- The Washington Times - Thursday, February 23, 2006

Health insurers face pressure to cover more weight-loss surgeries after this week’s decision by the federal government to cover more procedures for Medicare beneficiaries, a medical society said yesterday.

“We have every expectation this will put pressure on third-party payers to do the right thing,” said Dr. Neil Hutcher, a Richmond bariatric surgeon and president of the American Society for Bariatric Surgery, a Gainesville, Fla., group representing 1,800 surgeons.

Typically, health insurance companies will cover procedures that are first covered by the Centers for Medicare and Medicaid Services (CMS), the federal health agency in charge of the health insurance programs, said Rick Wade, spokesman for the American Hospital Association, a D.C. trade group.

“There have been a lot of changes [in the health care industry] where Medicare led the way,” Mr. Wade said.

But health insurers use other factors and scientific evidence when making policy decisions, said Mohit Ghose, spokesman for America’s Health Insurance Plans, a D.C. trade group for the health insurance industry.

“Our members will look at this new policy set out by CMS and consider it as they have in the past with other national coverage decisions as one of the factors,” Mr. Ghose said, adding that coverage for bariatric surgery varies nationwide.

CMS on Tuesday said the agency would expand Medicare’s national coverage of bariatric surgery for all participants.

The new ruling covers three more types of bariatric surgeries, which include another gastic bypass operation, gastric banding and biliopancreatic bypass. Prior to the decision, Medicare covered only gastric bypass surgery.

Report cards too high

Methods commonly used to create progress reports for the medical community may score doctors and hospitals too high, according to a study released yesterday by the Rand Corp.

“It appears that report cards based on just administrative information are incomplete and may lead to grade inflation,” said Dr. Catherine MacLean, lead study author and a physician with the Greater Los Angeles Veterans Affairs Healthcare System.

Report cards often are used by public health agencies and private medical facilities as a way to help consumers choose doctors, hospitals or insurance plans.

Additionally, “pay-for-performance” bonus plans, used by the government and several health plans, pay physicians’ bonuses or dole out fees based on their report card scores.

Rand, a Santa Monica, Calif., research organization, examined the medical care given over a 13-month period to 399 senior citizens nationwide who were at risk of declining health.

Researchers using just administrative information found the patients received 83 percent of the recommended care.

But when looking at a broader set of standards after examining the patients’ medical records, which are used less often for medical report cards, they found the same group received only 55 percent of the recommended care.

The study found administrative information did not provide data about quality measures for five conditions important to the elderly, which included end-of-life care, falls, malnutrition, pressure ulcers and urinary incontinence.

Health Care runs Fridays. Call 202/636-4892 or e-mail mhiggins@washingtontimes.com.

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