When should insurance cover body contouring?

Today in clinic, I interviewed a formerly morbidly obese woman. She has lost almost 300 pounds since undergoing gastric bypass surgery a few years ago, a presentation that has become increasingly common. She was here to see the plastic surgeon for her four week follow up appointment, status post abdominal skin flap removal.

See, after losing a ton of weight, loose skin remains, especially in places like the arms and abdomen.  The loose flap of skin is termed “pannus,” and the surgical excision of loose flaps of skin following massive weight loss is termed “body contouring.” The abdominal pannus is clinically relevant because it can strain one’s back or interfere with leg movement. The pannus also creates excess surface area that is hard to keep clean and hygienic. Rashes and ulcers and other painful things can develop as a result.

Luckily, this woman’s insurance covered her abdominal body contouring procedure because of how it would contribute to her quality of life. She was a pleasant lady, and so grateful to the plastic surgeon, but it was clear that there was something about her body that still bothered her even after all these procedures.

The elephants in the room were the huge saddlebags of excess fat that remain on her thighs. You can imagine how self-conscious that would make someone feel. What her insurance won’t cover is the body contouring procedure it would take to transform those log-legs into something she could at least stuff into a pair of stretch jeans. The rest of this patient’s visit comprised of removing her abdominal drain and reassuring her of the plastic surgeon’s optimism that she’d be able to go shopping for a new wardrobe soon.

Just as long as some paperwork gets filled out, she’ll be able to have the thigh reduction surgery further down the line, though it will cost more than she would like. Should her insurance help her out and cover much of the cost of this additional body contouring procedure?

If you’re on the patient’s side, you would think insurance should cover her thigh reduction surgery, as this would undoubtedly help improve her quality of life, health, and well being. This patient hopes to one day chase around her two adorable grandchildren and not worry about her inner thighs chafing together. On the other hand, if you think about the health care system as a whole, thigh fat removal surgery is perhaps somewhat appropriately not considered a priority.

Americans are always on the lookout for ways to cut health care costs and make quality health care more affordable and accessible. How do we discern which medical interventions are the most sustainable, cost-effective use of our funds and resources? To discover real solutions in health care, we must be honest with ourselves about what we’re spending money on now. Health education and physical activity are currently not priorities of American culture and lifestyle. Simply visit any airport or theme park in America for proof. We are now notorious for the rates of obesity and diabetes in our country.

Chronic disease in general is expensive because it involves long-term medical management, a myriad of medications, and increased morbidity. According to an article in the American Journal of Surgery, the incidence of bariatric surgery has peaked and remained stable since 2003, with approximately 113,000 cases performed per year. This same study reveals that bariatric surgery costs the health economy at least $1.5 billion annually. It is difficult to find data on the cost of any body contouring procedures that undoubtedly follow.

Open gastric bypass now constitutes only 3% of all cases but costs $4,800 less than its laparoscopic counterpart. Despite its simplicity, laparoscopic gastric banding costs the same as gastric bypass. Complication rates following bariatric surgery have fallen from 10.5% in 1993 to 7.6% of all cases in 2006. At least we’re getting better at bariatric surgery and the amount of money it costs us each year is not increasing.

Unfortunately, bariatric surgery is still considered a last resort to improve the quality of life of a morbidly obese patient who has no other medical options. As obesity and other chronic diseases trend upwards, it is not a stretch to say that an increasing amount of our medical resources is being spent on this type of health care.

As a medical student and future doctor, I envision a health care system that focuses on encouraging, maintaining, and prolonging quality of life. A system that prevents disease would save more money than a system that focuses on treating disease once it occurs. I hope to see increasingly fewer patients in clinic who have to buy back their quality of life from a chronic condition that potentially could have been avoided altogether.

Nonetheless, by reducing her thighs, my patient in clinic today will still ultimately contribute to the cause of preventive health. She will be able to run around with her grandchildren and help them establish habits of activity that could last them a long, healthy lifetime.

Stephanie Van is a medical student.

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