Dr. Ted's Home Page Site Additions Invisalign Info Menu Orthodontic Jaw Wiring Arrange a Consultatation Lingual braces
Other Perils of Overweight; Insurers Balk at Bariatric Operations,
By MILT FREUDENHEIM
One Alternative: A Ring That Squeezes the Stomach
By BARNABY J. FEDER (NYT)
The success stories of weight-loss surgery have been numerous and widely
reported. Dangerously overweight patients -- both the famous and the
unknown -- have lost hundreds of pounds, shown in before and after
pictures. Many overcame life-threatening weight-related diseases.
And as demand soared for new types of weight-loss surgery, known as
bariatric surgery, hundreds of general surgeons took quick courses and
started performing the procedures. The number of doctors rose rapidly, to
more than 1,300 now from a few hundred in the early 1990's.
But after several years in which the surgery was seen as the last best
hope by many obese people, a growing array of scientific data shows that
the risks are greater than patients realized. One new study reported that
almost one in 5 patients had complications after surgery. For one in 20
patients, the complications were serious, including heart attacks and
strokes. Another recent study said the mortality rate for the most common
type of bariatric surgery, gastric bypass, was one in 200 -- a rate higher
than for coronary angioplasty, which opens blocked heart vessels.
For thousands of patients, the weight-loss surgery has eliminated
debilitating diseases and improved the quality of life. But the threat of
malpractice lawsuits against doctors and hospitals, as well as the
reluctance of health plans to cover the surgery costs, is creating
difficulties for people now seeking treatment.
With an estimated one-third of American adults classified as obese --
based on a body mass index of 30 or higher -- nationwide spending for
weight-related conditions and associated economic losses is at least $117
billion a year, according to the National Institutes of Health.
Weight-control products and services, including drugs, diet and exercise
programs as well as the bariatric surgery, came to $15.2 billion in 2003,
the Fredonia Group, an industrial marketing firm, said. Patients and their
insurers spent more than $3.5 billion last year for 145,000 bariatric
procedures at an average of $25,000 each, according to the American
Society for Bariatric Surgery, a professional group. But complications can
raise a patient's costs to $100,000.
With the number of candidates for the operations increasing, the number of
procedures is expected to continue to grow, if more slowly. Some
malpractice insurers have dropped bariatric coverage, and some surgeons
have stopped performing the operations rather than pay sharply higher
insurance premiums. Now, health plans are scrambling to set up networks of
experienced doctors and hospitals with high standards and good results.
For some patients, that will mean traveling further for the surgery.
Insurers are already requiring anyone seeking the procedure to undergo a
lengthy regimen of dieting, exercise and psychological counseling before
getting coverage.
Doug S. Hess, a surgeon in Bowling Green, Ohio, said he decided to retire
rather than pay $300,000 a year to protect himself against legal costs.
His son, Douglas W. Hess, also a surgeon in Bowling Green, gave up
bariatric procedures, too. ''I can't afford to do bariatric surgery,'' he
said. ''The malpractice premium is a big jump up.''
Andrea Carrero, a New Jersey longshoreman's wife, paid for her surgery out
of pocket last November after her Cigna health plan insisted on
prerequisites she saw as delaying tactics. She said the plan refused to
approve the surgery, although her doctors sent letters saying she was
''extremely obese and had hypertension, severe depression, edema, skin
abrasions and sleep apnea.''
Mrs. Carrero said Cigna required ''six months of planning'' before a
bariatric procedure. ''I fought them,'' she said. ''In that six months,
you can have a heart attack.'' Mrs. Carrero added: ''I've been dieting
since I was 8 years old. This is a disease; it's not just because you like
to eat. Dieting doesn't work. I lost 300 pounds on my own and gained it
back.''
A spokesman for Cigna, Wendell B. Potter, declined comment on Mrs.
Carrero's case, citing federal privacy laws. But he said, ''Given the
significant risks associated with bariatric surgery, attempts to manage
weight using other methods are considered necessary'' before surgery is
approved.
Elliot Goodman, the lead bariatric surgeon at Beth Israel Medical Center
in New York, said Mrs. Carrero's procedure was effective. She has lost
more than 90 pounds and her sleep apnea and high blood pressure are gone.
At least five million adults are candidates for the surgery because of
weight and weight-related conditions like heart disease, diabetes and
sleep apnea, according to standards set by the National Institutes of
Health.
Almost one in 20 patients (4.8 percent) had serious cardiovascular
complications after surgery -- heart attacks, stroke or ''severe'' high
blood pressure -- according to a study by RAND, the California research
center, in the Annals of Internal Medicine last month. A study in The
Journal of the American Medical Association in October said the death rate
was one in 200 within 30 days after a gastric bypass.
