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Medicare panel 'favorable' toward weight-loss surgery

Posted - Nov. 9, 2004 at 6:40 a.m.



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As America comes to terms with ever-increasing weight gain in its population, votes by a Medicare coverage advisory committee last week may have broad implications for what treatments are available to patients nationwide.

Meeting in Baltimore, the expert committee voted on how effective bariatric, or weight loss, surgery was in comparison with non-surgical medical management.

''The overall sentiment of the members of the committee was favorable with respect to bariatric surgery,'' says Henry Buchwald, a surgery professor at the University of Minnesota, emphasizing he was giving his impression and not speaking for the committee.

In July, Medicare announced it would begin to cover obesity itself as a disease, rather than only covering so-called ''co-morbidities,'' obesity-caused diseases such as diabetes and high blood pressure.

As soon as an official request is made for the government insurer to pay for the surgeries -- and several groups are planning to do so within the next two months -- the Centers for Medicare and Medicaid Services will begin a nine- to 12-month decision-making process, aided by, but not limited to, the panel's input.

Bariatric surgery is generally done on patients who are at least 100 pounds over their healthy weight. It's estimated that there are 4.5 million morbidly obese people in the USA.

Holding up score cards like Olympic judges, the panel gave mostly threes, fours and fives on a one-to-five scale when asked whether there's good scientific data showing that the increasingly popular surgery produces important health benefits.

The panel also said the evidence shows that such stomach-reduction surgeries have a positive impact on long-term survival rates and reduce short-term mortality compared with non-surgical medical management.

''Although the evidence for applicability in individuals over 65 is not as voluminous as for patients under 65, the available evidence is equally compelling,'' Buchwald said.

While the panel does not set Medicare coverage policy, its findings are considered important beyond the government insurance system. When Medicare makes a coverage determination, private insurers often follow suit, though no law requires them to. For example, when Medicare decided to cover organ transplants, insurers that had balked and called the procedures experimental quickly began to pay for them.

''The kinds of exclusions that private insurers have tend to disappear over time once Medicare starts covering them,'' says Greg Herrle of the health care consulting firm Milliman in Milwaukee.

This will be important because the demand for gastric bypass surgeries, which reduce the size of the stomach and in 80% to 90% of cases cause large and permanent weight loss, is growing. The weight loss is almost always accompanied by a lessening or disappearance of weight-related illnesses such as diabetes and high blood pressure.

Private insurers are all over the map in terms of whether they will cover the procedures, which typically cost around $25,000.

While the short-term impact is higher costs, over the long term the surgeries might lead to savings, says Herrle.

A well-regarded study in Canada found that the cost of the surgery is paid back in 3 years, because of the high medical costs associated with morbid obesity.

The panel also found that doing the surgeries laparoscopically, via instruments inserted through tiny slits rather than by opening up the abdomen, was almost equally safe. While more demanding on the surgeon, laparoscopic surgery typically allows patients to recover much faster. But a technology assessment panel done by insurers last year suggested there wasn't enough information to support it.

''As a result, several insurance companies have decided that laparoscopic gastric bypass surgery is experimental and will not cover it -- and this panel clearly disagreed,'' says Harvey Sugerman, president of the American Society of Bariatric Surgery and a guest panelist.

The insurance industry is mostly concerned with patient safety, says Susan Pizano with America's Health Insurance Plans, an industry trade association.

''We don't want any patients to be put at risk,'' she says.

To see more of USAToday.com, or to subscribe, go to http://www.usatoday.com

© Copyright 2004 USA TODAY, a division of Gannett Co. Inc.

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