Tufts plan will restrict surgery for obesity
By Jeffrey Krasner, Globe Staff | February 14, 2007
Tufts Health Plan next month will start denying gastric-bypass and stomach-banding procedures to some obese patients and require others to enter a yearlong diet and counseling program before undergoing the potentially lifesaving surgery.
Tufts, the third-largest health insurance company in Massachusetts, said limiting the number of such surgeries could save the company millions of dollars and ultimately improve patients' health. While insurers routinely reject patients for certain procedures or restrict access to medical care, Tufts is adopting more stringent criteria for the procedures than the state's two largest insurers, Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care.
Doctors condemned the new policy, which takes effect March 6, saying Tufts is ignoring a growing body of clinical evidence that shows that such operations help those who have exhausted other methods to lose weight. Delaying surgery worsens conditions such as diabetes and heart disease that are often complications of pronounced weight gain, they said.
"This is Draconian," said Dr. Philip Schauer , president of the American Society for Bariatric Surgery and director of bariatric surgery at the Cleveland Clinic. "This flies in the face of the medical evidence. These policies sentence a patient to a life of dealing with obesity without the possibility of parole."
The most common weight-related procedures are lap-band surgery, in which silicon bands are tied around the stomach to shrink its size, and bypass surgery, in which staples are used to close off a section of the stomach. In both procedures, the aim is to restrict the amount of food a patient can eat by drastically reducing stomach capacity.
The popularity of the procedures has made them a target for health plans seeking to control costs. Last year, 177,600 weight- related surgeries were performed nationally, compared with 36,700 in 2000, according to the American Society for Bariatric Surgery. But these surgeries carry significant risks -- one in 200 patients undergoing gastric bypasses dies from complications, according to a study published in October 2004 by the Journal of the American Medical Society.
Gastric bypass surgery costs about $20,000, while the stomach banding procedure can cost less than $10,000.
A person with a body mass index greater than 25 is considered overweight and a BMI of more than 40 is classified as severely obese. Under guidelines sent to Tufts doctors last month, all patients would have to complete a yearlong "lifestyle management" program called iCanChange before being eligible for bariatric surgery. At the end of the program, those with a BMI of less than 40 would not be eligible for the procedures. Patients with an index between 40 and 50 would only be eligible for stomach banding, which is less expensive and not as invasive as stomach bypass surgery, unless they also suffered from medical conditions like diabetes or high blood pressure.
Dr. Allen J. Hinkle , Tufts' chief medical officer, said the new standards will lower risks to patients and save Tufts Health Plan money. The insurer spent $10 million on the operations last year, and demand for the procedures in Massachusetts is growing by 28 percent annually, he said.
But Dr. Scott Shikora , chief of bariatric surgery at Tufts-New England Medical Center, said the company should leave decisions about medical procedures to doctors. Shikora said he and colleagues have attempted to persuade Tufts Health Plan to reverse its position. He also wrote a letter complaining about the policy change to Dr. JudyAnn Bigby , Massachusetts' secretary of health and human services.
Tufts' cost cutting has angered physicians before. In 2005, it tightened controls on high-tech imaging procedures like MRIs by requiring authorization for some patients. It also required physicians to get authorization before performing hysterectomies and some back surgeries.
Cost controls are more urgent for Tufts than its larger competitors . Over recent years, membership declined from a million to about 600,000, although it has stabilized and appears this year to be growing. The company has been profitable, but it relies heavily on investment income from large cash holdings to bolster its performance.
Dr. Alan M. Harvey , an anesthesiologist at Brigham and Women's Hospital, criticized Tufts's requirement that patients spend a year in the weight-loss program, which includes weekly phone calls with counselors and "access to web-based tools."
"There's no evidence that delay is helpful for these patients," said Harvey. "Many have already been through many counseling and treatment programs."
But Hinkle said 20 percent of the patients who go through the program would lose enough weight to avoid surgery, while others would reduce the risk associated with surgery by improving their physical condition. The patients' medical problems, such as diabetes and high blood pressure, "aren't going to progress in a year to the point where the patient's health would deteriorate," he said, "and we'll deal with any exceptions."
While Blue Cross and Harvard Pilgrim said they are not changing their policies , other insurers nationwide have attempted to restrict access to the procedures. For instance, Blue Cross Blue Shield of Tennessee required obese patients seeking the surgery to take an intelligence test, but last month dropped the stipulation after a barrage of criticism.
The Obesity Action Coalition, a Florida patient-advocacy group, criticized Tufts yesterday, saying the policy is akin to discrimination against obese people.
"The biggest issue with Tufts is that patients and their surgeons need to be the ones to decide which weight-loss option is the best, not the insurance company," said James Zervios , a spokesman .
Obesity Surgery
This should cause a heated debate soon! I bet we will hear more about this soon!
, this is still pretty bad. I too fathom we have not heard the last of this. 
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