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Access to surgery

Obamacare denying patients access to bariatric surgery

ASMBS leading efforts to define the management of obesity and metabolic disorders as part of ‘chronic disease management’

The Affordable Care Act (also known as ‘Obamacare’) could have the unintended consequence of denying many patients access to bariatric surgery.

One of the key components of the ACA is a mandate that state health exchanges cover a set of health care service categories it has defined as Essential Health Benefits (EHB). Categories include ambulatory patient services, prescription drugs, and chronic disease management, among others.  

However, concerns over whether a uniform set of benefits could be too expensive in some states and a reluctance of the federal government to be seen making mandatory rules for all states, the US Department of Health and Human Services decided to match benefits to the most popular small group plan sold in each state, reflecting local competitive forces. This lead to obesity treatments not being covered in plans sold on the exchanges.

Dr John Morton

“There is a real geographic disparity and it's sad to say that many of the states expected to exclude obesity treatments can be found in the South, where the highest rates of obesity can also be found,” said Dr John Morton, ASMBS Secretary-Treasurer and former Access to Care Committee Chair, in a media briefing on the ASMBS website. “We are working very hard to change the equation so that all people with obesity, no matter where your home happens to be, can have access to evidence-based prevention and treatment programmes.”

It is expected 23 states will have obesity treatments including metabolic and bariatric surgery as part of its EHB, and five will also cover weight loss programmes. However, 27 states and Washington DC, states currently have no plans to include it.

States such as Alabama, Louisiana, Arkansas, Texas, and Mississippi will not require the plans to cover any kind of treatments for weight loss, whether by prescription drugs or bariatric surgery. It has previously been reported by the Centers for Disease Control and Prevention that Mississippi has the highest obesity rate in the US of 34.9%.

"Our hope was that there would be a single benefit for the entire country, and as part of that benefit there would be coverage for obesity treatment," Morton told Kaiser Health News.

"If they don't have insurance, they're not going to get therapy,” said Morton. “We see cancer therapy covered routinely. We see heart disease covered routinely. Why is it that we don't see obesity covered routinely?"

One of those states where obesity treatment for the newly insured may be excluded is Pennsylvania, where ASMBS State Chapter President, Dr Michael Bono, director of Northeast Bariatric Center in Hazelton, PA, remains “cautiously optimistic” despite the challenges that lie ahead.

“It's like playing chess,” said Bono. “When faced with a challenge, you have to counter with education, advocacy and evidence to support your position. We believe the evidence is on our side.”

Chronic disease management

In April, members of the ASMBS Pennsylvania state chapter, went to Capitol Hill to meet with legislative staff from seven Congressional offices. They returned with a commitment from US Representative Lou Barletta to spearhead a letter from members of Congress to US Health and Human Services Secretary Kathleen Sebelius calling for the agency to define the management of obesity and metabolic disorders as part of “chronic disease management.” Chronic disease management is one of 10 categories which must be included in each state's EHB.

This complements efforts by ASMBS and other groups including The Obesity Society, American Association of Clinical Endocrinologists and Academy of Nutrition and Dietetics who in a letter in December 2012 urged the secretary to also define obesity as a chronic disease, similar to diabetes, heart disease and cancer.

In April, ASMBS officials and members of other obesity organizations met with HHS to follow up on that letter and secure clear federal guidance regarding coverage of evidence-based obesity treatment services as a medically necessary essential health benefit. No guidance has been issued as of yet.

“The clock is ticking and we have to make the noise now and continue to make noise to improve patient access,” said Christopher Gallagher, Director of the ASMBS Washington Office. “It doesn't end in 2014 when the state health care exchanges get implemented. The defined Essential Health Benefits are subject to change again in two years and we want obesity treatment covered by every state, not just a percentage.”

Despite the exclusion of metabolic and bariatric surgery, the ACA does call for coverage of obesity screening and counselling regardless of what obesity treatments are covered or not covered.

”We believe that with more focus on obesity, there will be better access to evidence-based solutions like surgery, now and tomorrow,” added Morton. ”Prevention and screening alone cannot solve the obesity crisis, nor can surgery or other stand-alone interventions. The future solution will be a continuum of care, complementary to the many challenges of obesity. The sooner we marry prevention and intervention, the sooner we will be able to save more lives and turn back the twin epidemic of obesity and diabetes, an epidemic that is spiralling out of control."

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American Society for Metabolic and Bariatric Surgery

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