Obesity surgery Lawmaker wants to help patients bypass the costs
By BECKY PIEDEL
AROLE DASSONVILLE'S 5-foot-4-inch frame couldn't handle the 322 pounds stacked on top of it.
High blood pressure plagued her heart, and asthma attacked her lungs. A hernia protruded from her stomach. Sleep apnea kept her from getting a good night's rest. She took medications for just about everything.
But Dassonville, of Spotsylvania County, wouldn't accept that her weight was the problem.
Then one morning in 2003, Dassonville doubled over in pain while walking children from her home-based day-care center to the bus stop. She could hardly catch her breath.
A blood clot had formed in her leg and traveled to her lung.
Dassonville recovered after three days at Mary Washington Hospital, but she knew she was lucky. The clot could have killed her.
The scare prompted the 46-year-old to take her weight problem more seriously.
Dassonville started looking into gastric bypass surgery online. She mentioned the operation to her doctor, and they decided it was a realistic option for her.
"It was either I died because of the illnesses," she said, "or I'd die on the table. I was in a corner. I had to do it one way or the other."
In March 2004, Dassonville underwent gastric bypass surgery. She was one of nearly 200,000 Americans who had the procedure done that year.
Today, Dassonville is a slimmer 150 pounds. Her ailments are gone, and she feels like a new person.
"I'm 47 and I feel like I'm in my 20s now," Dassonville said. "I can run up the stairs now when before I had shortness of breath and arthritis."
Dassonville was lucky: While some gastric bypass patients face the burden of paying for the expensive surgery, she paid only her yearly deductible. Her insurance provider, Anthem, paid for the rest of the $25,000 operation.
Not all insurance companies foot the whole bill. Some say the procedure is too risky. And recent studies on gastric bypass say the risk of complications, including death, is higher than previously suggested.
But a Virginia lawmaker wants to require insurance companies to provide coverage.
During last year's General Assembly session, Republican Del. John O'Bannon, of Henrico County, proposed a bill that would require insurance companies to pay for the surgery as treatment for morbid obesity.
He will introduce a similar bill this session.
"I think the surgery has come of age," O'Bannon said. "It's where gall bladder and other surgeries were years ago. It's proven to be a value and I think it's appropriate that it be covered."
The limits of the law
Currently, Virginia requires insurance providers to "offer and make available" services for the treatment of morbid obesity that are approved by the National Institutes of Health. The only approved service is surgery.
But the offer doesn't mean coverage is guaranteed.
Insurance companies offer the benefit at an extra cost, and it's up to the individual or employer to purchase it.
Riders for the coverage can raise premiums $50 to $100 a month, making it a pricey and unattractive option for individuals and small market employers. The result is that many people don't have coverage for the surgery.
A bill proposed last year called for mandated coverage, but it was rejected before it reached a full vote in the General Assembly.
O'Bannon will introduce a slightly altered bill Thursday.
The bill will define "Centers of Excellence," which are hospitals and surgeons fit to perform bariatric procedures.
The mandated coverage in Virginia would be limited to these centers.
The centers will be certified by the American Society for Bariatric Surgery and the Surgical Review Corporation. Hospitals must prove that they have the resources, and surgeons the experience, to perform the surgery.
O'Bannon says he thinks limiting the mandate to these centers will help satisfy insurance companies' concerns and make the bill stronger.
There are about 60 centers nationwide, said Dr. Neil Hutcher, President of the ASBS. There are three in Virginia: VCU Medical Center and Saint Mary's Hospital, both in Richmond, and Sentara Careplex Hospital in Hampton. These hospitals include eight bariatric surgeons.
Approval is pending for 10 other hospitals and 20 surgeons in Virginia.
Mary Washington Hospital is not one of them. The hospital had a bariatric pilot program in 2003, but the procedures haven't been performed there since, said Kathleen Allenbaugh, spokesperson for MediCorp Health System and the hospital.
"We would like to see our own people take a different approach," Allenbaugh said.
MediCorp employees use Weight Watchers, which is encouraged by the hospital. Allenbaugh says the program has worked.
"Not to say [surgery] is something we disapprove of, but we're not 100 percent comfortable with the risk versus the benefits," Allenbaugh said.
Risks and costs
Recent studies on gastric bypass revealed that the complications associated with the surgery are higher than previously thought.
A 2005 study reported that patients are more likely to be hospitalized after having the surgery than they were before.
