MADISON — As Wisconsin considers self-insuring state employees, some want officials to take another step that could save money: covering weight-loss surgery for state workers who are severely obese.
Forty states pay for the surgery for state workers who qualify, five states are experimenting with coverage and four states provide no coverage, according to the American Society for Metabolic and Bariatric Surgery.
Wisconsin is in another category, covering less than 5 percent of workers through its most expensive health plan.
UW Health surgeons, who have pressed for coverage for all state workers, say the move could save $60 million over 10 years by reducing costs from diabetes, heart disease, sleep apnea and other conditions related to obesity.
“Obesity is a massive public health problem, and many citizens in Wisconsin do not have access to the most effective — cost effective — treatment options,” said Dr. Luke Funk, a bariatric surgeon at UW Health.
The Group Insurance Board, which oversees benefits for nearly 250,000 state and local government workers and their family members, in May considered covering weight-loss surgery for all employees this year but decided against it. The program would have cost $1.5 million the first year and $2.25 million over two years, the state estimated.
Mark Lamkins, spokesman for the state Department of Employee Trust Funds, which administers benefits for state workers, said the evidence on long-term savings is “inconclusive.” But, he said, “this benefit will be considered again in the future.”
Terrie Senty, an obese state worker, said she developed diabetes and heart disease — for which she has had three heart procedures since October — after looking into weight-loss surgery years ago. She said she couldn’t afford the more expensive health plan that does cover it or pay out of pocket for the surgery, which costs $30,000 or more.
If she had received weight-loss surgery years ago, “the state wouldn’t be paying for my heart procedures and my lancets because I never would have gone on insulin” for diabetes, said Senty, 59, of Evansville.
Coverage is available only through the state’s standard plan, administered by Monona-based WPS Health Insurance. Workers pay $250 a month for individuals and $624 a month for families for that plan, compared to $83 a month for individuals and $209 a month for families for any of 17 HMOs that don’t cover the surgery.
Medicare and nearly all Medicaid programs, including Wisconsin’s, cover weight-loss surgery. Most national insurers cover it for large employer groups.
In Dane County, Dean Health Plan covers the surgery for large groups. Unity Health Insurance and Group Health Cooperative of South Central Wisconsin allow coverage as an add-on if employers pay more. Physicians Plus doesn’t provide any coverage.
The Group Insurance Board is looking at self-insuring state workers, which could save $42 million a year or cost $100 million more, consultants have said. The state would pay benefits directly and assume the risk for large claims in the $1.4 billion program instead of buying insurance from the 17 HMOs.
The board is also considering another proposal to reduce the number of HMOs from 17 to no more than six, plus a statewide plan. That could save $45 million to $70 million a year, according to Segal Consulting.
Gov. Scott Walker said he would apply any savings from state worker benefit changes to public education.
Nearly 19,000 severely obese
Weight-loss, or bariatric, surgery, is approved for people who have a body mass index, or BMI, of more than 40 — or more than 35 if they have a health problem related to obesity, such as diabetes.
For someone 5 feet 8 inches tall, that is about 265 pounds — or 230 pounds with an obesity-related condition.
One type of surgery is gastric bypass, which shrinks the stomach and reroutes food, making the body absorb fewer calories. Another is sleeve gastrectomy, which results in a banana-shaped stomach that makes people feel full faster. A third option, the lap-band, puts a band around the top of the stomach, limiting intake.
The surgeries typically result in considerable, durable weight loss, studies say. But they carry risks, such as bowel obstruction, stomach perforation, hernias, malnutrition and, rarely, death.
If the state offered weight-loss surgery for all state workers, it would pay about $25,000 per surgery at the discounted rate offered to large groups, less than the $30,000 or more people typically pay on their own, UW Health surgeons said.
A 2014 actuarial study prepared for the Wisconsin Obesity Coalition and funded by Ethicon Endo-Surgery, a bariatric surgery equipment maker, said covering the surgery for all state workers could save taxpayers $60 million over 10 years.
An estimated 18,772 workers and family members are severely obese, with an average annual health care cost of $15,600, the study said. About 188 of them would be expected to have the surgery per year.
UW Health performs 130 to 150 weight-loss surgeries a year, surgeons said. Coverage for state workers likely would increase the total by 20 to 50 surgeries, they said.
Dean Clinic/St. Mary’s Hospital also does weight loss surgery.
Dr. Michael Garren, a bariatric surgeon at UW Health, said severe obesity is often misunderstood as primarily a behavioral issue. Even then, he said, it is singled out while other conditions linked to behavior are paid for.
“Are we going to stop treating lung cancer from smoking?” Garren asked. “Are we going to stop treating melanoma because people don’t wear sunscreen and a hat?”
Lamkins, of the Department of Employee Trust Funds, said that when the Group Insurance board considered weight-loss surgery coverage in May, “we did not have strong support of the health plans or overwhelming feedback from members.”
Hard to keep off the pounds
Senty, who was heavy as a child, put on pounds when she had three children between 1976 and 1980.
After she quit smoking in 1996, she gained 60 pounds, tipping the scales at 300. She is 5 foot 6 inches tall.
Last year, through a program at a gym, she got down to 230 pounds, which she weighs today. Her BMI is 37.
In addition to diabetes and heart disease, she has gastric reflux, a thyroid condition and anxiety.
After a mild heart attack in October, she had two procedures to put stents in her arteries and one to correct a heart rhythm problem. The total charges for the procedures exceeded $160,000, Senty said, though the cost to the state likely will be less after insurance discounts.
Senty has tried Weight Watchers and TOPS, or Take Off Pounds Sensibly, but said she has a hard time controlling her diet.
“It isn’t that I don’t know how to eat. It isn’t that I don’t know how to exercise,” she said. “Food is an addiction. Bad food is a really bad addiction.”
Ruth Williams, 48, of Madison, said she would pursue weight-loss surgery if it was covered for all state workers. Like Senty, she works at UW Hospital, where employees are covered by state worker benefits.
Williams, whose BMI is 40, has high cholesterol, high blood pressure and pre-diabetes. She assumes she will develop full diabetes and heart disease, which run in her family.
She has tried weight-loss programs, aerobics and counseling but said she can’t keep weight off.
“Wouldn’t it make more sense for insurance to cover this, at least in part, than pay the long-term price of heart disease and diabetes?” she asked.
“Obesity is a massive public health problem, and many citizens in Wisconsin do not have access to the most effective — cost effective — treatment options.” Dr. Luke Funk, a bariatric surgeon at UW Health.