Water Cooler Talk: Insurance Issues

From Thegreenhed.com

You probably have the same area in your building.  The area of the practice, the physical place, where the scuttlebutt gets discussed, where the issues of the day are reviewed and debated by those in the know. Those impromptu forums are always informative, sometimes emotional, and a good place and time to catch up on what's the latest theme or situation, and what to look out for so it doesn't happen again.

In my experience, sometimes these spontaneous get-togethers at the 'water cooler' better help to define and describe a new issue, and allow us to get a head start on it before it becomes a more perplexing isituation in the all too near future.  Usually those meetings are more efficient than a formal meeting might be, on the topic,  that would need to take place if the water cooler talk couldn't diagnose and treat the issue at hand.

Our water cooler is in the break room.  It's the very place I speak of for our practice.

The latest issue?  Insurance issues.  Here's a new twist on the recurring theme of moving the goal posts, in so far as insurance coverage of Bariatric Surgery for 'qualifying' patients.

Long gone are the simpler days of the recommendation of the NIH, that surgery should be covered for patients that have a BMI over 40, or a patient over 35 with comorbidities.

Then came the Medicare (CMS) standard a number of years ago that surgery could oly be performed and reimbursed at CMS "Accredited Centers of Excellence", which was somewhat recently overturned.

On a similar note, as far as a change from what is expected, certain insurances will not approve a patient who has a BMI in the range of 35-39.9 without a significant comorbidity.  Most are OK with OSA, HTN on at least one medicines, DM 2, and sometimes dyslipidemia on meds.

It can get very tricky though, as the indications have more stringent recently in which HTN is described as "controlled"if normalized on one or two or more meds.  We had a recent patient who was declined for surgery due to the fact that the Pulmonary note described the patient's newly diagnosed OSA (usually an absolute indication for surgery) as "mild" and the settings on the Cpap were "low.  Not covered by this insurance plan.

What's next? controlled DM2 on high doses of basal insulin, or a pump, but a glycohemoglobin under a certain range,  therefore "controlled" (even with their grossly overweight and contributory body habitus), and "not approved"?

Other tidbits of insurance coverage in our days at the office include Medicare's requirements that essentially any comorbidity can qualify a person starting at BMI 35, but weight alone does not.  So, when we get a patient referred to us by their primary, and their weight is say 350, and BMI of 62.... If they have no associated medical condition (although not very likely) that they come to us with, or a related malady we can acutely diagnose upon their visit to us, that insurance will not approve their surgery. Sounds unlikely to happen, but it does happen to us from time to time, especially in the younger patient with a significant weight but not much in the way of associated medical conditions...so far.

And a common conundrum we often visit from week to week: Revisions.

These days they mostly have to do with converting a Band to a different procedure, due to failed weight loss, or actual issues with their Bands (Dysphagia, pain, increased GERD, gastric prolapse). One insurance company in particular, a regional HMO, steadfastly denies any attempt to get these approved and do surgery. They have a policy of one lifetime weight loss surgery.  End of story.

We have tried many appeals in the past, peer to peer reviews, and even patients initiating their own appeals, with little success.

It's the first thing I look at when I have a patient in the office that may be interested in a revision, one who would otherwise qualify based on BMI and/or comorbidities.  Our talk requires an extra layer of disclosure, and a description of the poor likelihood of approval despite a long and lengthy process, as well as the unfortunate stance of their insurance company despite most other insurances working with us to help the patients get their surgeries completed.

I feel better now that I have vented some of those topics of discussion in the office lately, some old and some new.  Keep those in mind, or give us a call, if you ever have any related questions.

I am sure that your practice has a long history of dealing with insurance companies,  the good and the bad of it, as well as the whole 'moving the goalposts' scenario that seems to go along with this territory.

The next topic could be 'prior approvals' for medicines...... Don't get me started.

From Sophy.Ca

"From the Belly of the Beast"

From Philly.com  (MICHAEL HINKELMAN / Staff Photographer)

I honestly am not a fan of the Philly cheese steak sandwich, but I am not sure I have ever  had a true representative sample.  Coming close in our area, I would imagine is the Morette's steak sandwich, yet I am sure the 'Philly' aficionados would take issue with that comparison.

Check out this story out of Philly, from the heart of the Philly Cheese Steak country, and an icon of the storied business to boot, of a man who is in the process of making a drastic change in his life.

You know what they say about making a change in your life, by making a life change.

Even if you may dwell in the 'Belly of the Beast'.

He is the third generation owner of Geno's, and even his son is named after the family business. Cheese steaks are their game.

At 40 y/o,  5'6" and 336 (BMI of 54.2) he decided to make a change in his life, to essentially save his life and his life's business, and had LapBand surgery.

His story was detailed in a recent article in the Schenectady Gazette, as picked up from the Philadelphia Enquirer.

It's a great read, and peppered with similarities of many such stories of patients that are overweight, in need of a change in lifestyle, and make that decision to make a definitive change by having weight loss surgery.

It details how entrenched in his lifestyle he was prior to making the decision, the sentinel event that led him to look for a definitive surgical solution, some stinging memories of how he was treated by others based on his obese appearance, his recent development of comorbidities, and his plans for the future as he is down nearly 100# and on his way to a healthier approach to life.

