Apr. 15--The two-page report to Blue Cross and Blue Shield of Illinois is a record of failure: 13 diets tried for more than two decades, to no effect. Jeff Flanzbaum, who started a five-year Weight Watchers regimen at age 8, is now 378 pounds at 34 and paying for it with his health.
At night, the Algonquin man's sleep apnea is so bad he has to use a mini-respirator to breathe. In December, he learned he was severely diabetic. Having watched his obese father die of a heart attack at 42, Flanzbaum decided in January to have stomach-reduction surgery "to try and save my life."
That's when the run-around began with Flanzbaum's health insurer, which has yet to grant approval for the procedure.
Flanzbaum is one of an increasing number of obese people across the country running into a growing controversy over stomach-reduction surgery. Increasingly, insurers are questioning the procedure on the grounds of its steep costs, relatively high complication rates and the growing number of inexperienced doctors offering the lucrative procedure.
Some companies, such as United HealthCare, Blue Cross and Blue Shield of Florida and Nebraska, Humana and four managed care plans run by Cigna HealthCare, have dropped--or are dropping--coverage for the surgery in the last year and a half, citing safety concerns. In Massachusetts alone, three patients died after their stomachs were surgically shrunk in the last year.
Physicians and patients also charge that other insurers are erecting bureaucratic hurdles to obtaining the procedure.
"Insurance companies' criteria for these surgeries are a moving target, and they're putting up more barriers and roadblocks," said Dr. Robert Kushner, director of the Wellness Institute at Northwestern Memorial Hospital.
In Flanzbaum's case, two letters from Blue Cross and Blue Shield of Illinois indicate the health plan judged that hospital care for his obesity was necessary. But stomach surgery was another matter. Although Flanzbaum should be eligible for the procedure according to National Institutes of Health guidelines, and although his doctors recommended the procedure, he still can't get a firm yes or no from the health plan.
Meanwhile, his March 24 surgery date came and went.
The debate over stomach-reduction surgery highlights an emerging medical dilemma. Even as obesity threatens to overtake tobacco as the No. 1 source of preventable deaths in the United States, with 400,000 lives lost every year, employers and health plans are increasingly worried about the safety, effectiveness and cost of obesity-related treatments.
"Employers are very concerned," said Larry Boress, executive director of the Chicago Business Group on Health. "The bottom line is that as we start covering more and more of these procedures and interventions, it's going to raise medical costs, which many employers already can't afford."
Stomach-reduction surgery is particularly contentious because it's expensive and exploding in popularity.
Once a little-known procedure used as a last resort, the number of surgeries is expected to top 150,000 this year, a huge increase from 16,200 a decade ago, according to estimates by the American Society for Bariatric Surgeons.
Eyeing an enormous reservoir of potential patients, physicians are retraining themselves to do the surgeries and hospitals are setting up special surgery suites and marketing services aggressively.
"This has become the Cadillac of non-invasive surgeries," said Kushner, who is also a professor of medicine at Northwestern University.
The complex surgeries, which cost as much as $30,000, involve stapling the stomach or putting a band around it to make it smaller--about the size of a chicken egg--and harder to digest large amounts of food.
Complications are common and include gastrointestinal leaks, internal bleeding, blood clots, wound infections, nutritional deficiencies and respiratory failure.
"We are very concerned that hospitals and doctors who have very little experience are doing this difficult and very high-risk surgery," said Barry Schwartz, vice president of care for Blue Cross and Blue Shield of Florida, which is discontinuing coverage for the surgery at the end of this year.
The bariatric society has scheduled a meeting in May to evaluate how to ensure quality and safety. It is planning to set up a "centers of excellence" program later this year, officials said. The National Institutes of Health also has embarked on a five-year study of the surgeries.
According to NIH guidelines issued in 1991, adults who have a body mass index of 40 or greater should qualify as candidates for the surgery. About 8 million Americans fall into this "morbidly obese" category. Body mass index is a ratio of height to weight.
Adults with a body mass index of 35 or greater who have accompanying medical conditions such as diabetes -- a group that encompasses 23 million Americans -- are also candidates, the NIH said.
The usual prescription of "good diet and more exercise" doesn't work most of the time for this severely overweight population, experts say, leaving surgery as the only real option for many.
Proponents argue the investment is worth the expense. Dr. Walter Pories, past president of the American Society for Bariatric Surgery, followed 608 patients for 14 years and published the results in 1996.
His patients' mean weight loss over 14 years was 107 pounds. Of those with diabetes, 83 percent went into full remission after the surgery. Half of those with hypertension saw their blood pressure return to normal.
"Imagine there were a new pill with those kinds of results. Would you say only 100,000 or 200,000 out of millions of people should get it?" asked the surgeon, who has been practicing stomach-reduction surgery since 1978.
Dr. David Weichers, medical director for United HealthCare of Illinois, said "there are no hard numbers" indicating the investment in surgery is worth it over the long run in saved medical expenses. United HealthCare, which has 800,000 members in Illinois, has phased out coverage for stomach-reduction surgery in its standard plans throughout the country over the last two years.
Dr. Constantine Frantzides, director of minimally invasive surgery at Evanston Northwestern Hospital, was prepared to operate on Jeff Flanzbaum in March, before Blue Cross and Blue Shield of Illinois held up approval for the operation.
"This young man is 200 pounds overweight, with a [body mass index] of 45.2. He has severe diabetes and sleep apnea. If he doesn't have this surgery, he's going to become sicker and lose years of his life," Frantzides said.
"Obesity kills 400,000 people a year and yet you have major insurance companies dropping treatment for this disease? What could they possibly be thinking?" he asked.
The chief medical officer for Blue Cross and Blue Shield of Illinois, Dr. Stanley Borg, would not comment on Flanzbaum's case.
"Our job is to ensure... that health care is used appropriately," Borg said, noting that the health plan does cover stomach-reduction surgery for some members. For patients to be eligible, the insurer requires they be in a "supervised weight loss program," including nutritional education and dietary counseling for at least six months, he said, as patients will need to alter their eating habits permanently after the operation.
"This is major surgery. There is an expectation that an individual must be able to follow the program," Borg said.
Flanzbaum has been told all his life that his obesity reflects a failure of will, and he is tired of the "just do it" approach.
"This surgery is a last resort for me," he said. "Right now, I'm convinced it's the only thing that will save my life."
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