Smart Enough for Weight-loss Surgery?
Tennessee Insurer Does About-face on IQ Test for Bariatric Patients
Patients hoping to have their weight-loss surgeries covered by Blue Cross Blue Shield Tennessee no longer have to undergo IQ screens in addition to meeting BMI and obesity-related co-morbidity requirements. After being challenged by the Obesity Action Coalition last month, the insurer removed from its policy the requirement that prospective patients had to have their mental abilities measured.

The policy had stated that a psychiatrist or psychologist must submit an IQ screening in addition to documentation of the patient's willingness to comply with both the pre- and post-operative treatment plans, a personality inventory, an eating disorder inventory and an eating attitudes test. Further, the policy said, "if any of the [testing] provides a suggestion of cognitive slippage or psychosis, a predictive test" such as a Rorschach test is required.

There's no indication that a below-average IQ would prevent weight-loss success if the right post-op support is in place, says Lori Nevins, LCSW, the program coordinator at New York Bariatrics in White Plains, N.Y., which has earned the American Society of Bariatric Surgery's Center of Excellence designation for its care.

"It's a very thorough and precise policy, which makes the IQ test stand out so much more - it's just inconsistent, because there's nothing precise about [IQ results]," says Ms. Nevins. "What does the number mean? How is it evaluated? If patients aren't 'smart' enough, are they not worth spending the money on?

"It's condescending, and it's exactly the kind of negative message that patients encounter their whole lives with obesity," adds Ms. Nevins. "The policy sets patients up for more feelings of inadequacy and feelings that they will fail."

The requirement was "plain old discrimination," says James Zervios, the director of communications for the OAC. "It perpetuated the stigma that obese and overweight people are less intelligent. It didn't belong in the policy, and we're very pleased that it's been removed. It's a big step in the right direction."

Mary Thompson, APR, a spokeswoman for BCBST, says the IQ screens were used as complements to psychological evaluation "to make sure that bariatric patients are aware of and understand the risks" of surgery. The information also helped the insurer "assess the level of follow-up we're going to have to provide the patient," she says, noting that there was "nothing to indicate that a score on the IQ screen would be used to deny access to the procedure" and that "no members that we're aware of had been denied access because of this."

"Unfortunately, our use of the term IQ screening has been misconstrued," says Ms. Thompson. "Therefore, effective immediately (Jan. 26), we [removed] the term IQ screening from our medical policy, but will continue to require a psychological evaluation accepted by the American Psychological Association."

While definitive proof a patient will do well with surgery doesn't exist because of the unlimited permutations of physical and emotional factors that inform patients' experiences, Ms. Nevins says a psychological evaluation is one of the tools for making weight-loss surgery "a whole-person procedure."

"A psychological evaluation is one thing, but there's no proof that a high or low IQ score means that one patient is going to comply better than another," says Mr. Zervios. "Obesity is a disease, just as cancer is. You wouldn't require an IQ test of a cancer patient. The OAC welcomes [BCBST] to contact us to develop more acceptable and effective guidelines."

- Stephanie Wasek

View Blue Cross Blue Shield Tennessee's weight-loss surgery policy: www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_Obesity.htm
Visit the Obesity Action Coalition online: www.obesityaction.org

Charity in the OR
Free Surgery Programs Offer Care to the Poor and Uninsured
For 10 years, Andrew Moore II, MD, a plastic surgeon in Lexington, Ky., nursed the dream of being able to offer care to the needy people in his area, something akin to "Doctors Without Borders" without having to leave his family. He saw an opportunity in 2005 when the CEO of Health-South Lexington Surgery Center told him the facility didn't use its ORs on Sundays. He brought up his idea to have volunteer healthcare workers offer free services to the uninsured and needy, and Surgery on Sundays, Inc., was born.

According to director Larry Collins, this program includes 200 volunteer surgeons as well as primary care physicians, medical technicians and even free dictation services provided by volunteers. So far, doctors have treated 365 patients, most from central Kentucky but some from other parts of the state and even two infants from Guatemala. Lexington's Surgery on Sunday program is being expanded to Louisville with the help of $135,000 in funding from Anthem Blue Cross and Blue Shield of Kentucky. What's more, the mayor of Cooksville, Tenn., wants help in starting a similar program there. "It's beginning to spread," says Mr. Collins.

Such philanthropy isn't limited to Kentucky. Operation Access has helped the uninusured of San Francisco receive elective ambulatory procedures since 1995. "Everything from orthopedic surgery to urology," says program director Mary Gregory. The program works with a network of hospitals to care for patients who are referred to them through community clinics. They're either treated on a weekend or put into the hospitals' weekly schedules.

