Why can’t a person with diabetes and a BMI of 50 have bariatric surgery in Louisiana?

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#OBSM May 19, 2019:
Why can’t a person with diabetes and a BMI of 50 have bariatric surgery in Louisiana?

By Rachel L. Moore, MD, FACS, FASMBS, ABOM

The Louisiana State Capitol Building is the tallest capitol in the United States. The famous Governor Huey Long took great pride in its construction, which was completed in 1932, and then-Senator Long was assassinated there three years later. I’ve been knocking on the decorative door of this building for so long that my bloody hand bones are exposed, and I’m pleased to have the #obsm forum this month to tell you why.

There is still a lot of ignorance about obesity treatment and bariatric surgery, even among physicians, but the 1991 National Institutes of Health criteria are widely accepted worldwide. These criteria are so old that they were based on open bariatric surgery risks and outcomes, not the lower risk profile associated with laparoscopic surgery today. Nonetheless, body-mass index (BMI) >35 with weight-related health problems such as diabetes or sleep apnea or BMI > 40 are still frequently used as the starting point for a discussion about who qualifies for treatment. So why can’t a person with diabetes and a BMI of 50 have bariatric surgery in Louisiana?

At least three categories of Louisianians are excluded from bariatric surgery, no matter how severe their obesity or other weight-related medical conditions are:

-Patients with Blue Cross/ Blue Shield of Louisiana
-Louisiana State Employees including all the public school teachers
-Affordable Care Act (“Obamacare”) enrollees, because the state exchanges used the largest small-group insurer as the benchmark, and BCBS of LA is the largest small group insurer in Louisiana

Louisiana is not alone in this situation, and many other states still face obstacles to basic bariatric surgery coverage. Georgia, for example, also has no coverage for its state employees. Patients self-pay for surgery, sometimes with loans, or even go to Mexico where some have a safe surgery and some don’t.

                                                                       Figure from https://doi.org/10.1002/oby.22307

There are lots of people endorsing a single-payer healthcare system for the US and, on the surface, that would seem to offer a solution to the access to care problem. Medicare covers  bariatric surgery nationwide. Unfortunately, a 2018 study which analyzed 132,342 cases showed that publicly insured patients are much less likely to undergo bariatric surgery than patients with private insurance.

We have a system where people with money get treatment and patients with fewer resources get sicker every year as their obesity worsens and weight-related medical problems like sleep apnea, hypertension, type 2 diabetes, and high cholesterol develop. Can organizations like the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Obesity Action Coalition (OAC) use their national presence to intervene? Is social media a forum which can draw attention to this issue? Please join the #obsm chat on May 19th to share your thoughts and proposed solutions.

Discussion questions:

1. Please share any barriers to accessing obesity treatments you've experienced as a patient or healthcare worker.

2. Nationally, 39.8 percent of adults have obesity. Yet, in 2017 only an estimated 228,000 bariatric surgery procedures were performed. Why the disparity?

3. What could the national obesity-focused organizations (ASMBS, OAC, The Obesity Society, the Obesity Medicine Association) do to help patients get access to bariatric surgery? What can the general public do?

4. How can social media play a role in increasing access to obesity care?

5. What steps can be taken right now to improve access to bariatric surgery (and other obesity treatments) for patients who qualify and want treatment?

6. Share your successes with accessing care. What helped that process?


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