For individuals struggling with severe obesity and its related health complications, weight loss surgery can be a life-changing option. However, the cost of these procedures can be a significant barrier. This article explores the possibilities of accessing government-funded or otherwise affordable weight loss surgery, outlining eligibility requirements, available programs, and alternative strategies for managing expenses.
Understanding the Landscape of Weight Loss Surgery Funding
Weight loss surgery is often considered an elective procedure, which means coverage options can be limited. While "free" weight loss surgery is rare, there are avenues to explore for financial assistance. These include medical grants, charity care, and other strategies to make the procedure more affordable.
Medical Grants: Avenues for Financial Assistance
Medical grants specifically for weight loss surgery are typically directed towards individuals who demonstrate a genuine need for the procedure but lack the financial resources to cover the costs.
The Weight Loss Surgery Foundation of America (WLSFA)
The Weight Loss Surgery Foundation of America (WLSFA) stands out as a key organization offering grants for weight loss surgery. However, it's important to recognize that these grants are competitive and may not be accessible to everyone. Even when awarded, a grant might not cover the entire cost of the surgery, potentially covering only a portion of it.
WLSFA primarily raises funds to support the actual weight loss procedure or to aid in the recovery process following surgery. Grant recipients often "repay" the grant by volunteering their time and resources to support WLSFA's activities. This system allows the foundation to minimize operational costs and allocate more funds towards assisting a greater number of individuals in need of surgery.
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Eligibility Criteria for WLSFA Grants
To be eligible for a WLSFA grant, candidates must meet specific conditions:
- Medical Approval: You must have approval to undertake reconstructive weight loss surgery from a recognized health practitioner and facility, following physical, psychological, and nutritional evaluations.
- Insurance Status: Your insurance must have declined coverage for the surgery, or you must lack insurance and be unable to afford it, or your insurance policy must not cover this type of surgery.
- Full Participation: You must demonstrate a willingness to volunteer for the organization, provide all necessary information, and contribute to the cost of the procedure (often around 10% of the total price).
WLSFA grants primarily target individuals who fall within specific poverty level guidelines and lack adequate insurance coverage. The procedures are typically performed at local hospitals, emphasizing that surgeries are only performed when deemed medically necessary, excluding purely cosmetic procedures.
Charity Care: Exploring Hospital-Based Assistance
Another potential avenue for accessing affordable weight loss surgery is through charity care programs offered by hospitals.
Applying for Charity Weight Loss Surgery
The application process for charity weight loss surgery typically involves completing income declaration forms to demonstrate low income, along with providing personal details for verification. Having a referring doctor who is a member of the hospital staff can often facilitate the approval process.
Overcoming Referral Challenges
If you need the procedure but lack funds, and your doctor is hesitant to provide a referral, it's crucial to educate yourself and share information about the health benefits of weight loss surgery with your doctor, as some may have outdated information.
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Negotiating with Hospitals
Even if a doctor is unwilling to provide a referral, it's important not to give up. Explore options for negotiating a payment package with hospitals, potentially securing a reduced price or more convenient payment options.
Addressing Aetna HMO and QPOS Plan Exclusions
It's important to note that some insurance plans, such as most Aetna HMO and QPOS plans, may exclude coverage for surgical operations, procedures, or treatment of obesity unless specifically approved by Aetna. Some Aetna plans may entirely exclude coverage for surgical treatment of obesity.
Requirements for Aetna Coverage
To gain Aetna approval, members typically need to demonstrate participation in an intensive multicomponent behavioral intervention designed to promote weight loss through dietary changes and increased physical activity. This participation must be documented in the medical record, demonstrating compliance with the program.
For members with active substance abuse disorders, a history of eating disorders (in addition to obesity), severe psychiatric disturbances (such as schizophrenia, borderline personality disorder, suicidal ideation, or severe depression), or who are currently under the care of a psychologist/psychiatrist, pre-operative psychological clearance is often necessary to ensure informed consent and compliance with the pre- and post-operative regimen.
The Importance of Behavioral Interventions
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer or refer obese adults to intensive, multicomponent behavioral interventions, emphasizing that these interventions can lead to clinically significant improvements in weight status and reduced incidence of type 2 diabetes.
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These interventions typically last for 1 to 2 years and involve 12 or more sessions in the first year, utilizing various delivery methods such as group sessions, individual counseling, and technology-based approaches.
Pre-Surgical Preparation and Considerations
The NIH Consensus Conference on Surgical Treatment of Morbid Obesity recommends an initial goal of a 10% reduction in weight through medical therapy, with a reasonable duration of 6 months. The American Dietetic Association also recommends dietetic counseling and behavioral modification prior to surgery.
Benefits of Pre-Operative Weight Loss
Even modest weight loss prior to surgery can lead to substantial improvements in pulmonary function, blood glucose control, blood pressure, and other physiological parameters, reducing surgical risks. For maximal benefit, dieting should occur close to the time of surgery.
The Role of Patient Compliance
Given the importance of patient compliance in diet and self-care for improving patient outcomes after surgery, the appropriateness of obesity surgery in noncompliant patients should be carefully considered. A patient’s refusal to even attempt to comply with a nutrition and exercise regimen prior to surgery may indicate poor compliance with post-operative requirements.
Optimizing Health and Reducing Surgical Risks
Obesity itself increases the likelihood of pulmonary complications and wound infections. Weight loss prior to surgery can make the procedure easier to perform, reduce the size of the liver, and improve surgical access to the stomach.
Post-Operative Dietary Requirements
Following surgery, patients must adhere to a careful diet of nutritious, high-fiber foods to avoid nutritional deficiencies and other complications. The total weight loss from surgery can be enhanced by combining it with a low-calorie diet.
