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Insurance companies provide spotty coverage
June 2, 2003
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| Kathy Bedford runs the Midwest Center for Weight Control in Maple Grove. The clinic has opted not to deal with insurance at all, rather than sort out the complexities and frequent denials that accompany their weight loss services. Bedford holds five-pound models of fat and muscle used as visual aids for patients. (MPR Photo/Jeff Horwich) |
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St. Cloud, Minn. — Health insurance works mostly because of one fundamental principle -- most of the people are healthy most of the time. So imagine you're an HMO, discovering that more than half your members suffer from the same dangerous condition. Research tells you they're headed for diabetes, heart attacks, cancer and other things that cost insurance companies a lot of money.
More than half your members are overweight. So what do you do? Among other things, you tell them to take a walk.
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|  Walking the walk | | |
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Growing weight problems in their own ranks led HealthPartners to come up with the "10,000 Steps" program, essentially a statewide walking club. Part of the plan involves partnerships with parks and cities, including a kickoff event recently in St. Cloud.
The idea is to work up to walking 10,000 steps a day, whether you're taking a hike or just pacing around the office.
"It's about four to five miles during the course of a day," says HealthPartners President and CEO Mary Brainerd, who attended the St. Cloud event. "Most people get like two."
For $20, you get a pedometer and other materials to help chart your progress. For both the company and its members, it's a relatively cheap way for the state's third largest HMO to get at the expensive obesity epidemic.
In an internal study last year, HealthPartners found 54 percent of their members were overweight. Nineteen percent of all the money HealthPartners spent on patients could be traced to weight and lack of physical activity.
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| Pronk: "I think it's very frightening" | | |
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Nico Pronk is HealthPartners' vice president for health promotion. He says these numbers stand the insurance industry on its head.
"I think it's very frightening," Pronk says. "It sort of erodes the whole premise that (insurance companies) build on health."
Insurance companies have expanded coverage for new obesity drugs and surgeries. But they are also more interested than ever in your lifestyle. When it comes to diseases like type 2 diabetes, Pronk says there's no substitute for a good diet and regular exercise.
"If you can get (at-risk) individuals engaged in a lifestyle program, you can prevent up to 58 percent of new cases," Pronk says. "Much higher than if you were to give them a drug, much higher than if you weren't to do anything."
With colorful fitness newsletters and high-profile programs like 10,000 Steps, HMOs appear to be walking the walk. And doctors do like the new emphasis on preventive health. But some say when it comes to obesity medications, counseling or specialized weight loss programs, insurers follow the same old patterns.
Dr. Mike Gonzales is a St. Paul endocrinologist who says insurers often deny obesity coverage until more serious health problems appear.
"If you have depression, most always they will pay for the anti-depressant medications," Gonzales says. "They will pay for the cardiology visits, the coronary artery bypass grafts and the angioplasty. They will pay for knee replacements and hip replacements, but they're not paying for obesity itself."
Gonzales is also secretary of the Minnesota Medical Association. He sponsored an MMA resolution two years ago calling on Minnesota HMOs to provide comprehensive coverage for obesity, but the industry is not adapting as fast as he would like. That's especially true for the FDA-approved obesity medications he prescribes.
"I have to, every time, get on my knees and beg for my patients to be able to have their medications covered," Gonzales says. "As of 2003, it is still the vast majority of the time my patients are denied access to their medications."
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(My doctor) tried really hard. She first put in a request, and that was denied. We appealed that, and that was denied.
- Joanie Croalius | |
Two years ago, Joanie Croalius of St. Paul weighed 317 pounds. Her doctor decided to put her on Xenical, one of those FDA-approved drugs. But Croalius says her doctor found herself at odds with the HMO, Blue Cross and Blue Shield.
"She tried really hard," Croalius says. "She first put in a request, and that was denied. We appealed that, and that was denied."
Blue Cross told Croalius Xenical was not long-lasting, that the weight might come back. Just to show Blue Cross she was serious about losing weight, Croalius went to an informational session for a much more expensive option: stomach-stapling surgery. It was her doctor's recommendation, just to convince the HMO it would be worth it to pay for the Xenical.
"So I did, I went to that information gathering and to my shock, I was really interested," Croalius says.
More shocking, so was Blue Cross. The HMO would not cover the drug regimen, which would have cost about $100. But it quickly approved the surgery, which Croalius says cost $12,000 plus years of follow-up visits. In a year and a half, Croalius has dropped 100 pounds and continues to lose weight.
Over the past few years, the various kinds of stomach-reduction surgery have completely changed the insurance landscape for obese people. Through the '90s, many insurers were still reluctant. Obesity surgery was still a developing field, and it had the stigma of a cosmetic procedure.
But over the past year, 85,000 Americans had their stomachs surgically reduced. The procedure is now largely embraced by the insurance industry for patients who meet certain conditions.
Blue Cross's policy is typical -- patients who are technically obese can qualify. So can some who are not quite obese, but have other health conditions exascerbated by weight.
One reputable online bulletin board, www.obesityhelp.com, runs on for pages with the happy stories of Minnesotans whose HMOs paid for the surgery. As expensive as it is, it appeals to insurers for one undeniable reason -- it often brings quick and dramatic results. Bariatric surgery, as it is technically known, is a biologically-enforced lifestyle change. Joanie Croalius says she can comfortably eat just a few ounces of food at a time.
"When you do overeat, you throw up," Croalius says. "Sometimes when I finish eating I'll feel fine, but then a half an hour later I'll feel too full. And then (the stomach pouch) expands and it's like 'uhhhhhhhhh.'"
Not surprisingly, the rapid weight loss gives patients an important psychological boost. People who could not walk around the block can start an exercise regimen. Those medicated for diabetes or high blood pressure can often go off their medications, sometimes within days.
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For a lot of people they look at (the cost) and they think, 'You know, I just can't do it.'
- Kathy Bedford | |
Of course, obesity surgery carries medical risks, and is mostly reserved for those with major weight problems. There are other medically endorsed ways to lose weight, and for many of them insurance coverage remains patchy.
Kathy Bedford runs a weight loss clinic in Maple Grove. Patients meet regularly with the clinic's physician and exercise physiologist. They follow a regimen based on Optifast, a food supplement shake.
The product has been around for years, and most Optifast clinics are housed in hospitals. But Bedford says almost no Minnesota insurers will cover more than a portion of the program, which can cost $4,000 for a typical 20-week course. Some won't cover anything.
"Going over what the cost is going to be, and yeah, they'd like to do it ... but for a lot of people they look at that and they think, 'I just can't do it,'" Bedford says. "They can't afford it. That is our biggest struggle."
Licensed dietitians are another professional option who can help patients establish healthy eating habits. But there are still gaps in coverage when it comes to their services. Doctors frequently refer overweight children, who are too young for many other options, to professional dietitians to deal with budding weight problems.
But at one Twin Cities clinic, a pediatric dietitian says one-third of these children are never seen because their parents' insurance will not cover the service.
This is especially worrying. Experts say alarming numbers of children are assuming the shape and symptoms of a sedentary lifestyle.
It's increasingly clear today's overweight adults are going to cost themselves, their employers, and the insurance industry a bundle. But they'd all like things to be different for the insured of tomorrow.
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