Even after referral, however, considerable barriers remain. For many patients, cost becomes the main determinant of whether surgery can happen: a laparoscopic bariatric procedure falls in the range of $17,000 to $25,000, with the amount covered by insurance ranging widely.
All the major U.S. health care payers now include bariatric surgery in their policies. In practice, however, many benefit plans don't cover the option. The medical policy for United Health Care notes, "Most Certificates of Coverage and many Summary Plan Descriptions explicitly exclude benefit coverage for bariatric surgery." Cigna's coverage policy (PDF) includes a similar qualification, as does Aetna's.
Dr. Philip Schauer, director of the Bariatric and Metabolic Institute at Cleveland Clinic, stated that the rates of exclusion are considerable. "At the Cleveland Clinic, more than half of the patients who qualify for and wish to undergo bariatric surgery are unable to do so due to insurance issues," he said.
"Fat people don't need surgery," remarked a young doctor—a surgeon by training—who had learned of Natasha's operation. "They need to not put food in their mouths."
For patients who do find coverage, there is the additional hurdle of fulfilling various pre-operative criteria mandated by insurers. These include medically supervised dieting programs, often six to 12 months long, with monthly doctors' visits to document their progress. According to Schauer, this delay to surgery offers patients little benefit. "On average, my patients have been on 10 diets before they come to me," said Schauer. "Another diet isn't going to help them." What's more, he noted, the frequency of mandatory doctors' visits imposes considerable hardship on patients, requiring them to find transportation and take half a day off work every month for the better part of a year. If they miss one appointment, they're disqualified. Schauer estimated a 20 to 30 percent rate of attrition from the program as a result.
Shikora, too, cited examples of insurance barriers that have kept patients from surgery, including a stipulation by some insurers that patients prove they've been obese for at least five years. This policy, said Shikora, hurts many younger patients with debilitating obesity. "Patients have died on waiting lists," he said. "The bottom line is insurers don't want to pay."
But should they?
A few years ago, health economist Pierre-Yves Crémieux looked into the business proposition of bariatric surgery. His hypothesis was that since bariatric surgery reduced rates of many costly health conditions, it might actually save insurers money. With funding from Ethicon Endo-Surgery, a division of Johnson & Johnson that makes surgical devices, he studied actual claims data collected over a six-year period for more than 3,600 surgery patients. The analysis, published in the American Journal of Managed Care, estimated that it took two to four years for payers to "save back" what it had cost to cover the surgery.
"Bariatric surgery pays for itself," said Crémieux. He noted that his initial analysis had likely underestimated the time frame for breaking even; a more recent analysis of diabetic patients undergoing bariatric surgery, which he is currently in the process of preparing for publication, suggests that four years may be closer to the average than the upper limit.
According to Crémieux, however, the magic number that insurers are looking for -- the number that has come up repeatedly in his discussions with them -- is not four or even two years: it's 18 months. That is to say, insurers would be enthusiastic about bariatric surgery if the costs of the surgery could be offset within 18 months.
Dr. Carolyn Langer, the medical director of Harvard Pilgrim Health Care, dismissed the notion that return on investment determined reimbursement policies. Harvard Pilgrim's decision to cover bariatric surgery, she said, had been based on an extensive search of the literature on safety and efficacy. "It was pretty clear that patients had better outcomes compared to conventional treatment or no treatment," said Langer. "To the extent that obesity can be controlled through lifestyle changes, that would be much preferred. But we recognize that many habits are embedded, and that there needs to be a concerted effort to address the issue."
* * *
One view that surgeons, primary care doctors, and payers alike seem to share is that there is a subset of patients who stand to benefit disproportionately from bariatric surgery. The problem is that it still isn't entirely clear who these patients are. Are they the youngest? The ones who are most obese? The ones with the most severe co-morbidities? The diabetics? Figuring out how bariatric surgery can be better used will require first identifying this "sweet spot" within the patient mix.
Even for the patients with the greatest promise, however, bariatric surgery is unlikely to be a magic bullet. I recently met a woman in a surgery follow-up clinic who had weighed 300 pounds before undergoing gastric bypass a few years ago. After the operation, she'd dropped down to 150 pounds. But then, gradually, her weight had begun to creep back up. When I met her, she weighed 240 pounds. The weight gain frustrated and confused her, and she was beginning to question the integrity of her stomach pouch. She barely even ate anymore, she told the surgeon who was seeing her. All she consumed each day were six large iced teas from Dunkin Donuts.
