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Weighing the Risk

For some who are morbidly obese, bariatric surgery might be the last hope -- but economics plays a major role in determining who gets it and who doesn't.

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In 2004, approximately 145,000 obesity surgeries were performed nationwide. The number of local operations in New Orleans tripled in recent years -- but declined over the past six months.

When Sylvia Johnson's weight ballooned to 398 pounds, she turned to a bariatric surgeon. He agreed to perform a gastric bypass, but only after she met a requirement. "I had to lose 50 pounds," she says. "He wanted to make sure that I was dedicated enough."

Surgeons who perform the procedure say it should be the last resort. Bariatric surgery or obesity surgery can be fatal and has a reported mortality rate of anywhere from 0.5 to 2 percent. Plus, it carries a higher-than-normal risk for post-operative complications such as wound infection, gastrointestinal leakage, heart attack and stroke. Still, for those who qualify, it can improve their health dramatically.

"Morbid obesity leads to several health problems," says Dr. Todd Belott, a general surgeon trained in bariatric surgery at Methodist Hospital. "The risk of diabetes is four times higher in the morbidly obese; hypertension is higher, and so is sleep apnea, which can cause right-sided congestive heart failure and can be fatal. Additionally, there is high cholesterol. These four conditions are directly associated with the morbidly obese individual. It's been proven in many studies if a patient loses weight these problems go away as well. There is nothing I do surgically where I can do one procedure and cure four diseases at once -- except for this."

A recent report in the Journal of the American Medical Association supports Belott's assertions. A review of published studies on the procedure concluded that a substantial majority of bariatric surgery patients who had high cholesterol, sleep apnea, diabetes and/or hypertension experienced "complete resolution or improvement" from these conditions following the operation. With these kinds of results combined with large amounts of positive media exposure, it's not surprising the number of surgeries has climbed in recent years. In 2004, approximately 145,000 operations were performed nationwide. The number of operations also increased in New Orleans -- but according to Belott, the local numbers have started to shift again.

"In the past two to three years, the number of procedures performed in New Orleans essentially tripled," Belott says. "Over the past six months, however, there's been an across-the-board steady decline."

The decline isn't the result of fewer candidates. A report from the Centers for Disease Control states that the obesity rate in the greater New Orleans area is 25 percent. Obesity is defined by a BMI (Body Mass Index) of 30 or above. Morbid obesity is a BMI of 40 or above. A prospective bariatric surgery patient normally has to be at least morbidly obese, or have a 35 BMI plus two weight-caused conditions such as hypertension or diabetes.

Although the number of morbidly obese people in New Orleans is unknown, Dr. Kevin Stephens, director of the New Orleans Health Department, believes it is formidable. "It's definitely significant," Stephens says. "Sixty percent of New Orleans is overweight (BMI of 25 or higher) and our obesity rate is higher than the national average. So, our rate of morbidly obese people is likely higher."

Belott thinks the local decrease in operations has more to do with the bottom line than patient need. "It's the ultimate conundrum," he says. "You have a couple of procedures out there with proven efficacy that have demonstrated from an economic standpoint that if you lose the weight than the amount of money spent on medication and other treatments goes down dramatically. The money saved in the long run is huge. However, these are expensive procedures and it's been suggested that ... the average person switches companies every two years, so the long-term benefit that an insurance company will gain by approving the operation won't happen. It's basically, 'I pay for it, but I don't get the benefit. So why pay for it?'"

Blue Cross and Blue Shield of Louisiana, the state's largest health insurance carrier, doesn't cover bariatric surgery and never has. John Maginnis, a company spokesman, says the decision to not fund the surgery came from the company's medical director and staff, and both health and monetary concerns factored into the reasoning.

"We do not cover bariatric surgery," Maginnis says. "There are a couple reasons for this. First, bariatric surgery is not without risk and complication, and long-term effectiveness is incomplete at this time. Additionally, there is the philosophical consideration of why this should be promoted over diet and exercise. Cost is a factor and it would have to be figured into our premiums. With rising costs, when you include another surgery, it could conceivably price the premium beyond the reach of people who currently have it."

