“I will probably lose,” Josh told me. “But I want to fight this insurance denial. I think it is just wrong that my insurance company won’t cover this.”
This is a story with many interwoven strands: it is a story of unintended consequences; of illness shaming; of a young man trying to stand up against an insurance Goliath. It is a story about the explosion of a cottage industry of cosmetic surgery clinics that prey on people’s hopes for miraculous outcomes. It is a story playing out again and again for patients all over the country—and due to poor oversight, one that is leading to poor patient outcomes.
An unintended — and underappreciated–consequence of massive weight loss
As a physician, I was unaware that the weight loss that we so strongly encourage patients to undertake can result in serious unintended consequences.
Josh (not his real name) explained it to me like this: “The result of my weight loss was a large panniculus and excess loose skin all over my body–kind of like an apron of extra tissue that interferes with every activity I do. Imagine this: imagine filling several gallon plastic bags with water, then taping them to your elbows, waist, back and thighs. Then imagine walking, or driving, or going for a run. That will give you an idea of my life; an idea of why I have difficulty walking, standing,sitting or lifting things. The pressure all that excess skin places on my spine and arms and legs is painful. It even interferes with exercise by being constantly in the way. I can’t get rid of it any other way than surgery. I have tried physical therapy. There are no medications that can help.”
I had really never appreciated that there was a potential downside to weight loss–and an incapacitating one, at that.
And worse, not only have we physicians encouraged this, but the patient’s insurance company and employer had incentivized it. Yet curiously, even though they incentivized it–they were not willing to pay for this known consequence of weight loss. The procedure was explicitly excluded under Josh’s insurance policy.
Ours would be an uphill battle.
But a worthy one, I hoped: perhaps, I thought, it would help restore some of Josh’s self-esteem that had taken a hit due to a very bad habit in our society: that of illness shaming around obesity.
Josh shared with me how shamed he had felt when he was obese; but the surprising thing to him, he said, was that the discrimination seemed to continue even after he had lost a remarkable amount of weight.
“When I was twenty-one, I weighed 330 pounds. With the support of my doctors, family and friends–and a good bit of pressure from my employer and insurance companies, in the way of incentive programs–I lost 140 pounds in a year and a half. I lost it in a healthy way, by exercising and eating different foods than what I was raised on.
But it was so frustrating to have been successful, to have done all this work–I did everything that everyone wanted–but now I’m left with something I can’t change. It’s not like obesity is a tatoo: it’s not something I did impulsively, in the moment, that I now regret; obesity was part of the way I was raised, who I was.
I know that a lot of people think that my obesity was my fault. But my mother is obese; so is my father and my brother and grandparents. It was a cycle that I broke. I feel I shouldn’t be penalized or blamed for my predicament because I didn’t change sooner. It is pretty incredible that I broke this cycle. It wasn’t easy, and I did it with lots of support from my doctors. And now I am left with this skin that is painful. I didn’t know that this would happen.
Obesity is an epidemic in our country. Many people will know someone who is going through exactly what I am going through.
When I was overweight, I felt ashamed: I felt talked down to, invisible. But that humiliation has continued, even after I lost the weight–because I am left with this painful thing I can’t change,” he said.
Insurance Hoops
It turned out that Josh’s insurance did cover the surgery in some circumstances. But he had to measure the panniculus; he had to send in pictures. It was humiliating. He had to demonstrate recurrent infections–but he hadn’t had those. He needed testimony from his physicians and from physical therapy.
With free advocacy support from the Center for Patient Partnerships in Madison, WI where I was in a clinical clerkship, Josh and I crafted his argument. The legal team suggested that it could be argued that Josh’s situation was similar to that of patients who needed breast reconstruction after surgery for breast cancer. The need for reconstruction was a direct consequence of a medical procedure–just as Josh’s was the direct result of the weight loss his doctors had “prescribed.”
Josh said, “ In fact, the criteria for approval is more stringent in my case, because patients who have undergone breast cancer surgery don’t have to take photographs to prove that the surgery would be beneficial, as I have had to do.”
There can be other hoops to jump through too, depending on the insurance company. Some require that patients attain a BMI of less than 30. Which seems arbitrary: if someone has a BMI of 30.5, should they be denied coverage?
Standing up against the Insurance industry
Josh and I decided that we would appear together before the appeal board. An attorney from the Center for Patient Partnerships would attend too. I asked Josh if he thought he could memorize his testimony? It would be more powerful that way, I said. He could look right at the clinician and other representatives on the appeal board. He said he would.
He practiced his testimony with me. He was nervous–but delivered it perfectly. I was so proud of him. Then they heard my testimony: how his weight loss had been encouraged by his doctors and incentivized by his employer and insurance company. The latter would stand to gain thousands of dollars due to the cost savings of conditions that Josh would not now experience.
