Sunday, July 12, 2009 | 2 a.m.
Before you read this story, please suspend any biases you may have about fat people.
Now consider this question: If it saved you money for morbidly obese people to have weight loss surgery, would you suggest they do it?
The simplistic approach to weight problems is to tell people to stop eating junk and get off the couch. But experts say that’s not realistic for someone who is more than 100 pounds overweight.
“Data shows it’s difficult for someone morbidly obese to lose the weight through something other than bariatric surgery,” said Dr. Lisa Latts, vice president of clinical excellence for the insurance company Anthem Blue Cross and Blue Shield.
So if insurance companies affirm that morbidly obese patients benefit from stomach surgery, they must cover it, right?
Nope. They have their reasons. We’ll get back to that.
For now, consider the case of Vincent Daswell.
We met Daswell randomly in early 2008 at a seminar for people considering gastric surgery. He was 33 years old, and he was suffering. He had health conditions beyond his control — bipolar disorder and intractable migraines, which had set in about five years before.
And he had health problems that he could not control. The migraines disabled him. Being disabled depressed him. Depression led him to eat: Butterfinger ice cream by the half-gallon. Pizza by the box. Chicken by the bucket. King-size Snickers bars, three at a time, 560 calories apiece (that’s about as much as a Big Mac).
In his prime, in high school, Daswell carried a sturdy 200 pounds on his 5-foot-10 inch frame. He was a varsity running back. As he packed on the weight, his activity went from playing sports and pursuing his interest in rap music to watching TV and eating. His waist ballooned to 56 inches and he was so ashamed he wouldn’t even visit his mom’s house. He’d beg off when friends would invite him out: “I didn’t know what to say to them,” he recalls, sitting on his couch in early 2008 in sweatpants and a super-sized T-shirt. “I didn’t have nothing to wear. It’s just embarrassing.”
When he married Gail, in July 2004, he was 250, and climbing. He remembers putting on 30 pounds in May 2006 alone. He topped out at 380 in early 2008.
As Vincent was packing on the weight, Gail was going to school during the day and working at night. She tried to help him — even yelling at him a time or two. But after a while she gave up: “If you can’t beat ’em, join ’em,” she remembers thinking. Before long, they were gorging together and she was moving up in clothing sizes, too.
The hardest part for Vincent was his relationship with his boys: Phillip, 16, and Randy, 17, who are Gail’s sons from a previous relationship; and Deon, 13, his son from a previous relationship.
He longed to run with them in the park. Throw the football. Do dad stuff. But he strained to get off the couch and wouldn’t even walk to the mailbox.
And here’s where Daswell’s story matters to the rest of us. Obesity carries such a stigma — Daswell knows this — that plenty of people will be unmoved by his plight. Some will probably be angered by it.
But with his obesity came a slew of related health problems and associated costs to society. He injected himself with doses of insulin the size of your pinkie to control his Type II diabetes. His blood pressure and cholesterol were through the roof. He slept with a oxygen mask on his face because of sleep apnea. His weight caused the arches of his feet to flatten and his joints to flare. His main activity outside the house was going to doctors, who all knew him by his nickname, “Junior.”
And this is where we come in — Medicare, the government’s insurance for people who are over age 65 or disabled, picks up the tab for his health care. Thus, any taxpaying American has a stake in the care provided to patients like Daswell.
How big is the tab? According to Daswell’s Medicare summary notice, in the two months from Jan. 22 to March 28, 2008, the government paid doctors $4,662.08. That does not count costs of drugs or hospital visits.
Daswell’s plight illustrates a much broader problem. The number of overweight and obese Americans is on the rise. In 2005, more than a third of American adults older than 20 were obese — about 72 million people, according to the Centers for Disease Control and Prevention. The fastest growing group of obese Americans are those who are at least 100 pounds overweight, which increased by 500 percent from 1987 to 2005, the RAND Corporation reports.
Obesity is measured by a ratio of a person’s height to his weight. RAND, for example, categorized the following people as obese:
• Someone 5 feet 6 inches tall and more than 186 pounds.
• Someone 5 feet 9 inches tall and more than 203 pounds.
• Someone 6 feet tall and more than 221 pounds.
In 2000, the CDC estimated the total cost of obesity in the United States at $117 billion. By 2020, obesity problems will consume more than one-fifth of health care costs in the country, according to RAND. The federal budget is collapsing under the financial weight of Medicare, and reforming health care is at the forefront of the agendas of Congress and President Barack Obama.
