Medicare obesity coverage may grow
Recognition of it as illness opens door for additional claims.
July 21, 2004
By Lauren Stanforth
Medicare got the attention of the whole health care industry last week when it announced it might now consider obesity a legitimate illness.
But any impact on health care coverage for obese patients won't be known for a while.
Health and Human Services Secretary Tommy G. Thompson announced Medicare would eliminate the phrase “obesity itself cannot be considered an illness” from its policy books — possibly opening the floodgates for coverage for everything from diet regimens to behavior modification programs for obese senior citizens and disabled people.
Medicare, a federal health insurance program for those older than 65 or those with severe disabilities, does cover obesity surgeries, such as gastrointestinal bypass. But the surgery is covered only if someone has another obesity-related illness, such as heart disease, hypertension or diabetes.
It's not known whether that requirement will change under Medicare's new philosophy.
Obesity in the health community is measured using the Body Mass Index, which compares a person's weight to his or her height.
A healthy 5-foot-3-inch person weighing 130 pounds would be between 18 and 25 on the index. A person that height weighing 180 pounds would exceed 30 on the index, and a person that height weighing 230 pounds would exceed 40 on the index (or morbidly obese).
The federal government has actually been slower to recognize obesity as a major health problem compared with private insurers — although obesity is now the second-leading cause of death in this country, behind tobacco-related illnesses.
Locally, Preferred Care covers some weight loss programs, such as Weight Watchers, and also requires the customer to do an exercise program.
Preferred Care also covers some weight-loss drugs, such as the appetite suppressant Meridia. But those drugs aren't prescribed that often, said Preferred Care spokeswoman Elaine Fallesen.
“A lot of confusion is going to come into play as we go through this,” Fallesen said about Medicare's change of heart. However, she said, “Now there will be standards in place for all health plans to follow.”
Excellus BlueCross BlueShield covers nutritional counseling and medication if the drugs go along with a program to help a person take off the weight.
Excellus released a study in March saying that nearly one-fourth of upstate New Yorkers are obese and that treating obesity-related illnesses costs around $6.1 billion a year statewide.
For many private insurers, a patient must prove he or she has tried other weight loss measures before surgery will be covered. Aetna Inc. requires the same thing as Medicare — that a patient must be suffering with a health condition other than obesity to get the surgery.
“This announcement I think is good in that it allows people to recognize this is a far-reaching issue,” said Dr. Cheryl Pegus, national medical director for women's health at Aetna.
Surgeries used to be a part of Aetna's standard plan for employers. But starting next year, an employer will have to specifically request that the surgery be covered in order for employees to receive the benefit. Pegus said the change came from employers who thought weight loss was a lifestyle management problem that shouldn't necessarily be fixed with surgery.
Gastric bypass surgeries are booming at Highland Hospital, where surgeries have more than doubled from around 480 last year to likely around 800 this year. Dr. Bill O'Malley, director of the Strong Health bariatric surgery center at Highland Hospital, said he doesn't think there are more morbidly obese people, but that the surgery is becoming a more acceptable option in the public's mind.
According to O'Malley, there are very few options for people who are more than 100 pounds overweight. The success rate for these patients in keeping pounds off is only 5 percent if they practice a better diet and exercise alone.
“In the past we haven't been able to use morbid obesity as a reason for surgery,” O'Malley said about the Medicare ruling. “That's probably what's going to change.”
Source:www.democratandchronicle.com
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