Preparing for gastric bypass surgery by eating more

Thinking is hard work.  This is why so few people bother.  At least voluntarily.  So whenever it seems like the threat of brainwork looms in modern American medicine, we can thank our lucky stars for the geniuses behind healthcare reform and guidelines of care.

This comes up as a result of a conversation that I had with a patient the other day.  A pleasant, obese gentleman.  He had been struggling with his weight and type 2 diabetes for some time, and there were now some early indications of some potentially serious long-term complications.  He mentioned to me that he was working hard to prepare for gastric bypass surgery.   I asked him how he was doing that.

“Why, by eating!” he replied.  Huh?  By eating?

“Oh yes”, he explained.  “You see, I’m getting these complications from my weight and diabetes and all of my doctors think that I’m an excellent candidate for weight loss surgery.  Based on my previous weights, if I can just get lose about 40 or 50 pounds, I should have much better blood sugars and need far less insulin.  God, that stuff is expensive when you’re using hundreds of units per day!”

That sounded perfectly reasonable.  This gentleman is a walking advertisement for the virtues of slimming down.  And for gastric bypass, in fact.  So why is he holding that venti whole milk mocha with 508 calories and 27 grams of fat?

“Oh, this?”  He looked a bit sheepish.  “Well the problem is that the surgeons won’t operate on me yet because I don’t quite fit the guidelines they have to follow for doing the operation.  Insurance won’t cover the surgery until I reach a BMI (body mass index) of 40, and I’m a couple of pounds short.  So I have to gain the weight and have them document that I’ve reached the magic number.  Then I’ll actually lose the weight again when they put me on the special post-surgery diet to make sure that I can tolerate it.  If all of that works out okay, then they’ll schedule the surgery.”

Now I realize that I’m revealing some age here, but in the old days we would have looked at the patient, considered his history, physical condition, social situation and medical compliance, and decided whether the surgery was indicated and likely to be beneficial based upon all of those things.  He doesn’t quite meet the BMI criteria established by some study?  Well so what?  He’s a good candidate.  Let’s do it.  And we would.  And the patient would usually get better because we wanted to pick good candidates and have them succeed.  That was our job.  We were the medical experts and we were being paid to think.  Besides, if someone else knew way more about medicine and our patients than we did, why weren’t they the ones taking care of them instead of us?

But of course then we’d have to use our heads.  Thank God those days are over.  Now if the patient’s vital statistics don’t match whatever the insurer’s guideline computer tells the high school graduate who happens to be denying  authorizations that day, then you’d best go away and come back when they do.  No use fretting about it.  You’ll never make it through the insurer’s phone trees or get a reply to your voice mails asking to speak to a medical director anyway.

I wished our patient luck, and later brought up the case with the doctor who was taking care of his diabetes.  He was visibly exasperated about the whole ordeal.

“We’ve been working very hard on his diabetic control.”, she said.  “He’s been pretty good about his diet, but has one of those bodies that really uses energy efficiently.  It just hangs on to every ounce of weight.  We had his hemoglobin A1c down to 7% (normal is 4% to 6%), but since he’s had to start gaining weight it’s back up to 7.9%.  I’ll be glad when this whole ordeal is over and we can go back to treating his disease rather than the damned guidelines.”

Silly doctor.  Why would you want to do that?  You’ll have to think.  Besides, wake up and smell the mocha.  You’re being paid to follow the guidelines.

Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.

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  • SarahW

    Physicians seem to have given up their profession for some kind of technical career. In return for what? Some ass-coverage and the promise of a steady stream of silver.

    How’s that working out for you?

    • stargirl65

      This all goes back to insurance. I am sure the surgeon would be more than happy to perform this man’s surgery today but his insurance won’t pay unless the patient meets certain guidlelines. The patient can get the surgery today if he wants to pay for it but I am sure he does not want to pay cash for this procedure. It is not just doctors that have given up their decision making to the insurers; it is also the patients. Both parties could be freed from the insurance companies’ rules if they simply agreed to a cash based interaction.

      • Diora

        ut I am sure he does not want to pay cash for this procedure
        I have no clue how much this surgery is, but given that it’s not something to be done in a doctor’s office, If you factor in surgery and hospital costs as well as whatever tests he needs, I’d bet the bill would be in 5-digits if not high five digits. Not something most people can afford.

        • HJ

          “I’d bet the bill would be in 5-digits if not high five digits. Not something most people can afford.”

          He can always go to Mexico…starting at $7500.

  • jp

    Sarah W- what the heck are you saying???

  • jp

    Also meant to ask, how did the PCP know he ” has one of those bodies that really uses energy efficiently. It just hangs on to every ounce of weight. ?” Other than thyroid studies, how can you document that?

    As a GP I have patients say they “eat almost nothing” and their bodies won’ t lose calories, but when they get honest and show me a diet diary, I see their intake is excessive, that efficiency had nothing to do w/the obesity.

  • AnnR

    Does a person recover from bariatric surgery in less than a year?

    Someone plugging away at a diet could lose a pound a week and be down 40-50 pounds in a year.