In 2007, about 205,000 Americans took the desperate measure of undergoing a bariatric surgical procedure. The surgeries limit the amount of food that can be consumed at a sitting by reducing the size of the stomach by about 90 percent. But as Daswell found, surgery is no magic bullet. Successful weight loss after the surgery requires dramatic life change.
Before surgery, Daswell knew his situation was dire. He knew he would have to have the discipline to stop eating.
“I know I have to do it if I want to reach 40,” he said, laboring to get out the words. “If I want to have a life for myself, there’s no choice for me.”
It’s May 27, 2008, and Daswell is prepping for his surgery at North Vista Hospital with Dr. James Atkinson. His pre-op weight is 376.3 pounds. Medicare covers the surgery by Atkinson, at North Vista, because their short- and long-term outcomes have earned the Bariatric Surgery Center of Excellence designation from the American Society for Metabolic and Bariatric Surgery.
The bands are the latest iteration of bariatric surgery, which has been around since the 1960s. Back then, doctors performed bypass operations so food would go through only two feet of intestine instead of 20, so the body absorbed a minimal amount of food. That procedure lost appeal because it caused chronic diarrhea.
Gastric bypass surgery was also developed in the 1960s and is today the most common weight-loss surgery. A surgeon creates a pouch above the stomach with staples or a band and reroutes it to the middle of the intestine.
The gastric band procedure, approved in the United States in 2001, is much less invasive and is safer than the bypass — but requires much more behavior change. It’s usually done laparoscopically, using small incisions and long instruments to reach the stomach. The band includes a balloonlike collar that wraps around the stomach, creating a pouch that holds about an ounce of food. The band is filled with saline solution, connected to a tube that runs to a port that’s attached to the abdominal wall, under the skin. As the patient loses weight, the stomach loses fat and the collar becomes loose. Doctors’ maintenance includes injecting saline solution into the tube to keep the collar tight.
Atkinson and his partner do about 100 bariatric operations a month. The band is growing in popularity and now makes up about 80 percent of the procedures.
Daswell’s gastric band procedure takes about 20 minutes, and he now defines his life as “before surgery” and “after surgery.” In the first week he was allowed only fluids, for fear of stretching out the cell-phone-sized pouch that is now his stomach. He dropped 23 pounds. Within three weeks he fit into his size 48 pants and had been weaned off four pills — two for gastroesophageal reflux disease, one for diabetes and one for high blood pressure.
His stomach was so small he ate off a small saucer, using a child’s fork. During a meal about a month after his surgery, his 2-ounce serving of meat — about half the size of a deck of cards — was cut into about 20 tiny pieces. On the side he had a spoonful of brown rice and a tiny portion of celery and broccoli. He ate as he was taught at the doctor’s office, chewing patiently, putting the fork down and counting to 25 before taking another bite.
The ensuing months had their ups and downs for Daswell, but at his most recent appointment at Atkinson’s office, on June 29, he weighed 272.2 pounds — more than 104 pounds lost since his surgery.
Daswell looks and sounds like a new man. During a recent visit he wore a button-down shirt and shorts and was lean in comparison to his pre-surgery condition. He’s going to school to become a computer technician. He still suffers from headaches but looks forward to being off Medicare disability.
“That’s not my goal in life, to be disabled and on government assistance,” Daswell said. “I want to get better and see my family life better.”
The preliminary financial outlook for taxpayers is looking better, too. Daswell’s pharmacy records are a single measure, but were the most concrete way for the Sun to measure part of his cost to Medicare before and after the surgery. The Sun calculated the cost of drugs for his obesity-related sicknesses: arthritis, depression, diabetes, gastroesophageal reflux, high blood pressure and high cholesterol.
• In the first five months of 2008, taxpayers provided Daswell with 17 medications for obesity-related health problems at a cost of $8,374.19.
• In the first five months of 2009, taxpayers provided Daswell with 13 medications for obesity-related health problems, many at reduced dosages, at a cost of $5,106.54.
It’s a simple measure, but shows a savings of $3,267.65 in the five months, a 39 percent reduction in expenses in drugs alone.
Daswell’s surgery cost about $16,000 for the procedure and first year of follow up. If the pharmacy costs were the only savings realized, the expense could be recouped in just over two years. That does not count the costs Medicare would presumably save in doctor visits and medical equipment — he barely uses the sleep apnea machine he once depended on every night. The equation would also have to factor in the long-term chance that Daswell could contribute to the economy by getting a job and going off Medicare disability.
