Everybody Wins:

Model Collaboration Leads to Insurer Policy Change,
Greater Patient Access in North Carolina

Published in July 2014 Issue             

Blue Cross and Blue Shield of North Carolina (BCBSNC) published a revised coverage policy on July 15 that eliminates the six-month requirement for patients to participate in a non-surgical weight reduction program prior to being considered for bariatric surgery. The move comes after months of discussions between local and national bariatric health professionals and BCBSNC officials.

“The real victory is for patients,” said Ranjan Sudan, MD, president of the ASMBS Carolinas State Chapter, who spearheaded the efforts on behalf of the bariatric community in North Carolina and nationally. “We laid out our concerns, backed it up with evidence and worked with BCBSNC in a highly constructive way that led to a change in policy. They were very receptive to what we had to offer and we were very responsive to
their questions.”

Some insurers have adopted a six-month requirement for medical weight loss prior to surgery, despite what the ASMBS says is a lack of evidence demonstrating any benefit. BCBSNC had added this requirement in Sept 2013, to previously existing restrictions on revision surgery and duodenal switch. This led to objections from individual surgeons, which galvanized into a coordinated effort that resulted in the changes to the policy.

In addition to removing the six-month pre-surgery requirement, BCBSNC revision policy and duodenal switch patient criteria are now consistent with ASMBS guidelines and recommendations. Previously revisions were allowed only for complications from bariatric surgery and duodenal switch was reserved for patients with a BMI greater
than 50 kg/m˛.

“Overall the language and references have been updated to reflect current evidence-based practices,” said Dr. Sudan.

But the story of the BCBSNC policy change is more than one major insurer revising its policy based on the concerns of bariatric surgeons. It is the story of leadership, collaboration, coordination, compromise, consensus building, and a patient-centric approach to practice and policy.

“We were very pleased with the process,” said Janet L. McCauley, MD, MHA, Senior Medical Director, Medical and Reimbursement Policy, BCBSNC. “We received input, evidence-based data and feedback related to our policy in a consistent and consolidated fashion. We went from individual conversations with surgeons with varying points of view to unified discussions with the bariatric community. There was a collective voice.”

That collective voice was represented by Dr. Sudan, who rallied local surgeons through the ASMBS Carolinas State Chapter, organized and presented data, and leveraged the resources and expertise of the national organization of the ASMBS. According to Dr. Sudan, the key to the successful collaboration between the insurer and the providers was a combination of data and diplomacy. The providers reached consensus on all issues of contention before engaging in policy discussions and presented a united front in a collegial rather than confrontational manner. BCBSNC responded in kind by sharing its own data and perspectives.

“This has been a model process that has removed barriers and improved access to care for our patients,” said Dr. Sudan. “We remain committed to continuing a constructive dialog and building on the professional and trusting relationship we have established through
the chapter.”

John Morton, MD

John Morton, MD, president-elect of the ASMBS, who has been a leader on the issue of patient access to metabolic and bariatric surgery for several years, believes the state chapters play an important role and there are lessons to be learned from this experience for both the bariatric community and insurers.

“The data is there to support greater use of metabolic and bariatric surgery for obesity and related diseases, including diabetes, and we must continue to find common ground with insurers to improve access,” said Dr. Morton. “This experience in North Carolina shows us we can do that when we are organized, persistent and collaborative. Everybody wins.”

There is hope that insurers throughout the country who maintain a prolonged mandatory weight loss requirement before surgery will follow the example of BCBSNC, who studied the issue and concluded it was not necessary.

Dr. McCauley believes this is a distinct possibility. “The evidence is the same and there is more convergence than divergence among payers,” she said.