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Weighty Debate

Should insurers be made to pay for weight-loss surgery? At least one patient hopes to convince the General Assembly to say yes.

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On the advice of his doctor, Nowell visited Dr. Neil Hutcher at Bon Secours St. Mary's Hospital. Hutcher determined Nowell was a good candidate for gastric bypass surgery, the procedure of last resort for the dangerously obese. Nowell could barely walk. "His legs wept," Hutcher says. If he didn't lose weight, he faced death.

Even now, Nowell doesn't much like talking about the surgery, and keeps veering into stories about charity matches he organized for the local high school. "Talk about your bypass, Ronnie, not wrestling," his wife, Milinda, gently reminds him.

Nowell traded his stomach for a tiny pouch March 4, 2004. After a year of treatment, rehabilitation and physical therapy, he went home.

Today Nowell is 39 and weighs 255 — having lost 460 pounds. His face and torso are that of a thin man. His biceps and his dimples have reappeared, to his delight. A December surgery removed 23 pounds of excess tissue and skin from his thighs, and when the swelling goes down his legs will take on a more normal contour. He can shop at Wal-Mart. He can cast a line for catfish at the nearby pier. And at last, he can walk.

Nowell's now preparing to walk down the halls of the state legislature, to testify in support of a proposed bill that would require insurers to pay for weight-loss surgery for people like him. His plan is simple: "Tell 'em my story. How it's changed my life."

The fate of the bill isn't as clear-cut. Proponents argue that coverage of weight-loss surgery should be mandated by state law just as other medically necessary procedures are: cancer screenings and childhood immunizations, for example.

Opponents, most notably the state health-insurance industry and business owners, think that decisions on whether to include weight-loss surgery in insurance policies are best left to employers. "This approach lets the free market work," says Leonard Hopkins, head of government affairs at Anthem Blue Cross and Blue Shield in Virginia.

The bill's biggest champion is Dr. Neil Hutcher, director of bariatric surgical services at St. Mary's and the president of the American Society for Bariatric Surgery.

Hutcher has been performing bariatric (weight-loss) surgeries since the beginning of the practice in the 1970s. As surgeons refined their methods and got better results, he says, "we began to find more and more of the insurance companies were trying to limit patient access to the procedure."

In July 2004, Hutcher says, many major health insurers began requiring high-priced riders — costing $50 to $100 per month, per person — attached to policies in order to cover bariatric surgery.

The surgery, Hutcher says, is like any other treatment for a life-threatening condition. Yet it's treated like no other medical procedure "because of the prejudice that exists toward people of weight."

Most people believe those who are extremely obese made themselves that way, Hutcher says. The truth is sometimes more complicated, as in Nowell's case. Weight depends on the environmental impact on one's genetic code, Hutcher says. Do insurers deny coverage for lung transplants for smokers, he asks, or bypass operations for people who ate too much bacon?

Nowell's Medicaid paid for the surgery when his wife's policy wouldn't cover it. "They said it wasn't medically necessary," Milinda says.

Such declarations by insurance companies incense Hutcher. "Obesity is not a cosmetic condition," he says. People who are 100 pounds or more overweight, or have a body mass index of 30 or more, often develop Type II diabetes, heart problems and obstructive sleep apnea, a condition in which a sleeping person stops breathing for brief intervals.

In many cases, Hutcher says, bariatric surgery is the only way to cure these conditions. He points to a 2004 study published in the Journal of the American Medical Association that found bariatric surgery cured Type II diabetes in 77 percent of patients. Diabetes care alone — which can include dialysis and insulin — costs an average $22,000 annually per patient, Hutcher says, plus $11,000 in indirect costs to the patient's employer.

Thus, he says, the approximately $30,000 cost of weight-loss surgery more than pays for itself once the patient's other health problems dissipate.

Anthem officials say they don't doubt the benefits of the surgery for some people when it is performed by a qualified physician, but they say the procedure is still evolving. And, they add, insurance costs would go up for everyone if employers were required to include weight-loss surgery in coverage for their employees.

"But that could be said for any disease out there," Hutcher retorts.

If insurance doesn't cover the procedure, Anthem's Hopkins points out, "anybody can simply pay for it."

Del. John M. O'Bannon III, R-Henrico, and Sen. Benjamin J. Lambert III, D-Richmond, will sponsor the bill.

"In general, I think you have to be cautious about mandating anything," says O'Bannon, a neurologist. But he says he's seen "the ravages of morbid obesity and the successes of bariatric surgery" firsthand among his patients.

O'Bannon says that the bill is crafted carefully to ensure that people seeking the treatment really need it, and that facilities performing the surgery are endorsed by the American Society for Bariatric Surgery.

A commission of legislators and citizens assigned to review the bill after it was introduced last year voted 6-4 against endorsing it. Hutcher says that doesn't worry him — legislators will still consider the bill this session, which convenes Jan. 11.

Nowell, no longer "Big Daddy," says he's eager to speak to legislators. "I'm going to try not to talk wrestling," he vows. S



How it Works

The Procedure: In a Roux-en-Y gastric bypass, the most common type of weight-loss surgery, the surgeon creates a pouch about the size of an egg from the upper end of the patient's stomach. The new pouch is attached to a lower section of the small intestine. The rest of the patient's stomach is reconnected to the intestines so it can continue to produce gastric juices.



Benefits: The rerouting of the digestive system restricts the amount of food a patient can eat and reduces the absorption of calories. People who undergo the surgery can eat only small amounts of food at a time, but still feel satiated. Weight loss begins immediately and continues for 18 to 24 months after surgery. Most patients lose 60 to 80 percent of their excess body weight.



Risks: For months many foods are off-limits and may cause vomiting. Doctors must monitor patients' protein and vitamin intake carefully. In 2004, 1,977 gastric bypass surgeries, all on high-risk patients, were performed in Virginia. About 0.5 percent of patients died within 90 days and 6.2 percent were readmitted to the hospital (for any reason) within 90 days.

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