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What You Can Expect in Your Health Insurance Package: Health insurers backing off obesity surgeries

  • Increases of 6 to 7 percent in premiums -- and more in small firms.

  • More financing options, including higher upfront premiums for fuller coverage and lower premiums with the risk of higher out-of-pocket costs.

  • Financial incentives to stay well, including reduced premiums or extra cash in a health savings account for those who, for example, complete a personal health risk assessment or join a smoking cessation program.
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  • More consumer-driven health plans, requiring workers to take on more cost-sharing, often with tax-advantaged savings accounts.

  • Change in prescription drug co-pays, including more tiers of pricing to encourage use of generics and dropping co-pays for maintenance drugs.

  • More decision-support tools, including online medical cost estimators to calculate possible costs of care and slick "health benefit overviews" on DVD. Some of the largest plans will offer digitized personal health records for managing costs.

  • Health-care competitions: Taking the lead from reality TV, employers are sponsoring wellness programs in which workers join teams to get fit or lose weight. (Look for the company brass to participate, too!)

Health insurers, seeking to control overall costs, are trying to tip the financial scales by dropping coverage for popular but expensive obesity surgeries.

The moves respond to the increased use of gastric bypass procedures, which have been championed by celebrities and could swell the overall number of obesity surgeries in the country this year to 200,000. At a cost of about $25,000 each in simple cases -- and much more in complicated ones -- health plans say the costs have driven up premiums so much that their customers just can't afford it.

"Many employers are finding it difficult to provide health insurance at all these days," said Susan Pisano, spokeswoman for America's Health Insurance Plans, the trade group for health insurers. "What they see in gastric bypass surgery is a procedure that's being overused, and that's driving their health care costs up, so they face a dilemma."

But doctors counter that there is no overuse, just a growing recognition of the surgery's benefit. They say the procedures are clearly necessary for some morbidly obese patients, for whom dieting isn't a solution.

"If you speak to the world experts on the best available behavioral, diet and lifestyle interventions, they will tell you they are not successful long-term for people who have more than 100 pounds to lose," said Dr. Anita P. Courcoulas, director of bariatric surgery at the University of Pittsburgh Medical Center. "There's good data out there that shows for 60 percent to 80 percent of patients who have this surgery, their long-term health is markedly improved."

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A 2004 report from the Pennsylvania Health Care Cost Containment Council found that 6,791 gastric bypass surgeries were performed in the state in 2003, up ten-fold from 1999 when only 674 were performed. Between 1999 and 2003, the number of surgeons performing gastric bypass surgery increased from 31 to 84, the council reported, and the number of facilities increased from 26 to 49.

In the face of the increase, HealthAmerica has decided that, effective June 1, groups renewing their health benefits with the insurer no longer will receive obesity surgery coverage in their basic medical plan. Firms with more than 250 employees can obtain coverage if they purchase a rider for obesity surgery.

HealthAmerica's move follows similar steps taken by national insurers Aetna and Cigna.

Locally, Highmark and UPMC Health Plan continue to include gastric bypass surgery in basic health insurance coverage. But the number of surgeries covered by Highmark dropped during 2004 after the insurer tightened the criteria for patients seeking operations.

Robert L. Dawson, HealthAmerica's president and chief executive officer, said the company believes the surgery is "an extraordinary risk to take," particularly if patients don't also address the underlying diet and lifestyle issues involved with obesity.

But cost is a factor, too. "Coverage for obesity surgery benefits a small number of people at a cost that is incurred by all our members and their employers," a March 15 letter from HealthAmerica explaining the change said.But many of those patients who need the procedure will struggle to pay for it out-of-pocket, said Dr. Nilesh Patel, a bariatric surgeon at Allegheny General Hospital. Obesity is a socially acceptable prejudice, Patel said, and society has no sympathy for fat people, saying it is a self-inflicted problem.

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Courcoulas, the UPMC surgeon, said the risks of illness and death following obesity surgeries are no greater than with any other complex abdominal operations. While there are significant up-front costs with the procedures, Courcoulas argued that health plans would recoup their investments in about three years as post-surgery patients avoid other health problems.

Some insurers, including Highmark, now require supervised diet therapy prior to surgery. Dr. Martin Fenster, Highmark's medical director for utilization management, said he agreed that dieting along isn't a long-term solution for many patients. Even so, patients after surgery must make lifestyle changes so they don't regain the weight, Fenster said, and might as well develop the habits beforehand.

Highmark's restrictions drastically cut the number of covered surgeries from more than 3,000 in 2003 to less than 2,000 in 2004. Even so, the rate of surgeries in the region still exceeds the national average, Fenster said.

Some of the quality problems have simply been a function of surgeons learning how to do gastric bypass surgeries laparoscopically. Gastric bypass surgeries performed through large, open incisions have been around since the 1960s, but were never as popular.

"You have a lot of doctors on the learning curve, and everybody wants to get in on the learning curve," Fenster said.

If all the recent news about insurers clamping down on obesity surgery is casting a pall on this week's annual meeting of the American Society of Bariatric Surgery, Barbara Thompson hasn't noticed. The Upper St. Clair resident, who underwent obesity surgery more than 5 years ago and sings its praises, is attending the meeting in Orlando, Fla.

"I'm optimistic," Thompson said, noting that Medicare was asked this year to consider expanding coverage of gastric bypass to patients who are just obese -- as opposed to those who have certain related health problems.

"The surgery just gives you tremendous freedom," said Thompson, who has published books on the subject. "It's improved my health, my life, my self-esteem, my ability to live life fully."

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