So does this work for other morbidly obese people?
Research shows that Daswell’s weight loss has been exceptional, but that his improved health is the norm.
Atkinson, the doctor who performed Daswell’s surgery, said gastric band patients might lose only 15 percent of excess weight — versus the expected 50 percent — if they don’t do follow-up visits to tighten the band, or eat too many calories through snacking. But they could also lose up to 80 percent if they’re disciplined, he said.
The Surgical Review Corp. keeps comprehensive statistics for the bariatric surgery industry based on data from more than 57,000 people who have undergone bariatric procedures. Dr. Eric DeMaria, the lead researcher who has examined the database, said bariatric surgery patients generally lose about half the excess body weight.
But it’s more important to examine the surgeries in terms of improved health, DeMaria said.
A 2008 study in the Journal of the American Medical Association showed remission of Type II diabetes — one of the costliest conditions afflicting American society — was 73 percent in a group that underwent gastric band surgery, and 13 percent in a group that underwent conventional therapy. Other studies show decreases in cholesterol, high blood pressure and sleep apnea.
The failure rate for the surgeries can be as high as 20 percent, DeMaria said, but taken as a whole the surgeries are still cost effective.
“All the analysis seem to be supporting cost-saving from a population-based standpoint, as well as tremendous health improvement, even with average weight loss,” DeMaria said.
A study in The American Journal of Managed Care examined the economic effect of bariatric surgery for 3,651 patients who underwent the procedures. At a cost of about $28,000, gastric bypass procedures are more expensive than band surgeries. On average, the downstream savings from improved health offset the initial costs within two to four years, the study found.
“Third-party payers can rely on bariatric surgery paying for itself,” the study said.
Under certain conditions insurance companies do cover bariatric surgeries, but they often do not. Latts, the doctor who works for Anthem Blue Cross and Blue Shield, said the surgeries are covered by some of her company’s plans, but not others.
Insurance companies have several reasons for not automatically covering the procedures, Latts said. First is competition: If Anthem covers bariatric surgery universally but its competitors do not, then morbidly obese patients will flock to Anthem, raising the costs for everyone insured by the company.
Turnover is the second consideration. These days, people change insurance plans often, so Anthem could pay for the surgery upfront and never realize the savings, Latts said.
But heart surgery also costs a lot upfront and insurance companies may never realize the long-term savings. What’s the difference?
“That’s a great question,” Latts said. “I don’t have a good answer for you. But there is a perception that bariatric surgery is a choice. It’s a choice that people have rather than staying the weight they are or going for another mechanism of weight loss ... I can see both sides of the equation. For someone who is morbidly, obese their options are limited. We hear about weight loss on ‘The Biggest Loser’ but it’s incredibly difficult.”
Policymakers could address some of the insurance companies’ concerns by requiring all companies to cover bariatric surgery. But Latts said she does not favor mandates because then every interest group representing people with certain medical conditions would want them, and that would cause costs to rise for everyone else.
Latts said all proposals should be on the table when discussing health care reform. But Anthem spokeswoman Sally Kweskin wondered whether the American public “has the stomach” to endorse bariatric surgery.
“There’s so much prejudice against it, and anger and disgust,” Kweskin said. People tend to think that an obese person should be able to handle the problem on his own, she said.
Josephine Johnston, research scholar at The Hastings Center, a bioethics institute, said bariatric surgery does seem to have merits, but policymaking efforts should emphasize avoiding obesity in the first place. The U.S. health care system should be restructured so providers are paid to help people avoid extreme weight gain, Johnston said.
Michael Kalichman, director of the University of California, San Diego’s research ethics program, said he has not studied the issue, but the scenario may boil down to whether people recognize it’s economically sound and in their best interests for morbidly obese patients to get bariatric surgery.
It’s an “educational challenge for people who are insurers and insured to know what’s best,” he said.
Daswell isn’t thinking about the ethical or policy implications of his gastric band surgery. He looks over at his son Phillip, 16 and thin as a rail, and says one of his goals is to beat him in a
40-yard-dash when he gets down to 200 pounds.
He clearly relishes the thought of taking on the kid. Unlike the pre-surgery Daswell, he’s looking forward to his future.
Gail, too, looks forward to the future. Her gastric band surgery is scheduled in the coming months.
Sun reporter Alex Richards contributed to this story.