Insurer refuses gastric surgery
Norwalk resident Shawn Alvarado started packing on the pounds as a teenager, gradually becoming one of millions of Americans whose sedentary lifestyle made him a statistic in the country’s obesity epidemic.
By the age of 24, Alvarado weighed 300 pounds.
By the age of 31, he weighed 400 pounds.
Today he tips the scale at almost 500 pounds.
“I don’t know what to say,” Alvarado, now 53, told me. “I just stopped exercising. I got heavier and heavier.”
Still, you don’t get to weigh a quarter-ton by simply overeating. There are almost certainly other factors at work, both physiological and psychological.
Yet Alvarado’s insurer, Minnesota-based HealthPartners, refuses to see him as having an overall medical condition.
Twice, he said, his doctor sought insurance authorization for gastric bypass surgery to reduce his weight. And twice HealthPartners turned down coverage, deeming the roughly $20,000 operation a cosmetic procedure.
I could only wonder if Alvarado was getting a fair shake after California’s two main health insurance regulators, the Department of Managed Health Care and the Department of Insurance, announced investigations this week into Aetna, the country’s thirdlargest insurer.
A former Aetna medical director for Southern Cali-
fornia admitted in a deposition for a lawsuit that he never consulted patients’ medical records before denying claims. He said he relied on the advice of nurses.
“If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law,” said state Insurance Commissioner Dave Jones.
No one’s saying this is what happened with Alvarado. But the Aetna case raises questions about how seriously his insurer took concerns about the medical need for a gastric bypass — and the company’s responsibility for a policyholder’s well-being.
“To say this is a cosmetic surgery is unbelievable,” said Dr. Winfried Waider, Alvarado’s cardiologist. “His lifespan is going to be markedly shortened by this decision.”
He added: “They just don’t want to pay, that’s what this is.”
Catherine Scott, a HealthPartners spokeswoman, declined to comment.
Although Alvarado was willing to have his case discussed, Scott cited the insurer’s contract with Alvarado’s employer, a moving company, for which he works as a dispatcher.
“We can’t discuss the particular details of this employer’s benefit design,” she said.
HealthPartners certainly isn’t the only insurer to reject coverage for cosmetic or elective surgery. This is a way most insurance firms keep rates down for policyholders.
But here’s the thing in Alvarado’s case: He was hospitalized last year to the tune of almost $100,000 for congestive heart failure. He said HealthPartners covered most of the cost.
His other obesity-related complications — including Type 2 diabetes, high blood pressure, high cholesterol and sleep apnea — ring up annual medical bills in the tens of thousands of dollars. They too are covered by HealthPartners.
Yet the company won’t cover a procedure recommended by Alvarado’s doctor as medically necessary, one that could lower ongoing costs for the firm and other ratepayers.
How can that possibly make sense?
“From the insured’s perspective, it makes all the sense in the world to cover this thing,” said Tom Mayo, a medical ethicist at Southern Methodist University. “But insurers frequently wear blinders. If it’s not in the language of the policy, it’s not covered. Period.”
I’m not saying people like Alvarado bear no responsibility for their circumstances. Obviously there should be some accountability for poor health decisions and reckless behavior.
But it seems absurd for any insurer to pretend that the obesity epidemic is simply a matter of personal choice, and that the healthcare establishment bears no responsibility for turning things around.
According to the Centers for Disease Control and Prevention, more than 36% of U.S. adults are obese. Over 70% of American adults are obese or overweight.
It costs about $170 billion a year to treat obesity-related medical problems, the CDC says.
In many cases, obesity reflects bad dietary decisions or a lack of physical activity. But researchers say there also can be metabolic, genetic or emotional forces at work, especially in cases of morbid obesity.
Some people are more susceptible to food advertising, they say. Some demonstrate addictive behavior when it comes to sweets or high-carb foods.
The point is that the underlying causes of the obesity epidemic are complex, and it’s disingenuous for insurers to apply blanket policies to policyholders with extreme weight issues.
Gastric bypass surgery shrinks the size of the stomach, reducing the amount of food a person can consume. This is how NBC weatherman Al Roker slimmed down to about 190 pounds from a high of 340.
“It is an evidence-based treatment for a serious medical condition,” said Steven Joffe, an associate professor of medical ethics and health policy at the University of Pennsylvania. “To call gastric bypass a cosmetic procedure is ridiculous.”
He also pointed out that a notion of personal responsibility shouldn’t preclude an insurer covering effective treatments.
“If I injure my head in a motorcycle accident while not wearing a helmet, my insurance company won’t refuse to pay despite the fact that I’m at least partly responsible for my predicament,” Joffe said.
I wrote recently about how Obamacare pleased no one, but at least it sought to reprioritize the U.S. healthcare system, with an emphasis on keeping people fit instead of spending piles of cash when people get sick.
That’s one way to address the obesity crisis. Another is to make sure that the most effective treatment is available to people whose weight has become life-threatening.
I asked Alvarado if he’s tried dieting. Yes, he replied, many times. “It never works.”
I asked about getting more physical activity. He said he knows he should, but at nearly 500 pounds, he said he just can’t.
“Basically, I go to work and then I go to bed,” he said.
Alvarado told me his cardiologist believes he has maybe another 10 years to live. Maybe less.
If nothing changes, those will be costly years for HealthPartners as Alvarado’s condition worsens.
“Just from the insurance company’s self-interest, it makes sense for this guy to have gastric bypass surgery,” said Aaron Kheriaty, director of UC Irvine’s Bioethics Program.
“Insurance companies put in place rules that seem to make sense,” he said. “But with any rule, you need the flexibility to make exceptions.”
That, however, is not something insurance companies are particularly good at.
David Lazarus’ column runs Tuesdays and Fridays. He also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send your tips or feedback to david.lazarus @latimes.com.