  • http://www.drrovito.com Donna Baver Rovito

    My husband, Peter F. Rovito, MD, is a general and bariatric surgeon and has done almost 2,000 laparoscopic gastric bypasses. One of the biggest frustrations he and his staff must deal with is “The Program” at his hospital (a bariatric center of excellent, partly due to him) which requires his patients to pay a $415 fee (not covered by insurance) to participate in a 3 or 6 month program that includes numerous group and individual meetings with 110 pound dieticians and exercise therapists (with whom his patients have a LOT in common) and attendance at two support group sessions.

    Most insurance companies require “The Program” before they’ll approve the patient’s surgery, based on the BMI index Dr. Perednia outlined. Not only does the hospital require that additional fee, up front before they’ll schedule a single appointment or meeting, but they meet only once a month to review patient participation, and if a patient has missed a single appointment or meeting, they’ll postpone their decision until the patient has made up the missed item. Granted, once the program’s “review board” has generated their letter of approval, insurance companies almost always approve the surgery quickly.

    This past year, my closest childhood friend went through “The Program” and my husband did a gastric bypass on her. Without telling anyone at the hospital who I was, I attended every session with her as a friend, so no one knew that the wife of one of the two surgeons who do the procedure at our hospital was present at every session. While the information they presented might have been valid, it didn’t always agree with what my husband recommends to HIS patients – and as I also sat in on his two pre-surgery sessions with her as well, I noted that he covered everything she’d paid $415 extra for and driven and hour and a half each way to attend TEN meetings and individual sessions at the hospital, in two office appointments.

    And the reason I know that what HE tells patients is more appropriate is that I also attended two support group meetings with her (also incognito) and listened to patient after patient tell their stories of success – and praise my husband “as a god.” (That was a direct quote – my friend and I giggled a lot as we listened to patient after patient tell the group how much weight they’d lost, and oh, by the way, Dr. Rovito’s post-op diet worked MUCH better than the one the hospital gave them.)

    So here’s my point – insurance companies and Medicare in PA pay about $1,500 to the surgeon for the procedure. Prior to surgery, my friend called the hospital’s billing office, wanting to know in advance what her hospital bill would be so she could be prepared for her deductible charges. While they wouldn’t give her an exact number in advance, they told her to expect her fees to be between $46,000 and $52,000 – for the surgery and one night in the hospital!

    But they also made sure to get that $415 extra out of every single patient. Weight loss surgery is a HUGE cash cow for hospitals – but even so, they have to extract more.

  • SarahW

    Jp – Here is what I am saying: that physicians have ceded too much authority to insurers. Discretion over “suitable” candidates (not merely whether any particular procedure is covered by a policy) for procedures and medications is handed off to your supposed betters. Others take responsibility for determining what is medically appropriate for any given patient. The benefit of this includes “rules” to point to when care is not tailored to an individual, but set on the basis of what is good for a herd. Ceding this authority gives a steady stream of patients; this worked well enough in the salad days of medicare and private insurance, but I would point to where it has led – and ask, how is that working out for you?

    Your determination that a patient’s is a good candidate for surgery should trump

    • Jo

      Sarah, You do not get it. The Government is an insurance company and when that happens there is no negotiation. If you want to “play” with the insurance companies you also have to play with the Gov and the American Medical Association as they are the ones who create the code numbers that are used so physicians get paid, and the AMA charges physicians hundreds of dollars to play, and the Government threatens Jail time if you make a mistake. All other insurance companies usually pay a percentage of Medicare payment. Physicians are also threatened with collusion and jail time if they share with each other what they get paid and payment differs from state to state. Calif gets paid at a higher rate than AZ which is right next door. Yet….insurance companies and the governement can disclose to each other what they pay out to physicians so they can manipulate a certain region. You can thank Senator Pete Stark for most of these types of physician regulations, when you look at the legislation he alone has sponsered it is evident he hates physicians. (If attorneys were told they had to live by the same rules there would be a lot more lawsuits:)

  • gzuckier

    Similar tale: a friend of mine who fit all the guidelines for statins (which he knew since he was analyzing a study at the time) except that he had to gain 20 pounds before his doctor would consider it.

  • http://www.docbuse.wordpress.com Steve

    Insurance and human resources both look out for the almightly dollar. It’s plain and simple. I am a physician. In December 2009 I topped out at 342 lbs and had severe type 2 diabetes. I have 6 members in my immediate family and 5 of us are type 2 diabetics. I was on 9 rx medications and insulin. My employer refused to cover bariatric surgery under their policy. Insurance would not approve it on appeal. I paid cash for duodenal switch, which has an approximate 99% cure rate for type 2 diabetes. In 8 short months I now weigh 179 lbs. I have lost my morbid obesity, type 2 diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. I feel half my age and am running up to 4 miles daily. Duodenal switch saved my life. If I waited on my employer or insurance company to deem me worthy of surgery, I would be dead. My surgery has already more than paid for itself and I have no regrets. I have a long, happy future to look forward to because I took charge of my own healthcare as opposed to “playing by the rules”. No regrets!