Insurance Policies: A Serious Barrier to Treatment
Jennifer C. Seger, MD, FOMA, is the Co-clinical Editor of Bariatric Times; Diplomate, American Board of Obesity Medicine; Medical Director, Bariatric Medical Institute of Texas, San Antonio, Texas.
Dear Readers,
With the recent increase in media coverage around obesity treatment, I thought it might be helpful to gain some perspective from someone who is working on the front lines trying to increase obesity care coverage. Dr. Mickey Seger has served on the American Society for Metabolic and Bariatric Surgery (ASMBS) Access to Care committee for the past seven years and is currently the Chair. He has had a front row seat to the battle to improve obesity medicine coverage. For this editorial message, I have invited him to share his perspective on the issue, written below:
Over the past 7 to 8 years, I have had the privilege of collaborating with colleagues from around the country to fight for better access to care for patients with obesity.
Much of our work has centered around discriminatory policies that marginalize patients with obesity. Somehow it is perfectly legal for an insurance company to provide healthcare coverage to people but exclude obesity, which affects 40 percent of our population, as a covered disease. How has this gone unchecked? My work on the committee has convinced me without a doubt that it is more common to see arbitrary, illogical policies when it comes to the treatment of obesity than thoughtful and comprehensive ones, which is clearly what we need.
For example, we recently learned about a policy update by Blue Shield of California which now mandates, among other requirements, one year of pharmacologic treatment for obesity before they will approve a bariatric surgery.1
Here is the specific language as it relates to this point:
“Bariatric surgery for the treatment of morbid obesity may be considered medically necessary when all of the following criteria are met:
…C. The patient has failed pharmacologic treatment of at least one year by not achieving weight loss below a [body mass index (BMI)] of 30kg/m2 (27.5kg/m2 for Asian individuals) or failing to maintain weight loss below 30kg/m2 (27.5kg/m2 for Asian individuals) despite ongoing treatment.”
Don’t you just love it when insurance companies practice medicine? Even though the science shows that delaying bariatric surgery in individuals who qualify might actually be detrimental to their health,2 Blue Shield of California has stooped to a new low, requiring patients to complete a year’s worth of medication, and FAIL, prior to their approving bariatric surgery.
Have you guys done any Prior Authorizations lately? If a patient is approved, they are often only allowed to continue said anti-obesity medication (AOM) if there is “proof” that the medication is working and the patient is losing weight. How exactly can a patient EVER fail after 12 months, if they haven’t been allowed to continue the said medication because it isn’t working?
Fact: When an AOM is ineffective, the label directive is to stop or switch to a different medication. So, with this logic, Blue Shield of California patients who have indications for bariatric surgery would be put on a medication which has to fail to qualify them for surgery, but the very nature of the failing removes the clinical indication for the medication.
Additionally, the plan is unclear about what medications will be covered; however, it seems unlikely that the newer, more effective glucagon-like peptide-1 (GLP-1) analogue medications would be included, since the cost of these can be over $1,000 per month. It doesn’t seem to make good financial sense to require the full year of therapy at that cost, and then pay for the surgery after that. As Blue Shield of California reported $22.9 billion in revenue last year, I highly doubt they would want to foot that bill.
It seems like their plan is to not cover bariatric surgery at all with this nebulous and unfair policy, even though every major medical association and society is supportive of obesity treatment, including surgery.
When are we going to say enough is enough and stand up to these companies for withholding or delaying proven and needed care for our patients? Clearly, they are focused more on their bottom line than on helping people with obesity. And due to pervasiveness of weight bias, this discriminatory practice is normalized and all too common.
If you have a minute, take time to send a letter to Blue Shield of California about this ridiculous policy. Share with your patients on social media and in support groups, and ask them to speak up.
In health,
Jenny Seger, MD, FOMA
References
- Blue Shield of California. Medical policy: bariatric surgery. Effective 1 Feb 2023. https://www.blueshieldca.com/bsca/bsc/public/common/PortalComponents/provider/StreamDocumentServlet?fileName=PRV_Bariatric_Surgery.pdf. Accessed 20 Mar 2023.
- Kushner BS, Eagon JC. Systematic review and meta-analysis of the effectiveness of insurance requirements for supervised weight loss prior to bariatric surgery. Obes Surg. 2021;31: 5396–5408.
Category: Editorial Message, Past Articles
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