most popular procedure is gastric bypass, which involves stapling off a small pouch from the rest of the stomach and connecting it to the small intestine. Patients eat less because the pouch holds little food, and they absorb fewer calories because much of the intestine is bypassed. Another procedure called gastric banding places an inflatable ring over the top of the stomach to restrict how much food it can hold.

The latest long-term studies show that the typical patient loses about 30 percent of their excess weight with the bypass procedure and 17 percent with the band after three years. That compares with weight loss of just 2 to 8 percent with diet and lifestyle changes. Researchers estimate the initial costs of surgery are recouped within 2 to 9 years, as patients cut down on prescriptions, trips to the doctor and emergency hospital care.

On top of all that, two groundbreaking 2012 studies suggest bypass surgery can reverse and possibly cure diabetes.

But only 37 percent of health plans that are sponsored by employers cover weight loss surgery, according to benefits consulting firm Mercer. At large corporations, the coverage rate is higher at 58 percent, but most Americans work for smaller businesses.

The benefit is often hardest to find in states that have the highest levels of obesity, such as Mississippi and Arkansas, where less than 25 percent of employers cover weight loss surgery. Both states have obesity rates over 34 percent, the highest in the country.

When insurers cover weight-loss surgery, it often comes with a number of requirements. Patients must first pass a psychological evaluation, showing that their obesity is not due to an eating disorder or other mental problems that can contribute to weight gain. Most insurers then require six to 12 months of doctor-supervised dieting, in which patients keep a journal of their eating habits and visit their physicians for regular weigh-ins and check-ups.

Surgeons say many patients are unable to keep up with the appointments and never qualify for surgery — a fact which they say helps insurers control costs.

"Half of the people I see drop out because they can't commit to the time away from their jobs," says Dr. Carson Liu, a bariatric surgeon in Los Angeles. "Insurers know that 50 percent of patients will drop out."

America's Health Insurance Plans, the industry trade group, says companies are simply following federal guidelines that recommend surgery for "carefully selected patients" who have failed other methods.

But the National Institutes of Health guidelines insurers point to were issued in 1998, when weight loss surgery was still an emerging field with serious risks. At the time, about 1 in 100 patients died in surgery. The death rate today is 1 in 1,000, making it as safe as a hip replacement, according to surgeons.

Weight loss surgery is now nearly universally accepted in American medicine. Still, the approach is not an easy fix.

Patients must dramatically cut the amount and variety of food they consume, otherwise they will experience cramps, diarrhea and other unpleasant side effects. Additionally, about 20 percent of patients who get the gastric band regain nearly all of their weight within three years — a fact that has led to a decline in popularity for that procedure. Only a small percentage of bypass patients regain their weight.

Doctors who support weight-loss surgery warn that it's not a cost-effective solution for America's obesity epidemic in the long run. Dr. David Katz of Yale University's Prevention Research Center says a smarter approach lies in educating children and adolescents early on about healthy eating and exercise habits.

"We created the problem of severe obesity and we have to deal with it, but scalpels aren't the only solution," he says. "There is a better way."

But for Harrison, who takes 11 medications to control conditions related to her weight, surgery increasingly seems like her only hope.

"I spend every day worrying about how much time I have left. Everything hurts and my health issues get worse all the time," Harrison says.

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