Take a look - remind you of any of your patients who are lost in their lifestyle, with seemingly no way out of their weight and increasing disease states thus far?

There may be another option.  The remainder of their story is yet to be written, but we have a good idea how it may end up, if some kind of durable change is not enacted in the near future, surgical or otherwise.

Love Their Liver, Bariatric Surgery-Style!

How about this?

Despite most people out there in the lay public a little grossed out by liver (as a food) in general, and generally naive about the benefits of a healthy liver and its impressive array of necessary function -  I bring to you all, savvy health care providers, the results of a recent study published on the topic of liver benefits of bariatric surgery.

The liver, as you know, although having many other functions, has a great deal to do with glucose homeostasis, through storage of blood glucose as glycogen as well as conversion of glycogen back to glucose for energy needs.  The liver is certainly a site of fat deposition, as frequently occurs in obese patients, as is manifest in NASH (Non-alcoholic steato-hepatitis) resulting in liver dysfunction, as well and potentially cirrhosis as a long term result of severe disease.

So when a study released from the Journal of Hepatology recently detailed hepatic structural and functional changes to patients within 6 mos after Gastric Bypass and Sleeve gastrectomy (both metabolic procedures) vs. matched controls, it caught my eye.  Of additional note, the surgical patients were studied both pre and post-operatively.

The study revealed a marked improvement in liver size (by 26 %) and fat content (reduced by 76%) in association with the  substantial weight loss achieved in the 6 mos following surgery.

More importantly, hepatic insulin sensitivity was significantly improved, as measured by insulin-stimulated hepatic glucose uptake, and by measuring a decrease in endogenous hepatic glucose production. Both of these factors are noted to be part of the metabolic disruption that leads to hyperglycemia and the overt expression of DM 2.

All in all, perhaps not earth shaking news, as we are all becoming more aware of how the rubber is meeting the road as far as the anti-Diabetic effects of Metabolic and Bariatric Surgery demonstrate.

It is nice, though,  to have supportive scientific data to show a little more of the "Why" and the "How" to both quantify and qualify these amazing effects, as we see more and more success with our metabolically-challenged patients who undergo surgery.

Thanks for the time you spend with your patients, counseling them on the different pathways to better health and weight reduction, with Bariatric Surgery as one of those options.

And finally, a cheesy note from one of your patient's liver....

From Archive.constantcontact.com

The Tough Questions vs. The Right Questions

From epicvelocity.wordpress.com

Which is more difficult?  Asking the "Tough" questions, or asking the "Right" questions?

A case could be made for either, actually.

I would define the "Tough" questions as the type of question that implies intellectual pursuit; and the "Right" questions as those that need to be asked, and usually on the basis of a deeper understanding of the actual issues at hand.

Such is the case with an editorial recently published in the ACS Surgery News, by Dr. Bruce Schirmer, an ACS Fellow from the University of Virginia Health Sciences Center in Charlottesville.

In his editorial, he detailed an excellent point in regard to the "cost effectiveness" of Bariatric Surgery vs. other surgical procedures.  It followed another published report on the topic of an article recently published in JAMA that detailed the cost benefit to patients from Bariatric Surgery to an insurance company, vs. obese that didn't have the procedures.  It ends up by saying that more study is needed to measure the true benefit of bariatric surgeries, and look beyond just the financial aspects of short and longer-term benefit.

Why all the fuss about measuring the cost-effectiveness in regard to Bariatric Surgery, whereby other types of surgery and surgical procedures (i.e. joint replacements, hernia repairs, cataract surgeries, lung resections for Ca) seem to rarely undergo such investigation?

Thought-provoking point.  I am not sure that similar scrutiny in regard to other types of surgery could easily be justified by a strict dollars and cents (sense?) evaluation either.

There is certainly something more to the benefit of the procedures, including Bariatric surgical procedures, than just the measure of cost-effectiveness.  Most especially for metabolic and bariatric surgeries, quality of life is difficult to measure on a purely monetary scale.  That would include mental health, and improvement in sense of patient well-being, productivity, happiness, a deeper satisfaction in living, as well as an actionable concrete momentum to make other needed changes in their lives that heretofore they have been unable to actuate .  We have all seen these effects in our post-surgical patients, and if you ask them to 'count the ways' they are quick to detail many of them.

Or, more jermain to health care, is the fact that bariatric surgeries do save lives... and what's that worth?

There certainly are financial benefits to both patient and insurer as well, but not likely not as great as some of the other "touchy-feely" characteristics I attempted to detail above.

And, as Dr. Schirmer further puts forth, is it possible that weight loss surgical procedures are under repeated examination and criticism due to a "societal bias against obesity as being a byproduct of character flaws"?  Maybe.

As much as I am not a fan of the "victim mentality", or conspiracy theories, I guess that type of question does have merit, and would be likely more under the "right" side than the "tough" side.

Or do I have it reversed?

And, by the way, Happy New Year, and here's to more of both the Tough and Right questions, and  even some of their attendant answers over the next year!

(If you are under 21, please don't look at the following picture)

From letspour.com