Fresh Start Surgical Gifts in Carlsbad, Calif., offers plastic surgery to children with physical deformities. Spokesperson Amelia Devine says Dennis Nigro, MD, founded this program in 1991 after he saw a need for disadvantaged children to have such a service. Physicians in Fresh Start work in surgery six to eight weekends a year, performing 10 to 15 major surgeries, multiple minor surgeries and laser treatments.

"We offer the full gamut of services," says Ms. Devine. "Some of our surgeons volunteer every time we have one of these, despite putting in a full week working at their practice. They're very dedicated."

- Nathan Hall

Outsourcing Patient Care on the Rise
What's Driving Increases in Contracted Services?
Outsourcing is not just for food services and housekeeping anymore. More than three-fourths (78 percent) of healthcare facilities outsource at least one patient care service, such as diagnostic imaging, lab services, specialty equipment, outpatient surgery and bariatric surgery, according to the "2006 Hospital Outsourcing Trends in Clinical Services Survey" conducted by law firm Waller Lansden Dortch & Davis. And 83 percent of survey respondents say they expect their facilities' outsourcing levels to stay the same or increase over the next two to three years, compared with 17 percent who say they will look to decrease outsourcing.

More key findings from the survey of 266 facilities:

• Fifty-five percent say one reason they outsource is vendor expertise, 23 percent cite costs savings, 21 percent the addition of a service line and 18 percent revenue enhancement.
• Dialysis services, sleep disorder services and diagnostic imaging are the most outsourced patient services.
• The most common outsourcing arrangement (42 percent) is an agreement with an outside vendor in which the profits are retained by the healthcare facility or system.
• Fifty-six percent of respondents say that between 1 and 9 percent of total revenue is generated by outsourced services.

"Finding a quality service provider for the right price" is one of the biggest hurdles faced by healthcare facilities, the survey says, so "organizations must continually reevaluate outsourced services to determine wither such arrangements still make financial sense and meet patients' needs."

• "2006 Hospital Outsourcing Trends in Clinical Services Survey": www.wallerlaw.com/WallerSurvey.pdf
• Survey commentary: www.wallerlaw.com/WallerOutsourcing2.pdf

- Stephanie Wasek

In the Know

• N.J. Governor Vetoes Repeal of Plastic Surgery Tax. New Jersey Gov. Jon S. Corzine vetoed a bill last month that would have repealed the state's 6 percent tax on most elective cosmetic surgeries, one month after the Legislature unanimously passed it. New Jersey residents are reportedly bypassing the tax by going to neighboring states for surgery. When the tax was added in 2004, it was estimated it would bring the state $26 million a year, but it actually nets about $11 million. In a veto statement, Gov. Corzine says he couldn"t get rid of a reliable source of funding that provides charity care to the uninsured, especially when facing a $2 billion budget gap. "The revenues generated by the cosmetic medical procedure tax, while somewhat less than the original revenue forecast in 2004, are nevertheless recurring and dependable," writes Gov. Corzine.
• Inhalation Agent Linked to Alzheimer"s? The anesthetic isoflurane results in cell death and is a risk factor for Alzheimer"s disease, say scientists in the Genetics and Aging Research Unit of the Massachusetts General Institute for Neurodegenerative Disease in Charlestown, Mass. In a study published in the January issue of the Journal of Gerontology: Medical Sciences, researchers linked isoflurane to the destruction of neuronal cells and the enhancement of amyloid-beta oligomerization, the characteristic mechanism of Alzheimer"s disease. These results, say the study"s authors, provide a potential pathogenic link between delirium and dementia.
• Tweaks Likely for Georgia's CON Program. Georgia"s 27-year-old certificate of need statute needs overhauling, according to a 267-page report prepared by a commission of state legislators, doctors and hospital administrators. This is welcome news for physicians groups who are lobbying to relax the CON law, rated the fifth most restrictive in the nation by the American Health Planning Association, and an ominous sign for Georgia"s 152 hospitals and hospital associations that want to preserve it.

  Although the commission stopped short of repealing the CON rules - the worst-case scenario for the state"s hospital lobbyists - it did unanimously approve recommendations to streamline the CON process and to maintain existing CON regulation of freestanding multi-specialty ASCs.

• Two-minute Pre-op Chat Can Block Surgical Errors. You"ve heard of the surgical timeout. Now comes the two-minute briefing, a meeting during which all members of the OR team state their name and role, while the lead surgeon identifies and verifies the critical components of the operation. A study of Johns Hopkins Hospital"s surgeons, anesthesiologists and nurses suggests that hospital policies requiring a brief pre-op team meeting to make sure surgery is performed on the right patient and the right part of the body could decrease errors. Without such a policy, it's not uncommon for surgeons to walk into the OR and start working without a conversation of any kind and without even knowing the names of the nurses and other staff who were assisting them, note researchers.