Wrestling With Weight Issues
Many people know how difficult it is to lose weight and keep it off. It can also be expensive, if you count the cost of diet programs such as Weight Watchers or Jenny Craig, fitness club memberships and all the assorted gear and clothes that we buy to help motivate us to exercise. When diet and exercise don’t work, some people turn to medications to alter their metabolism and drop some pounds. And as a last resort--if obesity poses a severe risk to one’s health--some will opt for surgery.
Given obesity’s role in triggering heart disease, high blood pressure, diabetes and other ailments, it’s no surprise that people would expect their health insurance to pick up the tab for treatment. But getting your health insurance to pay for weight-loss treatments is a big “if,” depending on which type of insurance coverage you have and where you live. Coverage is spotty, and many insurers still seem to take the attitude that being overweight is a personal failure of will.
Attitudes are changing--but slowly. In California, one of the most common disputes between consumers and health insurers involves an operation known as gastric bypass surgery, used to treat morbid obesity. The California Department of Managed Health Care, which regulates health plans, reports 86 cases in which patients appealed a health insurer’s decision involving treatment for morbid obesity, a condition defined as someone who weighs at least 100 pounds more than his or her ideal weight. When those 86 cases were sent to an external review board, a panel of independent doctors hired by the state, the patients won 49 of the appeals, an unusually high success rate.
Despite the rulings, insurers are skeptical about the value of some obesity treatments. Aetna-US Healthcare, one of the nation’s largest insurers, largely excludes coverage for obesity surgery, said Jill Griffiths, a company spokeswoman. Employers who provide health insurance for their workers have the option of including obesity surgery as a benefit, she noted.
“There is a fair amount of disagreement in the medical community about when [gastric bypass surgery] is appropriate and when it is not,” said Jim Anderson, a spokesman for Kaiser Permanente. Anderson said that the surgery can be risky and that Kaiser wants to make sure patients have tried all other alternatives. Even so, Kaiser approves hundreds of gastric bypass procedures a year, he said. In at least one case, however, state medical reviewers overturned Kaiser’s denial of a patient’s request for obesity surgery, ruling that the operation was appropriate.
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Insurers are more likely to approve obesity treatments today than five years ago, said Dr. Gary Anthone, director of the bariatric surgery program at USC’s Keck School of Medicine. Attitudes have begun to change as the medical community has begun to consider that obesity is a disease itself, not just a contributing risk factor to other diseases.
Anthone says gastric bypass surgery is appropriate for people who have tried diet and exercise unsuccessfully and who are threatened by the other ailments that can come from obesity, including diabetes, heart disease and sleep apnea. But only as a last resort. The operation has a 1% death rate within 30 days of the surgery. And it means a permanent lifestyle change for patients who will be taking special vitamins and nutrients for the rest of their lives and eating tiny meals.
“We get calls all the time from people who say they want the surgery because they lost 20 or 30 or 40 pounds and gained all of it back,” Anthone said. He invariably refuses their requests. “We tell them diet and exercise--and stress the exercise.”
It’s not surprising that insurers would be reluctant to pay for many weight-loss programs when the most effective treatments, a more healthful diet and regular exercise, do not require a doctor’s involvement. After all, medical care in the United States has long emphasized treatment over prevention. So lots of money is spent on helping people after they have developed diabetes, heart disease or other ailments in which a serious weight problem is a key contributing factor.
Many health insurers have programs that focus, for example, on reminding diabetics to have annual eye examinations or to regularly check their blood sugar and cholesterol. Some insurers provide nurses to work directly with diabetes patients to provide education and encouragement to help them cope with their illness. But these efforts come after the fact, when someone has fallen victim to disease. There is mounting evidence that much earlier intervention could benefit patients’ health while also helping to reduce medical costs.
The American Assn. of Endocrinologists recently declared that “insulin resistance syndrome” is a tip-off that people will develop diseases associated with obesity, such as diabetes, congestive heart failure and sleep apnea. Perhaps as many as one in four adults have the condition. Not all of them will develop diseases, but the condition can be a trigger.
What causes it? Probably a combination of genetic predisposition plus the modern work and social environment. We exercise less and eat out more at restaurants serving hefty portions of food.
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The doctors say they can identify people at special risk long before they come down with costly ailments. They include: sedentary people older than 45. Those whose blood pressure exceeds 130 over 85, whose waistline is 40 or more for a man, and 35 or more for a woman, and whose “fasting” blood sugar reading is 110 or more.
Among ethnic groups, Latinos, Asians and Native Americans face greater risks. With all these risk factors known, health insurance programs shouldn’t wait for people to get sick with obesity-related ailments, said Dr. Daniel Einhorn, medical director of the Scripps Whittier Institute for Diabetes in La Jolla. He believes that insurers should pick up the tab for some people who enroll in weight-loss programs or who join gyms and health clubs.
“It’s not about cosmetics, not about looking better, but about medical disease with medical consequences,” Einhorn said.
Just as health insurers have helped to validate some alternative medical treatments, such as acupuncture, by offering these therapies as a benefit to members, the same might be true of weight-loss programs. If insurers covered weight-loss programs or gym memberships, it would send a signal that such activities are important, Einhorn said.
As obesity gets increasing attention as a vital national health issue, change is likely. Earlier this year, New York Gov. George Pataki signed legislation that orders state health officials to review information about obesity and its treatments and devise a plan to keep New Yorkers from getting too fat. One possible strategy: a mandate that insurance companies pay for members to enroll in weight-loss programs, said Guy Velella, a Republican state assemblyman who co-sponsored the legislation.
