Has anyone gone through Tufts insurance for their WLS, and their "I can change program"?  I have to do this program for 6 months before I can get approved - i'm curious how fast it can be approved after that since I'm spending these 6 months getting my ducks in a row.

I thought Tufts had dropped their cost-containing "6 month pre-op requirement" last summer, just a few months after it was instituted, after the Boston Globe reported on this new policy and they started to receive negative feedback from their subscribers and bariatric surgeons.  I'm sorry to hear that this isn't so. Just BTW, Harvard/Pilgrim was completely pain-free for me. /Steve

I thought I had read about this in the Globe a while ago!  Maybe all they did in response to complaints is change a draconian "1 year pre-op program" to an only slightly less draconian "6 mo. pre-op program".  /Steve

Tufts plan will restrict surgery for obesity

By Jeffrey Krasner, Globe Staff  |  February 14, 2007

Tufts Health Plan next month will start denying gastric-bypass and stomach-banding procedures to some obese patients and require others to enter a yearlong diet and counseling program before undergoing the potentially lifesaving surgery.

Tufts, the third-largest health insurance company in Massachusetts, said limiting the number of such surgeries could save the company millions of dollars and ultimately improve patients' health. While insurers routinely reject patients for certain procedures or restrict access to medical care, Tufts is adopting more stringent criteria for the procedures than the state's two largest insurers, Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care.

Doctors condemned the new policy, which takes effect March 6, saying Tufts is ignoring a growing body of clinical evidence that shows that such operations help those who have exhausted other methods to lose weight. Delaying surgery worsens conditions such as diabetes and heart disease that are often complications of pronounced weight gain, they said.

"This is Draconian," said Dr. Philip Schauer , president of the American Society for Bariatric Surgery and director of bariatric surgery at the Cleveland Clinic. "This flies in the face of the medical evidence. These policies sentence a patient to a life of dealing with obesity without the possibility of parole."

The most common weight-related procedures are lap-band surgery, in which silicon bands are tied around the stomach to shrink its size, and bypass surgery, in which staples are used to close off a section of the stomach. In both procedures, the aim is to restrict the amount of food a patient can eat by drastically reducing stomach capacity.

The popularity of the procedures has made them a target for health plans seeking to control costs. Last year, 177,600 weight- related surgeries were performed nationally, compared with 36,700 in 2000, according to the American Society for Bariatric Surgery. But these surgeries carry significant risks -- one in 200 patients undergoing gastric bypasses dies from complications, according to a study published in October 2004 by the Journal of the American Medical Society.

Gastric bypass surgery costs about $20,000, while the stomach banding procedure can cost less than $10,000.

A person with a body mass index greater than 25 is considered overweight and a BMI of more than 40 is classified as severely obese. Under guidelines sent to Tufts doctors last month, all patients would have to complete a yearlong "lifestyle management" program called iCanChange before being eligible for bariatric surgery. At the end of the program, those with a BMI of less than 40 would not be eligible for the procedures. Patients with an index between 40 and 50 would only be eligible for stomach banding, which is less expensive and not as invasive as stomach bypass surgery, unless they also suffered from medical conditions like diabetes or high blood pressure. Dr. Allen J. Hinkle , Tufts' chief medical officer, said the new standards will lower risks to patients and save Tufts Health Plan money. The insurer spent $10 million on the operations last year, and demand for the procedures in Massachusetts is growing by 28 percent annually, he said.

But Dr. Scott Shikora , chief of bariatric surgery at Tufts-New England Medical Center, said the company should leave decisions about medical procedures to doctors. Shikora said he and colleagues have attempted to persuade Tufts Health Plan to reverse its position. He also wrote a letter complaining about the policy change to Dr. JudyAnn Bigby , Massachusetts' secretary of health and human services.

Tufts' cost cutting has angered physicians before. In 2005, it tightened controls on high-tech imaging procedures like MRIs by requiring authorization for some patients. It also required physicians to get authorization before performing hysterectomies and some back surgeries.

Cost controls are more urgent for Tufts than its larger competitors . Over recent years, membership declined from a million to about 600,000, although it has stabilized and appears this year to be growing. The company has been profitable, but it relies heavily on investment income from large cash holdings to bolster its performance.

Dr. Alan M. Harvey , an anesthesiologist at Brigham and Women's Hospital, criticized Tufts's requirement that patients spend a year in the weight-loss program, whi*****ludes weekly phone calls with counselors and "access to web-based tools."

"There's no evidence that delay is helpful for these patients," said Harvey. "Many have already been through many counseling and treatment programs."

But Hinkle said 20 percent of the patients who go through the program would lose enough weight to avoid surgery, while others would reduce the risk associated with surgery by improving their physical condition. The patients' medical problems, such as diabetes and high blood pressure, "aren't going to progress in a year to the point where the patient's health would deteriorate," he said, "and we'll deal with any exceptions."

While Blue Cross and Harvard Pilgrim said they are not changing their policies , other insurers nationwide have attempted to restrict access to the procedures. For instance, Blue Cross Blue Shield of Tennessee required obese patients seeking the surgery to take an intelligence test, but last month dropped the stipulation after a barrage of criticism.

The Obesity Action Coalition, a Florida patient-advocacy group, criticized Tufts yesterday, saying the policy is akin to discrimination against obese people.

"The biggest issue with Tufts is that patients and their surgeons need to be the ones to decide which weight-loss option is the best, not the insurance company," said James Zervios , a spokesman .

Jeffrey Krasner can be reached at [email protected].

