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On the heels of the Medicare Coverage Advisory Committee's (MCAC's) recentsupport of weight-loss surgery as safe and effective, the Centers for Medicare& Medicaid Services (CMS) is preparing to evaluate possible changes to itscoverage policy.
If more procedures are covered more consistently, this could affect theprimary care physicians who make surgical referrals and provide most pre- andpostoperative care.
The 16-member MCAC panel considered evidence on three bariatric procedures:gastric bypass, gastric banding, and biliopancreatic diversion. The paneldetermined that all three offer sustained weight loss, acceptably low levelsof short- and long-term mortality, and significant resolution of illnessesassociated with morbid obesity. However, more research is needed in peopleaged 65 and older, the panel says.
In July 2004, the CMS removed language from the Medicare CoverageIssues Manual stating that obesity is not a disease (DOC News,October 2004). Yet neither that decision nor the committee's Nov. 4recommendations affect current Medicare policy, which covers bariatric surgeryonly when beneficiaries have related comorbidities, such as type 2 diabetes orhigh blood pressure.
CMS now will decide if it needs to change its policies internally basedupon the panel's findings or if it will open a National Coverage Decision toget additional public input, says Steve Phurrough, MD, director of thecoverage and analysis group for CMS.
Phurrough predicts some of the questions likely to be asked: "Shouldwe continue to cover bariatric surgery or should there be closer observationor more control about how bariatric surgery is provided to [the elderly]population?"
Officials also have suggested that changes in Medicare coverage could becontingent on establishing a patient registry to help CMS gather more evidenceabout bariatric surgery for different Medicare populations.
On the issue of regional inconsistency, Phurrough acknowledges that whenMedicare says it pays for a category of procedures, regional contractors canmake individual decisions about coverage of specific procedures within thatcategory. "It would not surprise me if we were asked to define coverageat the national level," he says.
Indeed, the American Society for Bariatric Surgery (ASBS) expects to submitsuch a request soon, says ASBS president Harvey J. Sugerman, MD.
"There is a great deal of discrepancy from region to region withregard to who gets covered and who doesn't and which surgical procedures arecovered and which may not be," Sugerman says.
When CMS opens a request for a national coverage decision, it has a maximumof 6 months to produce a draft decision. Once the draft is published, it issubject to 30 days of public comment, after which CMS has an additional 60days to make its final decision.
"We'd like to see that [Medicare] supports the 1991 [NationalInstitutes of Health] consensus conference guidelines," Sugermansays.1
Those guidelines recommend that weight-loss surgery be an option forselected patients with clinically severe obesity—body mass index (BMI)greater than 40 or greater than 35 with comorbid conditions—when otherattempts at weight control have been ineffective.
IMPLICATIONS FOR PRIMARY CARE
The most fundamental change for primary care physicians would be ifMedicare decides to cover bariatric surgery for obesity without comorbidmedical problems, says internist and nutritionist Christopher Still, DO,medical director of the Center for Nutrition and Weight Management atGeisinger Health System in Danville, Pa.
Still says Geisinger's integrated weight loss surgery program has a wealthof patients who fit that criteria now, and he is "cautiouslyoptimistic" that surgery for the obese without comorbidities will becovered.
"Just not waiting for other comorbid problems for reimbursement [forsurgery] will be a great treatment option for individuals with obesity,"he says.
Under current Medicare guidelines, these patients would not be eligible forthe surgery, Still reiterates. The potential change would increasesignificantly the number of eligible patients being referred to bariatricsurgeons, as well as general practitioners' pre- and postoperative caseloads,he says.
"We've made great strides for obesity treatment, not just withsurgery, but also with medical treatment that includes dietitians,nutritionists, psychologists, and exercise physiologists," says Still."This [Medicare change] will benefit our armamentarium to treatobesity." 
NEW MEDICARE PREVENTIVE BENEFITS
Medicare will begin covering initial physical examinations forbeneficiaries who join the program after Jan. 1, 2005.
The new "Welcome to Medicare Physical" is part of the agency'seffort to increase prevention, U.S. Department of Health and Human ServicesSecretary Tommy Thompson announced last November.
Medicare also will cover tests for diabetes and cardiovascular disease, aswell as screenings for hearing and vision problems including glaucoma, highcholesterol, and high blood pressure.
CMS has made two changes to the proposed paymentprovisions—physicians can bill and be paid separately for the screeningelectrocardiogram in addition to payment for the physical. The 2005 physicianspayment rule also lets doctors bill for a more extensive office visit whenperformed at the same time as the physical—provided the services aremedically necessary.
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