The Importance of Smoking Cessation
The pre-operative surgical preparatory regimen should include cessation counseling for smokers, as obesity places them at increased risk for cardiovascular disease.
Choosing a Qualified Surgical Center
Ideally, surgery should be performed at a bariatric surgery center with a demonstrated commitment to providing adequate facilities and equipment, as well as a properly trained and funded bariatric surgery support staff. This team should include experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff.
The Importance of Multidisciplinary Care
The American College of Surgeons (ACS) emphasizes the importance of the surgeon's commitment to multidisciplinary management of the patient, both before and after surgery, with active collaboration across various patient care disciplines.
Surgical Volume and Outcomes
Studies have demonstrated a relationship between surgical volumes and outcomes of obesity surgery, with higher surgical volumes associated with better clinical outcomes.
Multidisciplinary Screening and Assessment
A Multidisciplinary Care Task Group recommends multi-disciplinary screening of weight loss surgery patients to ensure appropriate selection, pre-operative assessment for obesity-related diseases, pre-operative weight loss and smoking cessation, peri-operative prophylaxis for deep vein thrombosis and pulmonary embolism, and pre- and post-operative education and counseling by a registered dietitian.
Weight loss surgery patients need to learn important new skills, including self-monitoring and meal planning. Many forms of weight loss surgery require patients to take lifelong nutritional supplements and to have lifelong medical monitoring.
The Impact of Pre-Operative Weight Loss on Post-Operative Complications
Anderin et al (2015) found that weight loss before bariatric surgery is associated with a marked reduction in the risk of postoperative complications, particularly for patients with higher BMIs.
Medicare Coverage for Bariatric Surgery
The Centers for Medicare & Medicaid Services (CMS) has determined that certain bariatric surgery procedures are reasonable and necessary for Medicare beneficiaries who meet specific criteria.
Covered Procedures
Covered procedures include open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS).
Eligibility Requirements
To be eligible for Medicare coverage, beneficiaries must have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.
Facility Requirements
Covered bariatric surgery procedures must be performed at facilities certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center or certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE).
Non-Covered Procedures
The two non-coverage determinations in the National Coverage Determination Manual (NCDM) remain unchanged - Gastric Balloon (NCDM Section 100.11) and Intestinal Bypass (NCDM Section 100.8).
Obesity and Related Medical Conditions
Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who meet the BMI and co-morbidity criteria and have been previously unsuccessful with the medical treatment of obesity. Treatments for obesity alone remain non-covered.
The Obesity Epidemic and the Role of Bariatric Surgery
Obesity is a growing epidemic in the United States, with over 60% of the population classified as overweight or obese. Overweight and obese persons have an increased risk of a number of diseases compared to those with normal weight and waist circumference, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain cancers.
Because of the relative lack of success of most weight loss programs, persons with co-morbid conditions related to obesity have increasingly turned to bariatric surgery.
Types of Bariatric Surgery Procedures
Several modifications of bariatric surgery have developed over the last several years. Two major types of surgery are now being employed: malabsorptive procedures, which divert food from the stomach to a lower part of the digestive tract, and restrictive procedures, which restrict the size of the stomach and decrease intake. Other surgeries combine both types of procedures.
Initially, bariatric surgery was developed as an open procedure, but in recent years, successful attempts have been made to convert some of the procedures to laparoscopic procedures, while new ones have been developed solely as laparoscopic procedures.
Common Bariatric Surgery Procedures
- Roux-en-Y Gastric Bypass (RYGBP): RYGBP achieves weight loss through both gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption.
- Biliopancreatic Diversion with Duodenal Switch (BPD/DS): BPD/DS combines both restrictive and malabsorptive mechanisms. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with the RYGBP. The most proximal areas of the small intestine are bypassed, and substantial malabsorption occurs.
- Gastric Banding (LAGB): Gastric banding achieves weight loss by gastric restriction. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc’s encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic.
- Sleeve Gastrectomy: Sleeve gastrectomy involves a 70%-80% greater curvature gastrectomy with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. It may be the first step in a two-stage procedure when performing RYGBP.
- Vertical Banded Gastroplasty (VBG): VBG uses mechanical restriction to cause weight loss, with no malabsorption component. The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach.
Historical Context of Bariatric Surgery
VBG was one of the more common surgical procedures for weight loss in the late 1980s and early 1990s but has been largely supplanted by LAGB since 1995.
Medicare's Stance on Obesity Treatment
Medicare covers services in connection with the treatment of obesity when such services are an integral and necessary part of a course of treatment for medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. However, program payment may not be made for treatment of obesity unrelated to such a medical condition.
Non-Covered Procedures Under Medicare
- Intestinal Bypass Surgery: The safety of intestinal bypass surgery for treatment of obesity has not been demonstrated, and it does not meet the reasonable and necessary provisions of §1862(a)(1) of the Act.
- Gastric Balloon: The use of the gastric balloon is not covered under Medicare, since the long term safety and efficacy of the device in the treatment of obesity has not been established.
Alternative Funding Options
Even if you don't qualify for grants or charity care, several other options can help make weight loss surgery more affordable:
- Surgeon Financing: Explore financing options offered directly by surgeons, which may be more affordable than traditional loans.
- Friends and Family: Consider seeking support from friends and family who understand your situation.
- Secured Loans: Investigate secured loans from banks and other financial institutions.
- Medical Tourism: Research medical tourism destinations where the procedure may be more affordable, potentially combining surgery with a tourism package.
- Tax Deductions: Explore the possibility of tax deductions for medically necessary procedures approved by a doctor.
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