According to Maginnis, any eventual cost-effectiveness of the procedure did not enter into Blue Cross and Blue Shield of Louisiana's decision-making process. However, some bigger companies fund their own health coverage and use the insurance carrier only to administer the policy, which could allow bariatric surgery.

"Self-insured larger companies can customize their plans and can include bariatric surgery," Maginnis says. "In that case, it would be covered. We provide the administrative services only -- they take the risk; we don't."

Medicaid isn't willing to take the risk very often either. Although the surgery can be covered, the Louisiana Department of Health and Hospitals, which is in charge of Medicaid in the state, states on its Web site, "If your BMI is more than 40 or is 35 or more and you have a serious medical problem that is made worse by your weight, surgery may be considered." It's not a guarantee and is up to the discretion of the agency.

Sylvia Johnson was on Medicaid and desperate. For 25 years, this New Orleans woman was trapped in an abusive marriage. During this time, her weight ballooned to 398 pounds. She had tried different diets, but she always ended up weighing more than when she started. She finally sought a surgical solution and turned to Dr. Louis Martin, a bariatric surgeon. Martin agreed to perform a gastric bypass, the stomach-stapling form of bariatric surgery, but only if Johnson met a requirement.

"I had to lose 50 pounds before the doctor would perform the surgery," she says. "He wanted to make sure that I was dedicated enough. He made me go to nutritional counseling and group therapy to prepare me for the surgery."

Johnson passed the test and in 1993 she had the surgery. The surgery was a success although she did develop an infection that had to be drained twice. She now maintains a weight of 190 pounds.

But that didn't mean Martin was paid for the work in a timely fashion. Even though Johnson had a BMI of 64.2 prior to the gastric bypass, and she suffered from weight-induced hypoglycemia and asthma, Medicaid refused to compensate Martin until five years later.

This doesn't surprise Belott, who has operated on two Medicare patients for whom he has yet to receive payment. He believes that many people in New Orleans who could benefit from the surgery don't have the means to afford it. "The patients who need it the most don't have the funding," Belott says. "Obesity, unfortunately, runs rampant in underprivileged communities."

Stephens notes that obesity spans across economic, race, age and gender lines. As for whether or not the federal government should pay for surgical procedures for the morbidly obese, he says it's a difficult question.

"No matter what you do with them, they are at increased risk," Stephens says. "If they have the bariatric surgery, a significant number of people will die from the surgery. If they don't have the surgery, a significant number will die from the complications of walking around with all this excess weight. So, if you're looking at the utility and if Medicaid or Medicare should pay for bariatric surgery, it's complicated.

"The first question I would have is, 'Did this person seriously try to do a nutritional and dietary intervention?' The problem is a lot of people are just looking for a quick fix. If people have no other resources, no other options, and at the end of their limit, that's what bariatric surgery should be reserved for."

Stephens would rather see tax dollars spent on preventative public health initiatives such as the New Orleans Health Department's "Step Together New Orleans." In September 2003, the U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention awarded the city's health department a five-year funding agreement as part of the Steps to a HealthierUS initiative. The agreement allows the health department, in conjunction with the Louisiana Public Health Institute and other local organizations, to coordinate city-wide efforts to reduce the burden of diabetes, asthma and obesity. Stephens says this kind of effort will benefit the many -- instead of selecting a few for surgery.

"The answer is simple," he says. "If you're spending $25,000 (the average cost of gastric bypass) per person and you have 10 people, that's $250,000. Is your $250,000 better spent on 10 people or is it better spent on infrastructure stuff that can help the 200,000 people who are overweight by putting in bike lanes and other kinds of public health interventions that we know can work?"

For her part, Sylvia Johnson wouldn't argue with Stephens about the need for better nutrition and exercise, and programs to support these endeavors. Since her operation, she routinely exercises, eats well-balanced meals and periodically attends nutrition classes. Even with her hard work, however, she credits most of her transformation to the surgery.

"If I had the money," Johnson exclaims, "I'd have a message written in the sky saying, 'Praise God and Dr. Louis Martin.'"

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