BCBS lauds leaders in weight loss surgery
September 17, 2004
By Sarah Avery
The demand for weight loss surgery has risen so rapidly that North Carolina's biggest insurer and a national surgeons' group are working to identify which doctors do the best job for patients.
Two "Centers of Excellence" designations were established this summer by Blue Cross and Blue Shield of North Carolina and the American Society for Bariatric Surgery.
The programs are designed to counter criticism that the surgery's popularity has fueled a dangerous market, with eager patients heading to inexperienced doctors and ending up with problems.
Nationally, 140,600 weight loss surgeries are expected to be performed this year, up from 103,200 last year, according to the bariatric surgery group. In an epidemic of obesity that afflicts one in four North Carolinians, the surgery has become a solution to those who are at least 100 pounds overweight.
When done correctly, gastric bypass results in lasting weight loss by shrinking the stomach and redirecting the intestines. The surgery can also reverse some of the worst problems of obesity -- diabetes, high blood pressure, sleep apnea and arthritis pain.
Even in the best of circumstances, however, weight loss procedures are dangerous and can result in internal bleeding, intestinal ruptures, severe malnutrition and death. When complications arise, care costs can shoot from $20,000 to more than $100,000.
Such risks have done little to scare off potential patients. Last year, Blue Cross and Blue Shield of North Carolina paid claims for 495 weight loss surgeries -- a 560 percent increase from 2001 when it paid 75 claims. So far this year, the insurer is seeing a 65 percent increase in claims over last year.
With both demand and costs climbing, many insurers are looking to pare coverage. In North Carolina, Aetna has announced plans to curtail its coverage of weight loss surgeries next year. Many of the plans Cigna offers through North Carolina employers do not pay for the surgeries.
And despite patient interest, some hospitals have cut the operations from the menu of procedures they allow doctors to do. Rex Healthcare in Raleigh phased out weight loss surgeries this summer, following WakeMed's decision last year to halt the procedures.
The surgeries are still being offered at Durham Regional, which has a bariatric program run by Duke University doctors. The three Duke doctors won Centers of Excellence designations from Blue Cross, and they are seeking the designation from the bariatric surgery society.
Helping patients decide
Being designated as a center of excellence is designed to help patients know which doctors have good track records and offer programs that follow national guidelines for care.
That kind of information has become increasingly important as the surgery has gained in popularity. In recent years, many general surgeons began doing gastric bypass operations despite having little experience with a difficult procedure on patients who often have complications.
"A lot of it is taking care of patients afterward," said Dr. Ross McMahon, one of the Duke bariatric surgeons. "Lots of things are going on with patients that are not in a textbook that you need experience to understand."
Complications are expected to arise in about 1 in 10 patients, said Dr. Don Bradley, senior medical director at Blue Cross and Blue Shield. But the insurer started seeing problems in 25 or 30 percent of patients, with complications occurring in up to half of cases for some surgeons.
"When we looked at our data, it appeared that surgeons who had done fewer procedures had higher complication rates," Bradley said. "This is to be expected. You could be a great surgeon, but there is a learning curve."
How insurers reacted
When higher complication rates drove costs up, insurers began backing away. Early next year, Aetna will take bariatric surgery out of its standard coverage plans.
"We view bariatric surgery as a last intervention strategy versus a first," said Aetna spokesman Walt Cherniak.
Blue Cross officials decided to attack the problem differently. Bradley said the centers of excellence program was established to keep the surgery available, while providing patients with a tool to evaluate their options. The insurer will continue to cover procedures done by other surgeons but will streamline the approval process and pay higher fees to the doctors designated as centers of excellence.
Similarly, the bariatric surgery association expects its centers of excellence designation to serve as a badge of quality assurance for patients and insurers. Its program began soliciting applications this summer and will announce provisional designations in November.
The national group, in announcing its program to members in a newsletter, acknowledged that quality issues have marred the successes of bariatric surgery: "What counts are outcomes. We cannot afford poor results, patients in ICUs with preventable complications, no matter what the size or experience of the center. One patient in septic shock can obliterate the fine results of a hundred patients."
Malpractice rates jump
Yet correcting the excesses of a booming market is a slow process, and it may not come in time for some doctors. Malpractice insurance rates for bariatric surgeons are rising quickly, pricing many individual surgeons out of business -- even those who have won centers of excellence designations.
Dr. Roc Bauman, a surgeon in Concord who performs about 300 weight loss procedures a year, said his malpractice rates went from $30,000 this year to $105,000 next year, despite his practice being named a Blue Cross center of excellence.
"They're putting me in a pool with all the people who have different track records," he said, noting that the system ought to work like car insurance, where those with bad records pay higher premiums. "The whole point behind the centers of excellence was to identify the surgeons who were doing good work. Our liabilities are less, so our costs should be less."
Without that happening, Bauman said, he might be forced out of the business, particularly as it gets harder to find insurers willing to pay for the surgery.
"It's almost as if the insurance companies are in collusion," Bauman said. "It's quite a squeeze."
Source:www.newsobserver.com
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