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Hospitals Pressured By Soaring Demand For Obesity Surgery

By Milt Freudenheim
The New York Times, August 29, 2003

Doctors and hospitals across the country are scrambling to satisfy the booming demand for surgery that shrinks the stomachs of severely obese people.

Dozens of hospitals are adding special operating suites for the procedure, called bariatric surgery, which attracted wide notices after public figures like Al Roker of "Today" on NBC, Sharon OSbourne of "The Osbournes" on MTV and Representative Jerrold Nadler, a Manhattan Democrat, had it done.  Some bariatric surgeons are fully scheduled 12 months in advance, and hundreds of doctors have jumped into the field recently and started to advertise their availability.

Bariatric procedures -- meant for obese people who are at extremely high risk of severe health problems, as defined by a National Institutes of Health consensus -- surged more than 40 percent last year, to 80,000.  This year, the number is expected to climb to 120,000 according to Frost & Sullivan, a consulting firm.  Spending on bariatrics is approaching $3 billion a year, at an average cost of $25,000 for each procedure.

With the number of people eligible for the procedures growing by an estimated 10 to 12 percent a year, bariatric surgery can be profitable for hospitals -- and even more so for surgeons.  But the costs are a major concern to insurance companies and employer health plans.  Surgeons say that some insurers routinely delay approvals.

"The companies throw up roadblocks," said Dr. James Rosser, a surgeon at Beth Israel Medical Center in Manhattan.  "They keep requesting more information.  Patients are left to really hound the insurance companies to get the approvals."

Doctors and patients, meanwhile, are putting pressure on insurers to lower the body-size threshold for paying for the operation for people who have advanced problems with diabetes and other weight-related diseases.  That could triple the number of people potentially eligible for the operation to more than 30 million, a panel of medical advisers to the national Blue Cross and Blue Shield association was told recently.

One group having trouble winning access to treatment is the poor, among whom obesity is an especially acute concern.  Doctors say that Medicaid programs in many states have been reluctant to pay for the procedures.  At the University of California at Davis, for example, Medi-Cal patients face a 12-year wait for bariatric surgery, said Dr. Bruce M. Wolfe, a bariatric surgeon and professor of surgery.  Medi-Cal reimburses Davis for the procedure at less than a third of the hospital's cost.

"Basically they're not getting access to the care," he said.  "They will suffer the consequences of untreated obesity."

Most bariatric procedures produce weight loss by restricting the intake of food.  Part of the stomach is partitioned off and the intestines are rerouted.  Afterward, many patients lose their outsize appetites.

"Patients can eat smaller amounts and feel satisfied," said Dr. Alan C. Wittgrove, a San Diego surgeon who is president of the American Society for Bariatric Surgery.  But there can also be unpleasant consequences:  if they eat too much, patients may vomit.

The procedure is approved for patients at the upper end of the body mass index, a measure of weight in relation to height.  Under National Institutes of Health guidelines, widely followed by health plans, candidates must first try diet and exercise regimens.

More than 10 million Americans, 4.7 percent of the population, are eligible for the procedure, according to the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

In addition to the average cost of $25,000 for the surgery and associated services, lifelong follow-up is strongly recommended, adding to costs.  "They need support groups, follow-up by nurses, exercise programs," Dr. Wittgrove said.  Insurance companies often do not pay for these programs or for counseling, Dr. Rosser added.

For some patients, overall costs can be much more, up to $100,000, said Helen Darling, president of the Washing Business Group on Health. Her organization, which represents large employers, recently opened a campaign to encourage overweight workers to slim down.

A spokesman for that campaign, Dr. Vincent Kerr, director of health care management at the Ford Motor Company, estimates that obese workers cost employers 4!@ billion annually in medical bills, reduced productivity, increased absenteeism and higher insurances premiums.

The National Institutes of Health, meanwhile, says that the annual costs of treating obesity-related conditions -- including diabetes, heart disease, osteoarthritis and breast and colon cancers -- are at least $120 billion.

Bariatric specialists say the surgery reduces those costs in the long run.  Patients with Type 2 diabetes, which the NIH said accounted for $98 billion of obesity-related costs, have normal sugar counts within a few days after the stomach bypass procedures, without medication, Dr. Wittgrove said.

A recent study by the Blue Cross and Blue Shield association "confirmed that surgery is far more effective than diet and exercise in treating morbid obese patients," said Naomi Aronson, executive director of the association's technology evaluation center.

But the long-term payoff has yet to be proved, said Dr. Alan M. Garber, a health economist at Stanford University who is a member of the association's medical advisory panel.  "Something of a leap of faith is involved," he said.

Health insurers will cover the cost only for patients who meet a long list of preconditions, partly based on NIH criteria.  Aetna, for example, requires that candidates for the procedure have spent six months in a diet and exercise program supervised by a physician.

"Insurance companies, unfortunately are somewhat schizophrenic about this procedure," Dr. Wittgrove said.  "Some authorize it quite easily and are patient-friendly.  They seem to get the fact that they are going to save money over all." But, he added, "other insurance companies want to put hurdles in front of patients rather than facilitate treatment."

Some of the most active hospitals for bariatric procedures are in California, New York and Boston.  But a number of hospitals in Indiana are adding bariatric facilities.  And in Florida, "just in the last six months in my neighborhood in Coral Gables, six surgeons have begun to advertise bariatric surgery," said Dr. Eneida O. Roldan, a physician who is chairwoman of the American Board of Bariatric Medicine, an accrediting group.

Hospitals in New York State reported 4,670 procedures last year, up 50 percent from 2001 and more than double the 1,981 in 2000, said Karen Heller, a senior health care economist at the Greater New York Hospital Association.

Dr. Rosser, the Manhattan surgeon, has personal knowledge of both obesity and bariatric care.  A one-time high school football player, he later soared to 450 pounds on a 6-foot-4 frame.

"I had sleep apnea, a very prevalent silent killer, and muscular-skeletal aches and pains," said Dr. Rosser, a specialist in laparoscopic surgery who does bariatric procedures with miniature instruments.  "I could see the handwriting on the wall."

He said he made "the maximum effort to lose weight for four years, but the weight came back."  Two years ago, when he was 46, Dr. Rosser underwent the surgery.  He has since lost 150 pounds -- and he shows his patients a video relating his story.

In California, Kaiser Permanente, the big health maintenance organization, is tripling its bariatric surgery capacity in the San Francisco area.  "There has been a tremendous increase in demand in the last four years," said Dr. Michelle Caughey, physician in chief of Kaiser's South San Francisco Medical Center, which treats 420 bariatric cases a year.

Kaiser recently added two centers nearby.  Combined, they expect to handle more than 1,200 cases by the end of next year, she said.

New centers like Kaiser's are big customers for special equipment.  They buy beds four feet wide that can support "patients of size," who may weigh up to 1,000 pounds, said Lynne Sly, vice president at Kinetic Concepts, a bed manufacturer in San Antonio.  With extras like built-in scales, the special beds can cost more than $20,000, or $170 a day to rent.

Sales of these beds and accessories have been growing 21 percent a year, another indicator of the trends in obesity surgery, said Dhiraj Ajmani, an analyst at Frost & Sullivan, the consultants.

Dr. Wolfe at U.C. Davis said that bariatric procedures were only "profitable by a small margin" for hospitals.  Complications are frequent, and the procedures often require extra employees in the operating room, he said.

But with demand so strong from patients, many bariatric surgeons are thriving, Dr. Wolfe added.

"Morbid obesity is life-threatening, and surgery is the only treatment that works," he said.  "The hospitals don't have much choice but to respond."

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