Beating a bulky hospital bill
Before consulting Dr. Belsley, I had talked to my insurer -- a freelance business writer, I got my health plan through the Authors Guild -- and was told I qualified for reimbursement for the surgery. I was lucky.
Access to coverage is far from a guarantee. Bariatric surgery typically isn't paid for by small-employer plans, according to a spokesperson for insurer Aetna. And among large companies, 42% won't pay for it under any conditions, according to 2013 data from HR consulting firm Mercer. Meanwhile, a study by the Obesity Action Coalition of plans offered on the new health care exchanges in the 50 states and D.C. found that only 23 of the 51 cover it. Medicare and 45 state Medicaid programs will pay for surgery, however.
Those who have the possibility of coverage will likely still need to jump through hoops. Insurers typically require you either to be morbidly obese or to prove the surgery is a medical necessity because of other obesity-related ailments, such as high blood pressure or diabetes. A third of large employers also require you to have tried behavior modification (a.k.a. diet and exercise) first, according to Mercer.
In my case I was fat enough, but I had to show that I had tried to lose weight. Fortunately I had kept records of the dates of treatment from the nutritionist and weight-loss therapist who had made yeoman efforts to help me shed pounds. So I had no problem getting approval. Again, I was lucky. A 2008 American Society for Metabolic & Bariatric Surgery study found that 25% of patients were denied coverage three times before getting a green light.
Why so tough? Because bariatric surgery is on the "fine line between elective and required in the insurance companies' minds," says McClanahan. It usually takes a few years for an insurer to recoup the expense with health care savings. And employers don't want to improve the health of employees for the benefit of the workers' next employers. (This, by the way, frustrates bariatric practitioners. "We don't talk about cost-effectiveness when we talk about surgery for lung cancer or surgery for heart disease," notes Ponce.)
Before insurance, the average cost of bariatric surgery in the U.S. is $20,000 to $30,000, Ponce says. But there are regional variations; not surprisingly, New York City is among the outliers. For my two restless nights at St. Luke's Hospital, plus charges from Dr. Belsley and the anesthesiologist, billings to my health care plan came to more than $67,000 -- though the insurer paid a discounted rate of $22,000.
All I was charged was a co-pay of $500. Yet again, fortune smiled upon me. Among large employers, the vast majority require coinsurance for hospital visits, the median amount being 20% after the deductible is met, according to Mercer. With the median PPO deductible of $500, I could have been looking at more like $4,800 if I had worked for a big company. (Worth noting, my insurance kicked up the patient responsibility in the last three years to $2,000.)
Despite the number of people who do not have coverage, fewer than 4% of those who get bariatric surgery in the U.S. pay out of pocket, according to the ASMBS -- perhaps because of the prohibitive price.
"Medical tourism" is one option for those without insurance, though a perilous one. While surgery in Mexico, India, and other countries can cost far less than in the U.S., the problem is in getting the necessary follow-up care. Ponce notes that doctors in this country are often reluctant to take on the patients of overseas surgeons both because of liability concerns and because they make money from the surgery rather than the follow-up.
That said, Michelle Vicari had her operation in Mexico and has no regrets. In 2006, then a director of child-care centers in Southern California, the five-foot-two Vicari was just over 300 pounds when she sought insurance approval for gastric bypass. The 35-year-old was being treated for sleep apnea, high blood pressure, and unsafe levels of cholesterol -- a shoo-in for coverage. Or so she thought until her request was denied. "I sat in the parking lot and cried," recalls Vicari.
Without insurance, her doctor told her, the surgery would cost $65,000. So she did some research online and decided to go across the border. She paid $14,500, including nine days of recuperation. The Mexican surgeon was available by phone or email for follow-up questions, and her U.S. physician ordered the periodic blood tests. Still, she acknowledges that by going abroad you lose out on some of the handholding you'd get staying closer to home. "So it won't work if you're high maintenance," she says.
Watch for a heavy sell
Going with Dr. Belsley, I got my pre- and post-surgery treatment plan à la carte. He didn't get compensation for anything besides surgery fees and office visits. My psychological evaluation was through a separate practice (and was covered by insurance, with just a co-pay). Belsley suggested the supplements and vitamins I take but didn't tell me where to buy them. He encouraged me to exercise but didn't force me to join a specific gym. A support group and nutritional counseling were provided at no extra charge.
Some bariatric surgeons charge extra "program fees" for everything I've just described and more. Patients of such doctors are required to pay an additional $500 to $3,000 -- typically not covered by insurance -- on top of the surgery costs as a condition for being taken on as a patient.
"One person was told if they didn't pay the out-of-pocket program fee, they'd have a collection agency put after them," says Nikki Massie, an obesity activist and gastric bypass patient in Baltimore who runs the Bariatric Foodie website. Massie, whose Facebook page serves as a kind of town hall for patients, has heard a litany of criticisms about program fees. The main gripe is that the fees can be more expensive than if you shopped for the services yourself. Case in point: Some complain about surgeons charging $500 for "starter kits" of vitamins and supplements -- the same stuff I buy for $40.
Not everyone in the industry supports program fees. "The thing that bothers me the most is that bariatric surgeons are always yelling about access to care, but then they put this huge financial burden in front of patients," says Cathy Carr-Dadin, a bariatric nurse coordinator at a hospital in Baltimore. "Isn't that a barrier to care as well?"
McClanahan says the fees are part of a trend in medicine following from doctors being squeezed by lower insurance reimbursements. "If they aren't getting paid what they used to, they're going to find other ways to increase their income -- so you have plastic surgeons selling face creams, dermatologists having rejuvenating systems," she says. "What I tell people is to be sure you're an empowered patient and know exactly what you're getting."
Expensive surgery, part deux (cont.)
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