Was she using cream in the tea? asked the surgeon.
Yes, the patient admitted, she liked a little cream.
"It's mostly cream," interjected the patient's husband, who had accompanied her to clinic. "It's practically white."
The surgeon looked somber as he explained that no pouch, however small, could keep her from regaining weight if she continued to consume six cupfuls of cream each day. Surgery could change her life, to be sure; but first, her life had to change.
* * *
After carefully weighing the risks and benefits, Natasha decided to proceed with gastric bypass surgery. She completed a professionally-led weight loss program, met with a psychiatrist, and underwent a barrage of testing. She was deemed eligible, and fortunately, her insurer agreed to cover the surgery.
The operation went smoothly. She stayed in the hospital for a few days to make sure her newly routed digestive system was working properly, and then she went home.
The first thing Natasha noticed was that her appetite had changed. "The difference was almost immediate," she said. "I used to think about food all the time. I would snack constantly. After the surgery, I didn't feel hungry anymore." She even started forgetting to eat. "Someone once told me, 'You might have to set an alarm to remind yourself.' I hadn't believed it before, but it turned out to be true."
She also started choosing healthier foods -- lots of vegetables, fruits, and protein. This was partly by choice and partly by necessity: junk food and sweets, previously staples of her diet, now made her sick. "Once, I ate a granola bar and then tried to eat a bowl of sugary cereal," she recalled. "The result wasn't pleasant."
Two months after her surgery, Natasha weighed 286 pounds. By three months, she weighed 265 pounds, and at four months, she was down to 247 pounds -- almost 90 pounds below her highest pre-operative weight. She was still above the normal weight range and had many more pounds to shed, but the change in her health was already dramatic. Her blood pressure had returned to normal, and her diabetes had resolved completely, with her hemoglobin A1c -- a marker of blood sugar levels -- dropped from 7.6 prior to surgery (a number above 6.5 indicates diabetes) to 5.1 (well within the normal range) in just a few months.
"Everything has changed," Natasha said. "I'm going out more with my friends; I'm doing things I never imagined. I used to feel ugly all the time. Now I look at myself, and I like who I am."
"People treat me differently, too," she added. "People are nice in the world, but I guess they weren't so nice to me before. Now they talk to me, they hold doors open ... it feels good."
Asked if there was anything she regretted about the surgery, she thought for a moment before answering. "Without the bypass, I'm pretty sure I would be 400 pounds by now," she said finally. "Getting surgery is the best move I've ever made. It's something I will carry with me for the rest of my life. There is nothing I regret."
* * *
"Fat people don't need surgery," remarked a young doctor -- a surgeon by training -- who had learned of Natasha's operation. "They need to not put food in their mouths."
Implicit in the surgeon's comment was the notion of choice, of individual responsibility. With a little more willpower and a little less food, the comment implied, obesity could be reversed. That made it somehow different from other chronic health conditions like heart disease or cancer.
The stigma attached to obesity may explain why many weight loss interventions have struggled to garner financial and social support in the past -- and may prove to be the ultimate barrier to the expansion of bariatric surgery. As Block put it, "There seems to be a higher threshold that obesity treatments have to overcome." Historically, this has been true for medically based weight loss interventions. Dr. Florencia Halperin, medical director of the Program for Weight Management at Brigham and Women's, observed: "It's extremely difficult to get insurers to pay for obesity-related treatments. Until recently, counseling for obesity wasn't even a billable physician's code. Even now, most weight management programs are out-of-pocket."
Stigma is arguably most dangerous when it distracts from clinical judgment and public health decision-making. In this sense, portraying obesity as an issue of willpower may be just as irresponsible as portraying teenage pregnancy as an issue of promiscuity: it places undue emphasis on an ineffective plea for abstinence. Just don't do it, the plea goes. Don't do it, and you won't have to deal with the problems.
But people are doing it, and the resulting problems aren't just their own anymore. As obesity takes its toll on America -- its families, its work force, its budget -- it gets harder to ignore the suspicion that obesity is now everyone's problem: the skinny and the fat alike, the still-healthy as much as the once-healthy, the rich as well as the poor.
"There's an element of denial," said Crémieux, speaking of the perception of obesity today.
Perhaps it's not denial, though. Perhaps it's just hard to make the leap from recognizing that something drastic needs to be done to doing something drastic. And perhaps before those with obesity can truly change their bodies for the better, we need -- all of us -- to consider changing our minds.