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OCALA, Fla. -- Ryan Wachtler has a dream: To return to Walt Disney World and walk around the vacationland like the many other tourists who visit the Orlando theme parks every year, "just like everyone else." What keeps him from doing so is his heft. At 19, he weighs in between 350 and 360 pounds, and his knees - still what many would consider young - are shot. He's supposed to walk on crutches but prefers not to, and he faces life in a wheelchair. He can take only a few steps without severe pain in his knees.
A few months ago Wachtler decided to chuck years of conventional ways of weight loss - "I've tried everything. You name it, I've done it" - and seek gastric bypass surgery, in essence surgically reducing his stomach to the size of a walnut, like thousands of others around the United States have done.
"I just want to do everyday things without a struggle, without the pain," he said. "I'd like to just toss a baseball with my friends." But the bariatric surgery was denied by Blue Cross Blue Shield and currently is lingering in appeal. Wachtler said Blue Cross Blue Shield told him the surgery was "not a medical necessity, it was cosmetic.
From my point of view, it's medically necessary." Soon, medically necessary or not, thousands of the morbidly obese like Wachtler won't even get to appeal denial of coverage for the weight-loss procedure that's fast gaining popularity. Insurers are quietly removing bariatric surgery as a covered item in their policies.
The latest is Blue Cross Blue Shield of Florida, the state's largest health insurer. On Feb. 12, Blue Cross Blue Shield announced in a press release it is discontinuing gastric bypass surgery coverage as of Jan. 1, a move that gained public attention earlier this week.
UnitedHealthcare and AvMed also have eliminated bariatric coverage from most group plans.
One local bariatric surgeon's office claimed Tuesday Blue Cross Blue Shield already is "dragging its feet on requests for coverage already in the pipeline," an allegation the insurer denied. Another claimed insurers keep "adding more steps" the morbidly obese need to satisfy to assure coverage.
Blue Cross Blue Shield cites a growing acceptance of stomach stapling, fueled by public successes in celebrities like Al Roker, Carnie Wilson, Sharon Osbourne and others, as one reason for ending coverage of "a high-risk surgery with questionable results." "The popularity is leading to more people to seek the procedure," Dr.
Barry Schwartz, company vice president for care and network management, said Tuesday.
Last year there were more than 100,000 gastric bypass surgeries performed nationwide, as many as 1,000 of them here in Ocala by Dr.
Muhammad Jawad, a local bariatric surgeon for 20-plus years, and Dr.
Todd Overcash. In 2002, there were only 63,000 nationwide, according to statistics from the American Society for Bariatric Surgery. In 1996, when health insurers began paying for the procedure, there were 23,100.
Bariatric surgery, in brief, involves surgically sealing off most of the fist-sized stomach, severely restricting how much food a patient can eat. Weight loss usually is quick and drastic; 100 pounds in a year is not unusual. The National Institutes of Health approved the procedure in 1991 and again in 1996.
Patients must be more than 100 pounds over clinically desirable weight or have another dangerous condition like diabetes, hypertension or sleep apnea. It's supposed to be a last-resort effort.
"We have a great concern about the efficacy of the procedure," Schwartz said. Moreover, he added that Blue Cross Blue Shield, which covers 3.4 million Floridians, "is concerned that this surgery is being pushed more and more in teens and children" and is being performed by surgeons with inadequate training and experience. Surgery advocates concede untrained surgeons is a valid concern, but Dr. Jawad said, "just weed out the inexperienced ones, not everybody. This is not quality care.
"I'm afraid this is will affect the health and longevity of life for many patients," he added.
Schwartz said the insurer's statistics show three in 1,000 patients die, while 20 percent require another surgery and 30 percent develop long-term nutritional deficiencies "that can run into costs of $100,000 or more.
"With the costs going up and complication rate about 50 percent, it's just not a wise expenditure," he added.
Without insurers picking up the cost, most morbidly obese patients may have to do without the surgery. An average cost is about $20,000 to $25,000, though it can be as high as $40,000 in larger metropolitan areas. Schwartz said those unable to pay themselves can lose weight through "exercise and diet. There is nobody who will not respond to that." John Lull faces that very scenario. At 44, he weighs 350 pounds and faces life-threatening conditions. He wants to be around to watch his five children grow, but his request for bariatric surgery was rejected by his previous group insurance because he "was not old enough and not big enough." "We switched to Blue Cross, but the doctor's office isn't even going to send in the papers," the Ocala man said. "I guess I'll just have to do without. What else can I do?" For many like Lull, the surgery can be "a matter of life or death," Overcash said.
He disputed Blue Cross Blue Shield's contention that the surgery is risky, saying the risk is less than one percent. Further, the monthly savings in prescription costs and food bills for each successful patient range between $200 and $500.
"They used to say open-heart surgery was risky, that liver transplants in children was financially not profitable. But look at the lives saved," Overcash said.
"If insurers were to say these types of procedures were too risky (and) they weren't going to cover them anymore, what do you think would happen? They don't because it would be a political mine field.
"But where will it stop? I think this is a slippery slope of discrimination," Overcash added. "Is this the first step toward health rationing?" Meanwhile, Wachtler's dad, Jeff Wachtler, said he will do "whatever it takes" to be sure his son gets his surgery. "The kid needs a break. If I have to sell my house, that's what I'll do. This is my son - I'll get him to Disney World." (Rick Allen writes for the Star-Banner in Ocala, Fla.) Editor Notes: NONE
c.2004 NYT Regional Newspapers