Another study said the risk of death among Medicare patients having bariatric surgery is higher than previously suggested. It showed that men and older people are more likely to die after surgery. Compared to younger patients, it showed mortality rates up to three times higher for people age 65 and older.
Though the surgery seems riskier for the elderly, O'Bannon's bill would not preclude them from getting insurance coverage for it.
All people interested in having the surgery are screened for a variety of factors, including psychological ones. Hutcher, of the surgery association, says Centers of Excellence will use the same criteria to evaluate surgical candidates of all ages.
"There is no age that is going to be an automatic cutoff on the upper end," he said.
The findings in the studies are only one source of opposition to mandated coverage.
Members of the insurance industry also contend that the mandate will raise the cost of insurance for everyone, not just people undergoing bariatric procedures.
Doug Gray, executive director for the Virginia Association of Health Plans, says the greatest burden will fall on individuals and employers who can't afford to self-insure.
"When you pass a very expensive mandate--and this would be the most expensive in Virginia ever--the impact falls predominantly on small employers," he said.
Larger companies wouldn't necessarily have to follow the mandate, according to the Employee Retirement Income Security Act. ERISA allows large companies to self-insure. Self-insured companies are exempt from state-enforced mandates.
Maryland is the only state with a mandate for bariatric surgery.
"Our main concern with any of these mandates is that any time you add one, the cost of insurance has to go up," said Keith Cheatham, vice president of government affairs for the Virginia Chamber of Commerce.
Advocates argue that covering the operation will save insurance companies money in the long run. Dassonville thinks she's proof of that.
"Before, I had to see five or 10 different doctors for different ailments," she said. "That's more costly in the long run than having the operation, which likely will eliminate some problems."
'The surgery is the beginning'
Dassonville applied for the surgery at VCU Medical Center in August 2003. The application was 15 pages long, and stacked with questions about her medical history.
She heard back four months later. After a physical exam and a psychological evaluation, her operation was scheduled.
Dassonville said she had been overweight her entire life. At 9 years old, she weighed 90 pounds. The traditional means of weight loss--diet and exercise--had never worked.
"It wasn't like I was a lazy person," she said. "I was always moving it's not like I was a couch potato."
Dassonville underwent Roux-en-Y gastric bypass surgery, an operation that restricts both food intake and the amount of nutrients and calories the body absorbs.
RGB is the most common bariatric procedure in the United States.
A small pouch is created at the top of the stomach where food enters from the esophagus. A Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach and also the first parts of the small intestine.
Laparoscopy is an option for most RGB patients. With laparoscopy, several small incisions are made rather than one large one.
This method creates less tissue damage, and recovery is faster than with open procedures.
Dassonville went in for her laparoscopic gastric bypass surgery on a Monday and was discharged from the hospital that Wednesday. She said she was back to work as a licensed day-care provider the following Monday. Recovery time is typically about a week.
"I was up and about and doing my thing," Dassonville said. "I wasn't laid out or anything."
She learned quickly that she couldn't eat whatever she wanted anymore. When she ate too fast or too much, she got sick.
"Dumping" is a common side effect of the surgery, caused by eating too much or eating sweet foods. Symptoms include nausea, vomiting and diarrhea.
To avoid dumping, Dassonville had to drastically change her diet. She replaced steaks with yogurt and cottage cheese. She ate a lot of protein to prevent hair loss.
The surgery decreases the amount of nutrients the body absorbs. Patients have to take vitamins and supplements to avoid malnutrition.
Dassonville takes multivitamins, Vitamin B12, calcium and iron.
"The surgery is the beginning of the process," Hutcher said. "Patients have to use it and do other things--exercise, make better eating choices, take their dietary supplements. It's a lifetime follow-up, it's not just having an operation and saying 'I'm fixed.'"
Quality of life
Bariatric surgery can help some people lose weight, and doctors say it also can help eliminate pre-existing illnesses.
"I have some of my patients who have had high blood pressure, sleep apnea and diabetes, and they've had it done and those things go away," said Del. O'Bannon, a neurologist. "It improved their whole quality of life."
But Gray, of the health plans association, says the mortality rate is too high and the cost of possible complications too great to mandate coverage of the surgery.
Dassonville hopes lawmakers will agree with her and decide that the benefits are worth the risks--and worth having insurance pay for.
Her ailments are gone, and so is her stack of prescriptions. As far as she's concerned, gastric bypass surgery saved her life.
"It really lifted my spirits up," she said. "I think it's a lifesaving tool for those who need it."