Yup, Tufts backed down and imposed the "6 month pre-op" requirement:

Tufts changes weight-loss policy; Restriction on surgery eased.(BUSINESS)

From: Telegram & Gazette (Worcester, MA)  |  Date: 5/1/2007

 

Byline: Elizabeth Cooney

Tufts Health Plan has changed its policy for members seeking weight-loss surgery, reversing restrictions on who can have the operations and cutting in half the amount of time they must spend in its behavioral program.

Under the new guidelines, effective April 16, members must complete six months of the insurance plan's lifestyle modification program, called iCanChange, before being considered for bariatric surgery. That's a change from the 12-month requirement Tufts announced March 6.

Members who have a body mass index between 35 and 40 may now be considered for weight-loss surgery if they have one of three conditions that need medical treatment - diabetes, hypertension or sleep apnea. The previous BMI minimum was 40.

Another change is the removal of BMI-based restrictions on the type of bariatric surgery for which a member could receive coverage. Under the March 6 rules, only laparascopic gastric banding was covered for people whose BMI fell between 40 and 50 unless they had diabetes or hypertension. Gastric bypass was covered for people whose BMI was 50 or above.

Both kinds of surgery are intended to shrink the amount of food the stomach can hold. Gastric bypass staples off a section of the stomach. The lap-band, which is reversible, cinches off the stomach to make its capacity smaller.

Tufts is the state's third largest HMO and had approximately 625,000 members as of March 1.

The Waltham-based health insurer issued a statement yesterday in response to questions about the change in policy.

"Tufts Health Plan and its physician partners are committed to providing access to high-quality treatment for morbid obesity including bariatric surgery that offers our members and patients the greatest opportunity for long-term success," the statement said. "Working most closely with bariatric surgeons at Tufts-New England Medical Center, we jointly agreed to guidelines for the coverage of bariatric surgery."

Spokeswoman Catherine Grant declined to elaborate further on why the change was made.

The insurer also requires its members, depending on their choice of health plan with Tufts, to have their operations at hospitals approved by the health plan, the American Society of Bariatric Surgery/Surgical Review Corp. or the American College of Surgeons.

When Tufts Health Plan first rolled out its new criteria for coverage in March, members, doctors and public health officials complained about limiting counseling to one provider and excluding patients with serious medical conditions and BMI of below 40 from the surgery. Nancy Ridley, assistant commissioner of the state Department of Public Health, wrote a strongly worded letter to James Roosevelt Jr., president and CEO of the health plan, warning about the dangers of delaying treatment for the morbidly obese. She reminded him that DPH could review denials of coverage for medical necessity.

The plan defended its policy as a safer, more cost-effective approach to the treatment of obesity.

Dr. Mitchell J. Gitkind, medical director of the UMass Memorial Medical Center Weight Center, voiced his concerns in March. Yesterday, he welcomed the change to bring Tufts back in line with other health plans and government recommendations.

"Now they're much more in line with criteria from the NIH (National Institutes of Health) for bariatric surgery," he said.

Things really have changed. Six years ago My Dr called and got an approval from Tufts. No wait no diet no 6 months bull****

what's really crazy is that the program is a behavior modification one that requires me to talk to my coach 8 times over 6 months and I must make and successful achieve 2 goals (at least) in the 6 months.  There is no weight loss requirement since I do not have to visit a doctor or coach in the 6 months.  My first goal was to eliminate the skin on chicken from my diet.  DONE.  I have also vowed to stop eating white bread. DONE.  Too bad I fulfilled 80% of the required stuff in 3 weeks.

I know nothing about Tufts but wanted to say hi, my hubby had Dr. G for his surgery (my Dr through the same practice retired)  and he also did a non weight loss related surgery on me.  We absolutely LOVE him to pieces!!  He's the best!I just wanted to say hi, welcome and good luck Gwen

i haven't met him yet, but his experience and reviews like yours give me faith that he's the right man for the job!

I totally agree about Dr. G and he wasn't even my surgeon!  You are in incredible hands, not only is he one of the most genuinely nice people I have ever met, but I go to the meetings just to hear his bits of wisdom which are always awesome.   The other person in the office who is awesome is Renee- from what I can see she does pretty much everything, AND she made rounds with the team when I was in the hospital post-op, very nice to see that.  She knows the insurance companies backwards and forwards, I would strongly recommend calling and talking to her.  I do know that the doctors at NWH consider a 6 month diet to be idiotic on the part of the insurance company, and they do what they can to move you through as quickly as possible.   Good luck!! 

I have Tufts and I was one of the very few that made under that new guideline BS. Are you involved in any other program that is sanctioned by the hospital you intend to have your surgery at? I have found that if you are involved in a support group ( such at the hospital) it will help you stay on track, and encourage your peers to do the same-they can see your progress and vice versa. Last time I looked ,they don't have video phones @ I Can Change, so how do they track your progress? My Hospital is the one that Tufts is battling with ( Tufts Medical Center) and Dr. Shikora is in charge of the surgeons @ our Obesity Consult Center. He knows that many of us have tried many diets and have failed and had developed co-morbidities that makes this surgery essential. We have a psych team that is the greatest-we went through  an intense 2 month behavior modification course that we had to complete before our surgery date. Again you watch your peers drop the weight, and you are getting a new mindset . So find out if you have any support groups @ your hospital, you'll find it to be way more enlightening than your phone call. Just hit my year from GBP (4-16-07)  !!! Take care and hope that it helps George