News Web Exclusive: Weight Management

September 1, 2004

Recent, increasing demand for obesity-surgery coverage among membersdoes not mean that cost and quality goals are doomed to fall by the waysidefor plans, according to John Pilcher, MD, Surgical Consultants of San Antonio.

Recent, increasing demand for obesity-surgery coverage among membersdoes not mean that cost and quality goals are doomed to fall by the waysidefor plans, according to John Pilcher, MD, Surgical Consultants of San Antonio.According to Dr. Pilcher, obesity surgery can be monitored by several easilyobtained parameters:

  • cost;
  • weight loss;
  • rate of complications: death, leak, re-operation, re-admission, pulmonary embolus; and
  • rate of resolution of medical comorbidity, such as diabetes, sleep apnea, hypertension, high cholesterol, GE reflux, etc.

Using this data, executives can proactively manage their cost and demandby:

  • setting rational qualification criteria;
  • arranging surgery through high-quality centers (The American Society of Bariatric Surgery is near completion of its designation of Centers of Excellence); and
  • working with employers to capture the long-term cost vs. benefit of obesity surgery, allowing selected increases in premium rates or contract features to promote long-term contracting.

According to Alan Muney, MD, chief medical officer of Oxford Health,it is likely his plan will give consumers the quality information aboutwhich hospitals are recommended so they can make informed choices. "Ultimately,we may only approve the procedure at certain hospitals based on the qualitymetrics," he says. "Communication of the guidelines and the outcomesis the first step."

At this point, it is hard to determine the costs that individuals whoare clinically obese might incur, and Oxford can't measure the long-termeffects of the surgery since it is fairly new. "As a result, it isdifficult to say over the long-term whether we will see a decrease or astabilization in overall obesity-related costs." Dr. Muney says. "However,over the short term, we may see an increase in requests for the surgery."

According to Trina Histon, PhD, project director, Weight Management Initiative,Kaiser, Care Management Institute, Kaiser has been looking at bariatricsurgery for a number of years. "We are developing ways to determinethe effectiveness of this treatment," she says. "We are criticallyreviewing our programs, and implementing a system to collect outcomes data.We have also created networks of clinicians and surgeons to discuss theprograms, their components, and the data that support appropriate care."

First Health, a national health benefits company, believes that the evidenceindicates that the appropriate use of weight-loss programs and treatments-includingbariatric surgery-may increase the costs of covered weight-loss treatmentsin the short-term, but it will lower the total healthcare costs of the morbidlyobese patients properly selected for the treatments, according to ScottP. Smith, MD, MPH, chief medical officer of First Health.

Employer Groups

As for employers, they have to look at the costs of all care, considerwhat the business can support, what all employees can support through theircontributions, and then design a competitive benefit package that balancesall factors, according to Helen Darling, president, National Business Groupon Health. "Depending where their work force is located or the competitivenessof their industry, they also have to determine the potential adverse selectionimpact if they cover something that has support groups, chat rooms, andother resources that could report on coverage availability at one employerin a community," Darling says.

"Plans must learn to work closely with employer groups to help influencethose who need constant reminders that personal health improvement is supportedwith quality tools and a personal responsibility," according to DavidHall, president and COO of My ePHIT, an online fitness, nutrition and wellnesscoaching service that is marketed as part of health plans. "Many whoare struggling with weight problems can solve them if they have proven toolsand professional support at their fingertips."