Since the presidential election of 2012, "a lot of states have held their fire about implementing these programs," said Dr. Morton. "But at the end of the day, you need to do what’s right for the patient."
Because bariatric surgery coverage is not mandated at the federal level, millions of American do not have access to obesity care, said Dr. Morton.
Role of prejudice
"The biggest problem we have had with this for 50 years is prejudice," Dr. Henry Buchwald, professor emeritus of the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery at the University of Minnesota, Minneapolis. "People are prejudiced against the obese."
Dr. Morton said that even though obesity is a disease recognized by the AMA, it is often described in exclusionary terms by third-party payers.
"When you look at the ACA, there’s language that says it cannot discriminate on the basis of a health condition, but if you look at some of these [insurance] plans, there is actually language that says ‘we will not cover obesity treatment.’ That’s exclusionary language, and we need to figure out why this is occurring."
However, Dr. Finkelstein suggested that part of the problem with getting coverage for weight loss surgery might be how the field frames their argument in favor of it.
"I think the obesity community has done themselves a disservice by pushing [return on investment] for bariatric procedures," said Dr. Finkelstein. "I don’t think bariatric surgery should be talked about in terms of value for money. The [health] value is there just like any other procedure, and so it should be covered."
Little incentive
Despite the fact that the costs of obesity over a lifetime are high in the aggregate, Dr. Finkelstein said that the costs are highest later in life. That, plus the current trend of employees changing jobs an average of every 3 years, means obesity is often overlooked.
"Even though the net costs from a lifetime perspective are significant, there is not a lot of incentive for any particular payer to do any obesity prevention because the costs are eventually shifted down the line," said Dr. Finkelstein. When the federal government picks up paying for the health care costs of everyone 65 years of age or older, you are unlikely to "see significant investments in prevention," he said.
In cases in which the individual has had no insurance prior to qualifying for Medicare, the costs are even higher, and the cases more complex. "About 25% of patients who have chronic disease with multiple comorbidities make up 85% of our costs," Dr. Wild said, adding that of those 25%, 5% are "superusers" who make up 50% of all CMS costs.
The CMS spends $1.5 billion a day, or $900 billion annually, on health care, according to Dr. Wild.
"When we talk about bending the cost curve and saving money, we need to focus on those patients with multiple comorbidities and chronic diseases," said Dr. Wild.
The agreement on this point brought the panel back to the question of what is the sweet spot for prevention and intervention, and who should pay for it.
Surgery not the only answer
"We’re not going to solve the obesity problem by surgery alone," Dr. Buchwald said, adding that a combination of approaches, including prevention, medical, and other approaches. "We have to look for things that will work together."
Dr. Morton agreed that more research into complimentary medical interventions for obesity was needed. "We have been hamstrung by not having a lot of options," he said.
"Diet and exercise do work, but we don’t diet or exercise as much as we used to and that’s part of the reason we’re in this situation," Dr. Finkelstein said.
The data support bariatric surgery as a viable way to cut costs, said Dr. Morton. "The data are on our side," he said. "We have a lot of patients in need, and I would call for some rational coverage decisions when it comes to health exchanges. I think the government can be our partners in this."
Dr. Finkelstein noted several disclosures including, Jenny Craig, Johnson & Johnson, and Sanofi-Aventis, among several others. Dr. Morton has worked with Covidien. Dr. Buchwald and Dr. Wild did not have any relevant disclosures