It may have been a little confusing for viewers last night on Emily Rooney's Greater Boston television show on WGBH. There we had a doctor from Tufts Health Plan debating a doctor from Tufts New England Medical Center about the insurer's decision to put restrictions on bariatric surgery.
This has been a controversial move by the health plan. I usually don't get into the "who won the debate" game, but four of us watching the show thought the Tufts-NEMC doctor won the night. In particular, he noted that THP's program conflicted with the recommendations of an expert panel convened by the Betsy Lehman Center for Patient Safety and Medical Error Reduction. This had been previously pointed out by Nancy Ridley, associate commissioner for the state DPH and director of the Center. The health plan MD was put in the position of saying, "Well, our evidence-based medicine is better than yours" -- not very persuasive against an expert panel than had met for months to review the situation.
Also, people are less inclined to believe an insurance company on such matters, anyway. Maybe that's not fair. But a friend viewing the show with me said, "They just want to make money by denying payment for treatment. That's all insurance companies ever want to do." Knowing the folks at THP -- and let's remember they are a non-profit with a long reputation for progressive policies in health care management -- I believe they have much better intentions than that. But this tv show demonstrated how difficult it can be for an insurer to win the public debate in these matters.
(Disclosure: BIDMC carries out bariatric surgery, and Dr. George Blackburn from our staff was intimately involved in the Lehman Center report.
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9 comments:
Unfortunately, not many people know just how much money docs and hospitals make on different surgical procedures. The Charlie Weiss story clearly shows this is a high risk procedure. It would be nice if we could get unbiased information about health care from a source not looking to its bottom line.
Thanks exactly what the Lehman Center did. It is part of the state DPH.
This reminds of the disputes over ABMT procedures for cancer. Insurers didn't want to cover them. Oncologists promoted them as the last chance for seriously ill patients. Litigation ensued against "greedy" health plans, who lost most of the lawsuits. Years later, a meta analysis of the literature, including randomized clinical trials, revealed that ABMT showed no benefit over conventional cancer treatments, and that the plans had been right all along. Deja vu all over again?
The bariatric surgical procedures being done today remind me of the rush to CABG procedures in the 80's. People need to know about the risks, alternatives and benefits of the procedure and often times they only hear the benefits, risks and rarely the alternatives. I agree with taking another look...
It could be that THP is just trying to do what's best for patients. On the other hand, THP could also be trying to make its plan less hospitable to overweight people. Not only will THP save on the cost of surgery, but will improve its patient mix. Is it too much of a stretch to believe that THP may be signaling to the non-obese that it is looking for patients with healthy lifestyles by diverting funds from the fat?
Except for the heat they're generating, it's a brilliant strategic move. After all BCBSMA can't really follow suit considering they're in the midst of a certification program for surgery centers that is itself generating resistance.
You can bet the return on investment for THP on this policy is a lot higher than for the rebates given to members for health club memberships, which are also designed to attract a healthier patient mix.
And finally, let's not forget that "evidence based medicine" can include cost considerations as well as efficacy and safety.
As a former medical executive from a health plan in the region, I can tell you that despite who Mr. Levy "feels" won the debate, the fact remains that most resistance from hospitals and doctors who do bariatric surgery against having clear guidelines is related to their drive to increase volume in a high margin line of business, and don't be deceived into thinking that they don't view this as a line of business. Frankly, I think the push to put clear expectations on the quality of the screening and treatment process for patients undergoing bariatric surgery in the end will benefit patients much more than the pockets of health plans.
The public and the press seem often to give a free pass to doctors and hospitals as the ultimate source of wisdom on what is acceptable practice that optimizes safety and outcomes, and there are many, many examples where this has not worked.
I say good for Tufts Health Plan, though I don't understand why they deviated from the Lehman recommendations, as this clearly hurts their credibility in this matter.
I am leaving this comment as a subscriber to Tufts and a patient, not as a nurse.
First off, I am one of the patients affected by Tufts decision to make it more difficult for their obese clients to have weight loss surgery. I recently had my first and only appointment at a hospital for the Lap-Band procedure, and was turned away even before seeing the NP I was scheduled with for two reasons:
1. I had Tufts
2. I was going to fall into their decline pile because my BMI was "just" 40 AND I wasn't on any medication for my hypertension.
I was told that in order for me to be eligible through Tufts was to "get fatter and sicker". What type of message is this?
What struck me odd about this decision is my understanding that studies thus far have shown that weight loss surgery is the only proven method for long term weight loss without the "yo-yoing" many of us fat people do. Also, Lap-Band is half the cost of gastric bypass as far as hospital expense and my understanding is that this is what Tufts will cover after you finish their year long online diet program. Their goal is to have people get their BMI's under 40 to make them ineligible for surgery. I've managed a BMI of 38 so far, which is still obese. I am still at the same risk for the comorbidities of obesity whether my BMI is 31 or 40.
I also wonder if Tufts looked at the long term health care costs of a person who was treated with weight loss surgery and had a healthy BMI the rest of their life versus the person who remains obese and has subsequent ongoing health problems because of it. My feeling is that it is probably more expensive to care for the obese person over their lifetime.
I guess that I am responding emotionally to this decision. I feel like it is one more blow to fat people. I feel like their online diet plan is an insult. Most people who desire weight loss surgery have done countless programs just like theirs and "failed". Most people who desire weight loss surgery are well aware of the risks but have weighed the risks of surgery over the risks of lifetime obesity. And how ironic that this issue is the only time in my life that I was discriminated against because I wasn't fat enough. Go figure!
Labor Nurse,
If you drop out of Tufts because of the policy they are likely to consider that proof of its wisdom.
Tufts doesn't necessarily care about your long-term costs. They may rather have that be the concern of BCBSMA or Harvard Pilgrim.
As patient of United Health Care, in my policy it wasn't covered, lapband or bypass. I have had to change jobs and insurance companies to Harvard Pilgrim to get it covered.
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