Should Gastric Bypass Be Covered By Insurance?

In an article in the Toronto Star, a number of patients who have had bariatric or weight loss surgery. Some of these people had their surgery covered by health insurance; some have not. Those who have had their surgery covered are considered to have a chronic disease (or multiple chronic diseases) for which the surgery is considered the "cure". 

What is bariatric surgery? In general, these surgeries reduce the volume of the stomach to a fraction of its current volume, and often bypass part of the intestine as well. There are several versions of what has generically become known as "gastric bypass": in fact, you could get one of four surgeries, including roux-en-y gastric bypass, mini-gastric bypass, duodenal switch, or adjustable gastric band surgery. The idea is to physically limit what the patient can eat and absorb.

This is serious surgery, but it is sometimes suggested as a cure of last resort for the morbidly obese. To be considered morbidly obese, you have to have a Body Mass Index (BMI) of more than 40. (A healthy BMI is 25 or less.)

The patients profiled are all from Ontario, Canada. Ontario has its own provincial medical insurance, which covers all residents after an initial waiting period. If you live in Ontario, you apply and you get insurance; it's pretty much that simple. The plan is called the Ontario Health Insurance Plan or OHIP. You do have to pay a medical insurance premium through your taxes of as much as $300 a year, but that's the maximum. For this small amount of money, you get medical insurance that includes doctor's visits, medical stays and surgeries -- as long as these things are OHIP approved. Generally, a procedure is either approved or not; there' s no such thing as a co-pay or deductible. By US standards, this is high end insurance.

Some of these patients had their surgery approved by OHIP and fully paid for, but others were left out in the cold. This is a challenge for those who want the surgery. In fact, I've blogged on how to get your bariatric surgery paid for by your insurer, because there are patients out there waiting and wanting this surgery.

But is obesity surgery really elective or essential? Should health insurance cover this surgery?

The patients profiled by this article all say yes. So do some of the doctors. Dr Laz Klein of Humber River Regional Hospital says that we have to look at obesity as a disease. "We have no problem treating gallbladder problems or cancer. We have to treat them all the same," says Laz. He also says that surgery works better for the morbidly obese than other weight lose methods. Ultimately, the argument is that it is much more expensive to continue to treat a morbidly obese patient than to help them get the surgery, and get them down to a normal weight again.

The other argument is effectiveness. Bariatric surgeries have a much better success rate than the best diets, which only help 2 to 3 percent of overweight people to lose weight permanently. That alone is a significant factor for many health professionals.

Another problem for health professionals is that health care associated with obesity is estimated at a staggering $1.6 billion (Canadian) per year in Ontario alone. How can you get these costs down unless you get the weight off the patients? The answer is: you can't. The weight has to come off.

However, bariatric surgery is just a first step. The patient will forever have to carefully manage what they eat. This includes high quality nutrition plus vitamin and mineral supplements in order to keep healthy. The surgery is just one of a set of tools that the patient will have to use in order to reach their goal weight.

It's a serious decision to have one of these operations. About 1 in 200 patients will actually die from the surgery, due to complications. However, doctors point out that a death from overweight is much slower and often as painful, and that your chances of dying from a complication of overweight is 1 in 10.

Should insurance cover this surgery? From the long term perspective of the cost of treating an obese patient, the answer would seem to be yes. However, surgery needs to be coupled with support after the surgery, as patients learn to live with their new eating restrictions and deal with the (often) emotional issues that got them overweight in the first place. In fact, I recently blogged on my own weight loss journey and the cost of insurance; while I'm not morbidly obese, I am over my healthy BMI. Even though I have a lot less to lose than some, I have definitely had to put together a set of tools, and the emotional aspect is a really important part.

Here's the rub for many patients who are struggling with really severe weight problems: from the standpoint of the (initial) expense to insurance companies, most insurers would answer no to paying for these surgeries. Follow up care is also difficult to get covered. However, their policyholders are getting bigger. They are also getting older. As our population ages, and weight becomes a more significant challenge for aging bodies while those same bodies become less able to tolerate a surgery, we could see insurance rates escalate. Treating obese patients, without surgery, is not a "no cost" solution.

Given the epidemic of weight problems in our society, we need to tackle the issue of obesity now, and give people the tools they need to manage their health. This should include helping to pay for such surgeries, since we'll all see the benefit in our insurance premiums in the long run.

Monique L. Attinger 

Posted by John on June 15,2007 at 7:52 AM

Nice post! You have said it very well. Keep going.

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