From The Plain Dealer
By Evelyn Theiss
CLEVELAND, Ohio -- Last fall, the Cleveland Clinic named "bariatric surgery for diabetes" its top medical innovation of 2013.
The Clinic used to pay for the surgery for employees who had uncontrolled diabetes and a Body Mass Index of 35 and higher, which is considered obese. Now the institution has expanded its employee health care coverage of the weight loss surgery to include Type 2 diabetics who fall into a BMI category that is categorized as mildly obese.
The program will cover an individual as long as he or she has a BMI of 30 or higher, has diabetes that medication is not controlling, and has been under the care of an endocrinologist for at least six months.
BMI is a measure for estimating human body fat based on an individual's weight and height. A woman who is 5'5" and weighs 180 lbs. would have a BMI of 30. The lower BMI cut-off puts the medical center at the frontier of bariatric surgery coverage.
The program also makes financial sense for the Clinic.
"Relatively speaking, very few medical interventions have been proven to save money," says Dr. Philip Schauer. "Heart bypass, for example, can cost $75,000, and you never get that money back in terms of future health care cost reduction. "But this is an intervention that pays for itself."
Bariatric surgery can cost between $20,000 and $25,000 and several studies show that an employer will recoup that money in about four years, from savings in prescriptions and doctors visits for the patient, and the prevention of complications from diabetes, such as foot ulcers, retinal damage or the need for kidney dialysis.
Clinic employees have a co-pay of $2,750, but that is gradually reimbursed over a 5-year period, as long as they stay employed by the Clinic. Employees must have worked for the Clinic for at least two years before being eligible for coverage of bariatric surgery.
Health care insurer Medical Mutual of Ohio covers bariatric surgery for its employees, but only for those who have a BMI of 35 and above and have other complications from obesity, such as asthma or sleep apnea, says Paula Sauer, vice president of care management at Medical Mutual. Starting this year, the company will pay up to $20,000 for bariatric surgery for insured employees.
"It depends on the severity of where people are, because with bariatric surgery, there's also a likelihood that people will develop complications," Sauer says.
As literature from bariatric centers points out, the procedure carries the risks of any major surgery, as well as specific risks such as abdominal hernias, bowel obstruction and stomach perforation.
Sauer adds, "We also look at the psychological components -- people always have to be evaluated before being approved for the surgery.
Also, she notes, more studies need to be done on patients who have the surgery, following them long-term, to see how much weight, if any, they gain back.
As for the companies that Medical Mutual insures, "We have not seen a rise in employer groups who want to offer the coverage."
Medicare, like Medical Mutual, offers bariatric surgery coverage only if the patient has a BMI of 35 or higher.
Limiting bariatric surgery to those who have a lot of weight to lose may be changing, given the power of studies that Schauer says that have show it can knock out diabetes, even in patients with mild obesity, meaning a BMI less than 35.
That usually happens within days of the surgery, well before substantial weight loss occurs, says Schauer. It occurs, the study stated, because of "physiologic effects in addition to weight loss, likely related to alterations in gut hormones," though the specifics of what happens are still being studied.
The Clinic's study included patients who had either gastric bypass or a sleeve gastrectomy. (The Clinic does not cover lap band surgery, which while less expensive, results in far less weight loss and has a negligible effect on diabetes.) Other patients received solely intensive medical therapy.
The result: 42 percent of gastric bypass patients were able to reach nondiabetic levels in their blood sugar; 37 percent of those who had sleeve gastrectomy were able to do so, and only 12 percent of those who got only medical therapy achieved those desirable numbers.
After the bariatric surgery, Schauer explained, there was a significant increase in a hormone that stimulates insulin production to a level at which the individual is no longer diabetic.
Schauer has heard people cast aspersions on bariatric surgery to address obesity. "The belief is that it's lazy slobs who are this overweight, who don't care about themselves," he says. "But we're learning more and more about the science of body weight. We know people can lose weight by diet and exercise, but it will usually creep back on."
That's because as people lose weight, their metabolism slows down and appetite increases, making it all too easy to start gaining again, he explains. "We are evolutionarily designed to preserve our body weight. Human drives that are triggered by hormones are very powerful. Some people can fight it for a few weeks or months, but very few people can do it longer than that."
St. Vincent Charity Medical Center has been performing bariatric surgery since 1999, the longest of any Cleveland hospital. Some 7,000 people have had the surgery there.
Courtney Holbrook, program manager for the Center for Bariatric Surgery at St. Vincent, also said that the effect on some patients with diabetes has been immediate. "Sometimes, when people come in for the operation with diabetes, they leave the hospital without their diabetes medications," she says. "With other patients we see that in two months, four months or more. Many quickly see improvement in their diabetes, and in their hypertension."
The Cleveland Clinic's study of the effect of bariatric surgery on diabetes was reported in the New England Journal of Medicine last year. It looked at 150 people, some of whom received medical therapy, others who received one of the two forms of bariatric surgery.
Those who had the surgery achieved glycemic control at far higher levels than those who did not. The surgery was deemed superior to intensive medical therapy for eradicating diabetes in an obese person.
That study's results were echoed in that same issue of the Journal by another study of bariatric surgery's effect on diabetes, conducted in Italy.
"Yes, it's different if someone is 25 lbs. overweight. Then, lifestyle interventions are much more effective for weight loss," Schauer says. "But this study and others show that if a person is severely overweight it's rare that they will lose the weight with diet and exercise alone and keep it off."
Here's the bottom line," Schauer says. "When a patient is 100 lbs. or more overweight, the probability of them losing it with diet, exercise or drugs and keeping it off is less than 1 percent."
Despite post-surgical side effects, such as possible infections, or digestive distress if they eat too much or of the wrong kinds of food, bariatric surgery gives patients a chance to achieve the significant weight loss they need, Schauer says.