WILL BLUE CROSS BLUE SHIELD HELP MAKE “DIABETES SURGERY” MORE ACCESSIBLE?
BCBS Technology Evaluation Center (TEC) Has Groundbreaking Assessment
November 14, 2012 is “World Diabetes Day” so I cannot think of a better day to make people aware of news that appears to be coming very soon. Pending final editorial re-writing, the Blue Cross Blue Shield Technology Evaluation Center appears poised to “endorse” the concept of gastric bypass surgery as a treatment for type 2 diabetes in people who are not morbidly obese. The ramifications are, in my mind, monumental and could lead the way to more diabetics, including those suffering from morbid obesity, getting access to RNY for their diabetes. At least it bodes well for the future and it is well worth watching for the final publication. Of course I will alert you when that it available.
I first became aware of the idea of bariatric surgery as a possible treatment for Type 2 Diabetes shortly after I started this practice in 1996 when I read a medical journal article provocatively entitled “Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.” (Annals of Surgery 1995;222:339-350) The lead author was the esteemed Dr. Walter Pories, proving once again that all the coolest guys are named “Walter.” The operation Dr. Pories and his colleagues were talking about was the RNY gastric bypass, the operation I had in 1994. Since that time there have been tons of research dedicated to treating type 2 diabetes with metabolic surgery like gastric bypass. The research done and the powerful data accumulated showing the potentially curative effects of various forms of weight loss surgery on type 2 diabetes eventually even led to the re-naming of a medical society, recognizing that its members (including yours truly since 1996) do far more than “weight loss surgery.” They became the American Society of METABOLIC and Bariatric Surgery (ASMBS).
So what does any of this have to do with the title of this Blog post? At the risk of sounding like the History major I was in college (along with Philosophy – no wonder I had to go to law school!) it is difficult to appreciate the present or map out the future without understanding the past. It appears that we are on the verge of having an important arm of the National Blue Cross Blue Shield Association, the “umbrella organization” if you will, for all the local “Blues” that so often give patients and providers the blues, recognize that gastric bypass surgery is an effective treatment of type 2 diabetes for persons who are not morbidly obese, meaning people with diabetes (type 2) who have a BMI over 30. You can go online and read the Executive Summary of Bariatric Surgery in Patients with Diabetes and Body Mass Index Less than 35 kg/m2 . Certainly it provides our office and health care providers with more ammunition to fight against denials of care, whether for reasons of “medical necessity” or even in the face of contract exclusions or limitations for “obesity” or “morbid obesity.”
While I recommend that you go to their website to learn all the details (http://www.bcbs.com/blueresources/tec/), in a nutshell the BCBS TEC evaluates medical devices, diagnostic and therapeutic interventions, etc. under 5 “criteria” and quite often access to those devices or treatments depend on whether or not TEC criteria are met. The 5 elements examined are:
1. The technology must have final approval from the appropriate governmental regulatory bodies.
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
3. The technology must improve the net health outcome.
4. The technology must be as beneficial as any established alternatives.
5. The improvement must be attainable outside the investigational settings.
We have battled for patient access in multiple instances where a treatment or device has been found to “not meet TEC criteria” and therefore the local BCBS entity determines that it should NOT be covered. Often the Blues use TEC criteria to support a claim that a device or therapy is “experimental” or “investigational” and therefore not medically necessary. It’s very nice, albeit very different for us, to applaud an upcoming BCBS TEC (remember this isn’t final yet – it is “In Press”) because so often patients are on the wrong side of the answers to one of more of these 5 questions.