Bariatric Surgery Now Covered for
PA State Employees, But With Limits

Published in February Issue             

After more than a decade of denying bariatric surgery as a covered treatment option for severe obesity, the Pennsylvania Employees Benefit Trust Fund (PEBTF) will now offer insurance coverage to state employees who have a body mass index (BMI) of 40 or more and type 2 diabetes.

According to the new policy, both severe obesity and diabetes must be present, and patients must participate in a six-month physician-supervised nutrition and exercise program prior to surgery. The new coverage policy went into effect January 1, 2018.

PEBTF administers health care benefits to approximately 77,000 state employees and their dependents, and 63,000 retirees and their dependents. The State of Obesity: Better Policies for a Healthier America reports Pennsylvania has the 25th highest rate of adult obesity in the nation. It’s currently 30.3 percent, up from 20.3 percent in 2000 and from 13.7 percent in 1990.

Samer Mattar, MD

"Our Pennsylvania state chapter and local members have been relentless for nearly a decade to enable access to this life-saving treatment that until now has been denied to so many state employees who could otherwise benefit, so in that sense it’s a real victory,” said Samer Mattar, MD, president of the American Society for Metabolic and Bariatric Surgery (ASMBS). “But, we’re certainly disappointed that coverage comes with stipulations that run contrary to the evidence, expert opinion and our real-world experience in treating patients.”

The ASMBS disagrees with the Pennsylvania plan’s six-month mandatory diet and exercise requirement before surgery and restricting surgery to only those with diabetes and a BMI of 40. At a minimum, the new coverage policy stands in contrast to longstanding national guidelines from the National Institutes of Health (NIH) that recommend bariatric surgery for patients with a BMI of 40 and above, or a BMI of 35 and above, when linked with an obesity-related condition including, but not limited to, type 2 diabetes.

Furthermore, guidelines developed in 2016 and endorsed by 45 health groups, which included the American Diabetes Association and the International Diabetes Federation, declared that metabolic or bariatric surgery should be considered for patients with a BMI as low as 30 when their diabetes is inadequately controlled despite optimal treatment.

Ann Rogers, MD

Ann Rogers, MD, director, Penn State Surgical Weight Loss and an ASMBS State Access to Care Representative has been leading the fight with other ASMBS members for coverage for more than a decade that included countless meetings with PEBTF, state and federal officials, including the governor, the state’s insurance commission, members of Congress, the Physician General of PA, bariatric surgeons, patients and other advocates.

“It has been a long struggle, and to have this turnaround at the state level is incredibly significant. It’s better to have some access, than no access,” said Dr. Rogers, who is the ASMBS State Access to Care Representative (STAR). “Our experience shows that we can never give up for our patients, and we expect with continued work, we will see more victories in Pennsylvania and around the country.”

There are now only seven states that do no currently offer a bariatric surgery benefit for state employees -- South Carolina, Louisiana, Montana, Idaho, Utah, Wisconsin and Georgia.

"We continue the hard work of improving access and reducing restrictions for patients in need,” said John M. Morton, MD, ObesityPAC chair and past president of the ASMBS. “I’m gratified that the ObesityPAC donated to two Pennsylvania elected representatives to assist Dr. Rogers and other Pennsylvania bariatric surgeons achieve their goal of coverage. As a society, both at the national and local levels, we will continue to fight for our patients.”

The executive officers of the Pennsylvania State Chapter include: Fernando Bonanni, MD, president; Michael D. Bono, MD, past president; Joseph McPhee, MD, vice president;
Luciano Dimarco, DO, secretary/treasurer; Ann Rogers, MD, STAR (State Access to Care Representative); and founding members Amjad Ali, MD, Fernando Bonanni, MD,
Micheal Bono, MD, Alan Brader, MD, Scot Currie, DO, and Luciano DiMarco, DO.

The 90-strong ASMBS Access To Care Committee led by Chair, John Scott, MD, continually makes gains on improving patient access and supporting local chapters throughout
the country.

John Scott, MD

“Coverage policy throughout the country needs to catch up to best clinical practice, which includes access to the most effective treatment for severe obesity,” said Dr. Scott. “The health consequences of denying bariatric surgery to those who could benefit are significant, and in some cases, tragic.”

For more information about the ASMBS Access to Care Committee, click here .