Tufts Decision Demonstrates the Misguided Policies of Managed Care

For all the uncertainties associated with modern medicine, most people continue to believe in the sanctity of the doctor-patient relationship and the basic right of all patients to the best available care. Health plan and insurance company policies that jeopardize these beliefs warrant very close scrutiny.

The prerogatives of physicians, the needs of patients, and the exigencies of business are often at odds. In the 1990s, insurers limited post-partum hospital stays to 24 hours, putting mothers and infants at risk. When doctors’ protests fell on deaf ears, legislators were forced to mandate extended coverage for those with legitimate need.

Today we face a similar situation with weight loss surgery — a unilateral decision by Tufts Health Plan to delay and/or deny treatment to those with legitimate need.

Such need and best practices have been defined by the National Institutes of Health, the Massachusetts Department of Public Health, the American Society for Bariatric Surgery, and other established organizations. Unfortunately, Tufts seeks to rewrite well-established guidelines without medical justification.

Tufts’ new policy, which went into effect in March, limits who can get weight loss surgery and dictates the kind of operation those who remain eligible can have. It takes medical decision-making out of the hands of doctors. It also requires that all potential surgical patients participate in the plan’s “behavioral management” program for one year, a 12-month delay that, for some, could be a death sentence.

Bariatric surgery is the only effective treatment for extreme obesity, the only known way to achieve significant, long-term weight loss. It improves or reverses diabetes, hypertension, infertility, and other weight-related conditions. It reduces risk of death by 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} compared with non-surgical treatment options.

Nearly every candidate for bariatric surgery has tried such options. Eighty percent of the time, they don’t lose enough weight to make a difference. And even if they do, 95{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of them gain it all back and then some.

In 2004, the state’s Department of Public Health and the Betsy Lehman Center for Patient Safety and Medical Error Reduction convened a multidisciplinary expert panel to explore patient-safety issues related to weight-loss surgery. The group’s final report is based on an extensive, six-month review of the medical literature.

Published in 2005, it sets best practice standards for bariatric surgery. Its comprehensive guidelines define safe and effective delivery of surgical care for severely obese patients.

The report’s recommendations have been accepted by national medical societies, implemented by Blue Cross Blue Shield of Massachusetts, adopted by the American College of Surgeons, and put into practice by Kaiser Permanente and other health plans. Tufts’ new policy ignores these recommendations.

It does so at the peril of obese patients. According to expert opinion and scientific evidence, obesity is a disease, no different from cancer or heart disease, and bariatric surgery is the most clinically effective treatment option. It’s also the most cost-effective.

Complications from severe obesity require multiple hospitalizations and are extremely expensive to treat. Weight loss surgery reduces these costs — a financial advantage that becomes evident about three years after the operation.

Tufts’ new direction reverses the plan’s longstanding policy on weight-loss surgery. The company’s CEO, James Roosevelt, claims that its approach is “marrying high clinical quality to prudent attention to costs.” Rather than denying care, it is “preserving bariatric services for patients who need them most.” The preponderance of clinical and scientific evidence indicates otherwise.

Unilateral decisions by health plans and insurance companies have a history of backfiring in unexpected ways. This is especially true when administrators make medical judgments and implement policies that undermine the doctor-patient relationship.

Such policies warrant very close scrutiny indeed. This time the new rules are aimed at obese patients who need weight loss surgery. The next time they could be aimed at you.

If one insurer can change coverage with little notice, on scant medical evidence, and with little respect for access to care, all patients of all insurers must ask, “what’s next, and will it affect the health care I receive?”

George L. Blackburn, M.D., is chair, and Alan M. Harvey, M.D., M.B.A., is vice chair of the Expert Panel on Weight Loss Surgery of the Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction. Also contributing to this article were Scott Shikora, M.D., and Malcolm K. Robinson, M.D. Reprinted with permission from the Worcester Telegram & Gazette.

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