Coverage Offered for Bariatric Surgery on Limited Basis to Pennsylvania State Employees

| March 1, 2018

This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery (ASMBS) leadership—past and present—on relevant topics in the field of bariatric surgery.

Funding: No funding was provided for this article.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Bariatric Times. 2018;15(3):23–24.

An Interview With:

Samer Mattar, MD, FACS, FRCS, FASMBS

Medical Director, Swedish Weight Loss Services in Seattle, Washington

President of the American Society for Metabolic and Bariatric Surgery (ASMBS)

Introduction

According to a press release from the American Society for Metabolic and Bariatric Surgery (ASMBS), the Pennsylvania Employees Benefit Trust Fund (PEBTF) will now offer insurance coverage to state employees for bariatric surgery with a variety of restrictions. Now only seven states do not offer some level of coverage for bariatric surgery for state employees.

The new coverage policy, which was made official January 1, 2018, would only cover patients who have Type 2 diabetes and a body mass index (BMI) of at least 40. Additionally, patients must spend at least six months before surgery in a physician-supervised nutrition and exercise program. The PEBTF currently covers about 140,000 people in Pennsylvania.

However, while the ASMBS is grateful for the step forward, it disagrees with some of the coverage’s restrictions. The organization notes that Type 2 diabetes should not necessarily be a requirement for patients seeking bariatric surgery. Additionally, the organization’s 2016 guidelines, which have been endorsed by 45 health groups, state that bariatric surgery should be a possibility for patients with a BMI as low as 30, not 40. Obesity currently afflicts just over 30 percent of people in Pennsylvania.

“Despite the restrictions, this is real progress and a victory for patients,” said ASMBS State Access to Care Representative (STAR) Ann Rogers, MD, director, Penn State Surgical Weight Loss. “Our hope is that this is just the beginning and once the plan sees for itself the impact bariatric surgery has on its members, it will expand its access even further and many more patients will benefit.”

What are your initial thoughts on the Pennsylvania Employees Benefit Trust Fund (PEBTF)’s decision to cover bariatric surgery for state employees, even though it comes with restrictions?

Dr. Samer Mattar: This is yet another advancement for our noble mission to increase and enhance access to life-saving care for thousands of deserving patients, even if it comes with some restrictions. We should still consider it a win.

What was the role of the ASMBS in helping Pennsylvania state employees gain this coverage?

Dr. Samer Mattar: This monumental effort was the fruition of relentless efforts, much energy, and provision of resources by numerous components of ASMBS. It is a prime example of what can be achieved through the power of organization and unified sense of purpose.

Our Access To Care committee under the leadership of John Scott, MD, FASMBS, and our Political Action Committee (PAC), under the directorship of John Morton, MD, MPH, FACS, FASMBS, played important and sustained roles in this effort, but a lot of credit should also go to Ann Rogers, MD, FASMBS, and her local team of activists who doggedly and repeatedly pursued opportunities to meet with state legislators and decision makers and explain the myriad benefits of providing access for our patients.

What do you think is the No. 1 reason why insurance companies are so hesitant to offer coverage for bariatric surgery?

Dr. Samer Mattar: I hate to sound cynical, but the reality is that insurance companies enter their respective fields for the prime purpose of making a profit. Unfortunately, many insurance executives focus on short-term gains through cost cutting measures, such as erecting barriers to life-saving surgery or increasing denials to surgery, all of which are measures inherently designed to save money.

How long do you think it’ll take before all states offer some level of coverage for bariatric surgery for state employees? Is it likely this will ever become a nationwide trend?

Dr. Samer Mattar: As a surgeon, I am essentially an optimist, but having said that, there are many reassuring signs that our message is being increasingly heard. Our colleagues in other subspecialties are accepting the superiority of metabolic surgery as the most effective, most durable, and safe option for many life-threatening weight-related diseases, such as diabetes, sleep apnea, and cardiovascular disease. Indeed, many societies are issuing guidelines to that effect. Many orthopedic surgeons will now routinely ask us to help their patients achieve reversal of inflammatory joint conditions through dramatic weight loss before they operate on their patients. These are undeniable forces that compel legislators and administrators to accept that metabolic surgery is indeed the most effective solution for their employees, thereby rendering coverage decisions that will continue to align with scientific facts.

I predict that we will soon witness a tidal wave of coverage by states for their employees. What a happy day that will be!

Are there actions that patients can take to help pressure insurance companies to cover bariatric surgery? If not, who holds the biggest responsibility in getting these companies to offer coverage?

Dr. Samer Mattar: Definitely patients, family members, and their friends can play a decisive role in influencing these types of decisions. This is exactly what it will take. We need a tumultuous grassroots groundswell of a movement that will result in a seascape change in the minds of insurance executives. Another group we should target is employers who are charged with purchasing coverage for metabolic surgery. These administrators and owners need to be educated on the countless benefits that can be achieved through metabolic surgery, resulting in reduced absenteeism, reduced workplace accidents, reduced sick days, increased productivity, and increased retention of happy employees.

 

 

Tags: , ,

Category: Ask the Leadership, Past Articles

Comments are closed.