Sixty-four percent of large employers, those with 10,000 or more workers,
cover bariatric procedures, according to a survey by Hewitt Associates, a
benefits consulting firm. Smaller employers are less likely to provide the
coverage.
But malpractice insurance companies say that covering them is generating
losses.
The largest malpractice insurer in New York, the Medical Liability Mutual
Insurance Company, recently notified surgeons that it would end all
coverage for bariatric surgeons on July 1, unless the state insurance
department approved a 50 percent increase in premiums. The insurer, known
as Mlmic, stopped accepting new applicants for this coverage last year. It
had a ''loss ratio on bariatric coverage of 400 to 600 percent,'' Edward
Amsler, a vice president, said.
Paresh Shah, a bariatric surgeon who moved to Lenox Hill Hospital in
January from the Lahey Clinic in Massachusetts, said he was rejected by
Mlmic and two other insurers, ''even though I had no lawsuits, no
judgments, no settlements'' in five years as chief of obesity surgery at
Lahey.
He was forced into the state insurance pool for doctors who cannot get
insurance. His premium there was $170,000, more than $100,000 higher than
his colleagues were paying. ''It has a very chilling effect,'' he said.
If regulators approve new rate increases, the premium for bariatric
surgeons in Manhattan would rise to $93,000 from $62,000 now, and to more
than $120,000 in Nassau and Suffolk Counties.
Most malpractice lawsuits are settled without publicity, but $1.6 million
was awarded to the family of Tracey Mayes, a 39-year-old school district
employee in a California case that went to trial two years ago. She died
from complications 62 days after a stomach-stapling surgery procedure in a
Pasadena hospital, said Bruce Fagel, a physician who was her lawyer.
In a current case, Glennalee Smock, 65, a retired city employee of Long
Beach, Calif., suffering complications after a gastric bypass procedure,
has been hospitalized and unable to get out of bed for almost two years,
her daughter Lisa said. The family is suing the hospital and doctors.
Like Mlmic in New York, other malpractice insurers are raising rates and
reviewing the qualifications of each bariatric surgeon and hospital.
''Surgeons will get out of the specialty and others may not take on more
difficult cases because they don't want to be exposed to the liability,''
Dr. Goodman said.
Restrictions on malpractice protection and on authorizations by health
insurers are putting surgeons in ''a double squeeze,'' said Dr. Harvey J.
Sugarman, president of the American Society for Bariatric Surgery. The
society said its membership has risen steadily, to 1,364 from 162 in 1992.
Big insurers like UnitedHealth Group, Aetna and Cigna typically offer
bariatric coverage only as a rider that employers can purchase for an
extra charge. The rider raises the insurance costs as much as 12 percent
in some parts of the country.
A number of states, including New York, California and Maryland, require
the coverage. But a federal law exempts most large employers, who are
self-insured. In New York, ''in general it's covered,'' said Dr. Alan
Sokolow, chief medical officer of Empire Blue Cross and Blue Shield.
Frank Sloan, a health economist at Duke University, said malpractice rate
increases could play a positive role by reducing the number of costly
operations in cases where the prospects for success were poor. ''It's a
risky procedure,'' he said. ''Maybe some of these guys will look before
they leap.''
Obesity Inc.
Articles in this series periodically examine causes, costs and possible
cures for obesity, one of the nation's major preoccupations.
Previous articles are online at nytimes.com/business.
Correction: June 2, 2005, Thursday An article in Business Day on Friday
about the risks of bariatric surgery for weight loss misspelled the name
of a marketing firm that collected data on spending for weight-control
products and services. It is the Freedonia Group, not Fredonia.
Photo: Andrea Carrero of North Bergen, N.J., with a photo taken before her
surgery. Her insurer refused approval despite doctors' letters. (Photo by
Marko Georgiev for The New York Times)
Chart:
145,000 bariatric procedures were performed last year, up from 16,000 in
1992, according to the Agency for Healthcare Research and Quality.
The increased demand led to 1,364 surgeons to pay dues to the American
Society of Bariatric Surgery last year, up from 162 in 1992.
A RAND study found that almost 5 percent of patients had serious
cardiovascular complications after surgery.
The high death rate, one in 200, cited in The Journal of the American
Medical Association, could be partly attributed to the poor health of many
patients. (pg. C1)
Copyright 2005 The New York Times Company | Privacy Policy | Home |
Search | Corrections | Help | Back to Top