Gastric surgery: Bill would mandate that insurance pay

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Weighing 386 pounds, Jeff Haaga believes he will be dead soon without gastric bypass surgery.

"My doctor said, 'You're going to die if you don't lose weight,' " the 52-year-old West Jordan man said.

His insurance company, SelectHealth, an Inter- mountain Health Care company, has denied his appeals for the company to pay for the operation. And he fears going ahead alone.

"If I paid for it myself, they don't cover any complications from the surgery," he said. "It could bankrupt someone like me if I got pneumonia or something else related to the surgery."

To help people like Haaga, Rep. Steve Mascaro, R-West Jordan, has drafted a bill mandating that insurance companies cover gastric bypass surgery for morbidly obese Utahns.

Haaga, whose siblings also have struggled with being overweight, urged Mascaro to sponsor the legislation. His argument: Paying for the $17,975 surgery is cheaper in the long run than covering care for all the health problems that can accompany obesity, including heart attacks, strokes, knee and hip replacement surgeries and diabetes management.

He plans to testify before the Legislature, which convenes Jan. 15.

"Our state laws have not defined morbid obesity as a medical disease," Mascaro said. "Medicare covers gastric bypass procedures in certain situations. People are having a devil of a time getting surgery that their doctors say will cure morbid obesity."

In February, the Centers for Medicare & Medicaid Services (CMS) expanded Medicare's national coverage of bariatric surgery for beneficiaries.

"Bariatric surgery is not the first option for obesity treatment, but when performed by expert surgeons it is an important option for some of our beneficiaries," CMS Administrator Mark McClellan announced then. "While we want to see more evidence on the benefits and risks of this procedure, some centers have demonstrated high success rates and we want to ensure access to the most up-to-date treatment alternatives for our beneficiaries."

About 100,000 people die a year due to obesity related diseases, according to the Centers for Disease Control and Prevention.

Joe Nadglowski, president of the Obesity Action Coalition in Tampa, Fla., said people are dying while fighting their insurance companies to get weight-loss surgery.

"There is a bias when it comes to obesity treatment," he said. "We need to prevent future generations from becoming obese, but we also have to take the approach that we need to treat obesity as well."

The trend of states mandating payment for the surgery is growing, including Maryland and Indiana.

Under Mascaro's H.B. 225, morbid obesity is determined by a certain body mass index. BMI is a ratio of weight to height, in which 24.9 and under is considered normal, 25 to 29 overweight and 30-plus obese.

Mascaro suggests defining morbid obesity as an index of 40, or as 35 or higher when combined with a medical condition such as hypertension, cardiopulmonary problems, sleep apnea or diabetes.

"We obviously feel that more coverage should be available," said Darren Cluff with Rocky Mountain Associated Physicians in Salt Lake City, which specializes in bariatric operations. "For cosmetic reasons it probably shouldn't be covered. But for patients with a life-threatening comorbid condition," it should be.

Patients come to Utah from other states and even other countries to get the procedure done because it is cheaper here than in other places, Cluff said.

Haaga's goal is to get SelectHealth, one of the state's largest insurance companies, to change its policies. He thinks if the medical giant gets onboard, other companies will follow.

SelectHealth has covered gastric bypass surgery since 2005, but it is an optional benefit that adds to premiums. Most employers don't opt to pay the extra money.

Starting this year, the company is offering free nutrition counseling and group 12-week classes that teach people how to eat well, curb cravings and exercise.

"Beginning Jan. 1, we've added coverage for medical treatment and nutritional therapy to target obesity specifically," said spokesman Jason Burgess.

Jeff Whipple, spokesman for Regence BlueCross BlueShield of Utah, said the mandate is of concern.

"We offer [gastric bypass surgery] to our large employer groups as an option," Whipple said. "It's up to the employers to choose what benefits they offer. Mandates like this can have a negative effect, because they can price employers out of offering health benefits to their employees. Legislation like this is often well intended, but it can cause economic problems down the road."

Kelly Atkinson, executive director of the Utah Health Insurance Association, said the legislation would cause the most trouble for small businesses. And he is concerned that the surgeries can have costly complications, and even result in death.

"When you have a piece of legislation like the obesity bill you impose it on the smallest businesses," he said, "the businesses that are already struggling to pay for insurance."


body mass index

* BMI is a ratio of weight to height.

* The formula for calculating it is ''BMI = Weight in pounds divided by height in inches squared x 703''

* The procedure was developed in the 1960s based on the weight loss observed among patients undergoing partial stomach removal for ulcers, according to the American Society for Bariatric Surgery.

* The stomach is converted to a small pouch that holds limited amounts of food and liquids. According to the society, the number of procedures increased from about 16,000 in the early 1990s to more than 103,000 in 2003.