“You, Josh’s insurance company, incentivized his weight loss not because you have an altruistic concern for the health of the patient, but mostly because you will benefit from considerable cost savings due to the numerous complications of obesity that your insuree will avoid after successfully losing weight, such as heart attack, Type 2 diabetes, joint replacements, and high blood pressure. The surgery Josh is requesting, an abdominoplasty, costs $7,000. The complications of obesity that he –and his insurance company –would be spared–cost upwards of $100,000. The insurance companies and employers will benefit from having a healthier insuree and employee. The bottom line for both companies will benefit. But this strategy has inextricably linked consequences for Josh, “ I said.
“Why should breast reconstruction be covered by insurance companies,” I asked, “when abdominoplasty for massive weight loss–that is usually carried out because we physicians, insurance companies and employers have encouraged it–is not? This surgery is not cosmetic,” I pointed out. “It is the position of the American Medical Association and the American Society of Plastic Surgeons that panniculectomy and abdominoplasty are reconstructive when performed to relieve specific clinical signs and symptoms related to abdominal wall weakness and panniculosis.”
Josh’s voice carried clearly at the appeal hearing: “This surgery has the potential to restore my ability to function normally and live my life. I hope that you will grant this exception and agree that I meet the criteria for reconstructive panniculectomy and abdominoplasty.”
The insurance appeal board listened quietly to Josh’s testimony. They all stood up and applauded him at the end and came over to shake his hand and congratulate him on his fine testimony.
And less than an hour later, they denied his insurance appeal.
Josh and I talked it over afterwards. It had made him really proud to memorize his lines and to feel listened to by the board. The outcome, though, was so discouraging.
In this case–a patient who deserved to be commended for what he did–who should be a poster child of success for other insurees and employees–was instead denied the opportunity to have a fully experienced life. It is even more egregious, since the cost of the procedure is fairly minimal; and insurance companies could in fact capitalize on the experience of patients like Josh to inspire and motivate other patients.
Big Business
According to this study , 800,000 people undergo this operation each year, making it the sixth most common cosmetic procedure. At an average of $10,000/procedure–it’s a big business. Not to mention the cottage industries that have sprouted up in its shadow–like the lawyers that now specialize in suing for damages due to the complications that may follow these surgeries.
In the state Josh lived in, the out of pocket price for abdominoplasty and panniculectomy was a little over $7,000. There were credit card machines at Josh’s plastic surgeon’s office–the patients just ran the card through on their way in.
Poor regulation and oversight may be leading to poor patient outcomes: a cottage industry with a high complication rate
Patients should be aware that this procedure has a not insignificant complication rate: while rates vary across studies, this US study showed that 4% suffer a severe complication, almost 3 times higher than the 1.4 percent complication rate in most cosmetic surgeries; and the 4% rate didn’t include minor complications, which have been reported in 29-48% of abdominoplasty procedures according to this study.
Some patients travel out of state for an abdominoplasty and liposuction–only to return with a massive wound infections or other complications. These cases of “medical tourism” complications are now happening within the US with increasing frequency. It is no longer necessary to go to Mexico or overseas to be the victim of such scams. Some glossy websites like this one are over the top–and just feed into the unrealistic expectations around these procedures.
There needs to be more awareness of the risks and complications of these surgeries–and redressing the underlying cause–viz, the insurance denials that force patient who experience massive weight loss to turn to these cottage industries in the first place.
Some of these clinics are set up in shopping malls. And medical teams performing the surgery may deny any follow up to the patient after they have left the state. In one case that was described to me, the treating surgeon refused to share the patient’s medical records from the procedure after the patient developed an impressive wound infection–a lack of accountability that should not be permissible.
How the insurance industry can be protective of patient health
“In 2005-2006, the issue of bariatric surgery came to the attention of hospitals,” Paul Levy, former CEO at BIDMC shared with me. “Blue Cross Blue Shield was very strict about the hospitals and plastic surgeons it would approve. It only approved certain providers. But they had a very robust process; they covered everything from the counseling prior to surgery to plastic surgery following the procedure. BCBS was very attentive to all these details,” he said.
It is very likely that this policy was good for patient health. Plastic surgery following massive weight loss has a relatively high complication rate–so approving only certain providers means that the insurance company knew it would limit patient infections and other complications because the providers they covered were more experienced.
Unfortunately, since that time, the industry has burgeoned–and now, with the procedure largely no longer covered–there is no record of the number of complications, since that data is no longer collected by insurance companies–or anyone else.
There is so much illness shaming around obesity. Perhaps it is time to reverse the roles. Perhaps it is time to start shaming the insurance companies that are refusing coverage for this procedure. And shame the predatory businesses skulking in our shopping malls selling beauty and serious surgical complications. Insurance denials and fly by night surgeries both result in excess patient morbidity– harming patients who have already paid such a high price in the shame that society heaps on their plate. If insurance companies all elected together to cover this procedure, it would go a long way towards making it safer for patients–and more fair for patients who have suffered this side effect.
All names and identifying details have been changed to protect client confidentiality. The suggestions given here are not intended as a substitute for the medical advice of your physician.
Photo credit: Matteo Vistocco, Unsplash.com
