Access to Care Challenges: Bariatric Surgery Discrimination by Insurance Companies
Obesity is a rising problem in the United States. According to the CDC, 93.3 million adults, roughly 40%, were affected by obesity in 2016. That’s up from 36% in 2008. Along the same lines, the counts of severe obesity rose from 5.7% to 7.7% from 2008 to 2016.
Despite the prevalence of obesity in the U.S. and the numerous, severe health risks associated with being obese, obesity was not classified as a chronic medical condition until 2013, when the American Medical Association finally recognized obesity as a disease.
In drafting this article, I consulted with Dr Isaias Irgau of the CHRIAS, who noted that “the 1991 NIH consensus on the indications for bariatric surgery excluded obese patients with a BMI 30–35. Since then, much knowledge has been accumulated implicating obesity with a plethora of dangerous illnesses. Bariatric surgery is much less invasive and much safer than it was 30 years ago. The risk–benefit ratio currently favors bariatric surgery for patients with BMI greater than 30.”
Despite the classification as a disease and the risk–benefit ratio favoring these procedures, obese patients still have a difficult time getting the professional medical care that could make significant improvements in their health and well-being. Bariatric surgery is a safe and effective for obese patients to improve their health, but our current healthcare system makes obtaining such procedures a needlessly difficult and complicated task.
Needless Complications
Cholecystectomy, or the removal of the gallbladder, is a common medical procedure in the United States, so common that should a surgeon recommend the procedure, it can usually be done within a week or two of the diagnosis and be completely covered by all insurances. There are few prequalifications to satisfy before the procedure if it is elective surgery. It is a different matter entirely when it is a medical emergency, and at that time the procedure is done immediately as is necessary for the patient’s health. There are few hoops to jump through when it is an elected surgery. It is a straightforward procedure for patients to get.
Bariatric surgery, on the other hand, has many hoops patients need to jump through both before a patient can be considered for bariatric surgery and before they can be approved for surgery. These qualifications and clearances are required by all insurances, though with differing criteria.
Perhaps these requirements would make sense if bariatric surgeries were prohibitively expensive or was medically unnecessary. Neither of these are the case, however. Bariatric procedures bear a similar cost to the easy-to-get gallbladder removal, and they are no more dangerous than elective, cosmetic surgery undertaken for non-health-related issues.
Bariatric Surgery Criteria
First, there are certain minimum criteria that patients must meet before bariatric surgery can even be considered as an option:
- Despite obesity being defined as a BMI (Body Mass Index) of 30 or higher, in order to qualify for bariatric surgery
- Patients must have a BMI of over 40 or
- A BMI of 35 to 40 if there are other health conditions (such as sleep apnea, coronary heart disease, or type 2 diabetes)
- A two-year history of being overweight (though some insurances require up to a five-year history of being overweight)
- Failure of a physician monitored weight-loss program to reduce the patient's weight after four months
Yes, this means that before a patient can even be considered for bariatric surgery, a safe, effective procedure that can help improve their overall health and well-being, they must not only already be in a state of physical deterioration—being morbidly obese—but they must have been in this state for a few years and have failed other avenues of health improvement.
Even at this point, we are failing our patients by setting such rigorous and superfluous criteria for these procedures. And it only gets harder from there.
Once Bariatric Surgery Is Recommended
From the time bariatric surgery is recommended as a viable option, there are several more steps that patients need to take before the procedure can be scheduled. First, the patient has to see a nutritionist. The requirements vary greatly among insurance providers, but the most common requirements are six consecutive, monthly visits. If even one of these is missed, the patient has to start over again from the beginning.
Outside of those nutritionist visits, there are several other medical clearances patients may need to get:
- EGD (Esophagogastroduodenoscopy) clearance
- Psychology clearance
- Pulmonary clearance, Cardiology clearance
- Medical clearance from the primary care physician
Without proper guidance, it is easy for patients to miss one of these steps, further delaying when they can be approved for the bariatric procedure. All of these various doctors’ visits and tests can be extremely expensive if not covered by insurance.
Furthermore, these steps take time. Patients being considered for bariatric surgery are already suffering from health issues, some of them quite severe. And yet this system requires they wait even longer before getting a potentially life-saving medical procedure.
After the Surgery
Even after the procedure, there are five years of follow-up visits that patients are supposed to make, far more than following other, more invasive surgeries. This includes a two-week, one month, three month, and six month visit, and then goes to yearly visits after.
Most patients lose 50 to 70 pounds in the months following the surgery. With that level of immediate success, they often don’t come back for these follow-ups.
Why Is It So Hard?
Bariatric surgery has the potential to help obese patients reach a healthy body weight in a short amount of time. Naturally this weight loss leads to a reduction of the various health ailments associated with obesity such as sleep apnea, coronary heart disease, or type 2 diabetes. The procedure is safe and relatively inexpensive. Given the significant health risks associated with being obese, and the staggering cost obesity has on our healthcare system, why is it so difficult to to get this procedure?
Despite the 2013 classification of obesity as a disease, the social stigma behind obesity has been slow to change. Often being overweight is viewed as a character flaw: a lack of willpower to maintain a diet or being too lazy to adhere to a workout program. Bariatric surgery is viewed as a cop-out rather than a legitimate pathway toward improved health and well-being. As shown in this report, as of 2018, there were still states that did not provide coverage for bariatric surgery as part of the state’s Medicaid plan (Mississippi and Montana) and an even greater number of states that do not provide coverage to state employees (Georgia, Idaho, Louisiana, Montana, South Carolina, Wisconsin, and Utah).
The prequalification criteria and the various medical clearances are needless roadblocks that are a result of insurance discrimination based on these societial views of people suffering from obesity. These roadblocks not only delay patients from receiving medical care that can improve their health, but these unnecessary complications are frustrating and disheartening.
Kemal Erkan, Chairman
American Surgery Center
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