The unprecedented campaign to force insurers to cover bariatric procedures

As a result of several scientific reviews of the evidence on bariatric surgeries which found the risks and costs “too great,” Blue Cross Blue Shield of Florida decided to follow the footsteps of growing numbers of insurers and drop coverage for bariatric surgeries for its members, effective January 1, 2005.

In response, the American Obesity Association, the lobbying organization for weight loss interests, launched project OPERATE to compel the company to reverse its decision. The OPERATE coalition included OAO sponsors, bariatric surgeons and companies, hospitals and others interested parties — but was designed to appear a grassroots advocacy effort, even by the acronym chosen: “Obese People Entitled to Reasonable Appropriate Treatment Equitably.” In addition to a write-in campaign to Florida company representatives and officials, they set their sights nationally. Knowing that most insurers follow the guidelines of the Centers for Medicare and Medicaid Services (CMS), they focused on getting them to cover bariatric surgeries.

They were joined by the American Society for Bariatric Surgery (ASBS), the lobbying organization for the bariatric surgery industry; a newly formed “patient advocacy” coalition, the Obesity Action Coalition; and others. OAC was founded by a bariatric surgeon who also serves as an educator for Ethicon Endosurgery, on the board of directors for Viking (3-D endoscopic technologies), and is also Vice Chairman of the Surgical Review Corporation, Center Review Committee (responsible for certifying the “Centers of Excellence in Bariatric Surgical Care” in the U.S.). The OAC’s mission is to educate the public on “obesity and morbid obesity,” successfully placing hundreds of articles in media across the country to date, focus national attention on obesity, and advocate for action and public policy change.

On November 23, 2005, CMS released their proposed rule change which will extend coverage for bariatric surgeries and it will go into effect February 21, 2006. Its February 21, 2006 press release stated it will cover bariatric surgeries for Medicare recipients in “high-volume centers that achieve low mortality rates” (Centers of Excellence).

These coalitions are now working to get private insurers to follow suit, by supporting legislation to mandate insurance companies cover the surgeries. The pressures on Blue Cross Blue Shield may be working. It’s November 2, 2006 Medical Advisory Panel meeting voted that “laparoscopic adjustable gastric banding for morbid obesity meets the TEC criteria, when performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.” This was despite no new evidence to counter its scientific assessment one year earlier which had concluded that the long-term evidence “had not demonstrated improved net health outcomes.”

© Sandy Szwarc 2007