After Surgery, the Bills may Pile Up

Following bariatric surgery, Barbara Warnock-Morgan, 46, lost 125 pounds.

By LESLEY ALDERMAN
AFTER dieting unsuccessfully her entire life, Barbara Warnock-Morgan, 46, decided she needed to do something radical.

“I was the fat kid,” she said. “Over the years I yo-yo dieted my way up the scale. I’d lose 20 pounds, then gain back 30.”

The cycle was so insidious that by her early 40s, Ms. Warnock-Morgan, who lives in Brooklyn with her husband and daughter and works for a music company, was obese, with a body mass index over 40. (A B.M.I. of 18.5 to 24.9 is normal; over 30 is considered obese.)

In November 2009, she decided to have adjustable gastric banding, a form of bariatric surgery in which a silicone band is placed around the top portion of the stomach, restricting the amount of food a person can comfortably consume.

Bariatric surgery costs $15,000 to $30,000, depending on the procedure and the area of the country in which the patient lives. Ms. Warnock-Morgan was fortunate in many ways. Not only was her surgery successful (she has lost 127 pounds), but her insurance covered all the costs.

Even so, she’s facing new bills. Once she loses all her excess weight, she said she would need to spend thousands of dollars on cosmetic surgery to “rebuild my body” — which she will have to pay for herself.

Indeed, many bariatric patients like her discover that there are unexpected expenses associated with weight loss surgery. High co-payments, nutritional and behavioral counseling and cosmetic surgery, for example, can easily add up to thousands of dollars, mostly out of patients’ pockets.

Despite the cost, more and more people are signing up.

The number of bariatric surgeries performed in the United States rose 804 percent from 1998 to 2004, to 121,055 from 13,386, according to a study by the Agency for Healthcare Research and Quality. The number of annual surgeries now is closer to 200,000 or 250,000, according to Dr. Robin Blackstone, president-elect of the American Society for Metabolic and Bariatric Surgery.

The surgery is also becoming safer; the rate of complications is down, and so are the number of deaths. “It’s the only good treatment for severe obesity,” said Dr. James Mitchell, a professor of clinical neuroscience at the University of North Dakota School of Medicine.

Ms. Warnock-Morgan has no regrets: “I feel better, and I look better. I’m happier than I have been in 25 years.”

The National Institutes of Health recommends bariatric surgery for people with a B.M.I. over 40 (or 35 to 40 if they also have related medical condition, like diabetes). A Food and Drug Administration panel recently recommended that the B.M.I. base for lap-band surgery (a form of adjustable-band surgery) be lowered to 35 and higher (30 to 35 if they have a related disease).

Adjustable gastric banding is the second most popular form of bariatric surgery. The most common is laparoscopic gastric bypass, which decreases the size of the patient’s stomach and also the body’s ability to fully absorb food and thereby calories.

Gastric bypass is more expensive but typically results in greater weight loss than gastric banding.

If you’ve been considering bariatric surgery, tally up all your expenses upfront so you’ll know your liability down the line. Here’s what you need to know, along with tips on how to minimize the costs.

INSURANCE COVERAGE Just half of large employer health plans cover bariatric surgery, while small employers rarely cover it at all, Dr. Blackstone said. Medicare pays for weight loss surgery, but the majority of people who have the procedure are under age 55.

Even if your insurer covers bariatric surgery, make inquiries about the fees involved. Co-payments tend to be much higher than for other operations, sometimes as much $5,000, Dr. Blackstone said.

Ask, too, how your insurer typically responds if there are complications and you need to spend a month or so at a skilled nursing facility. And what is your insurer’s policy if the first surgery doesn’t work and you need a second operation?

FOREIGN OPTIONS Some people without insurance coverage choose to have bariatric surgery in Latin America or Asia, where the cost is 40 percent to 70 percent less than in the United States, according to Joseph Woodman, author of “Patients Beyond Borders,” a consumer guide to medical tourism. He estimates that 20,000 Americans went abroad for weight loss surgery last year.

But choose the doctor and hospital carefully. Look for a facility that has been accredited by Joint Commission International, a United States-based nonprofit that accredits hospitals abroad.

“Spend some time online reading about bariatrics abroad,” said Vicky Gould, 48, who had adjustable-band surgery in Monterrey, Mexico, in 2007. “If a hospital is not doing good work, people will write about it.”

Be sure you have found a doctor to care for you once you return home, said Dr. David Flum, a professor of surgery and public health at the University of Washington. “It’s not necessarily a bad idea to go abroad for surgery, but it’s a bad idea to go there and not have established a method for follow-up care at home,” he said.

ADDITIONAL EXPENSES Gastric bypass patients normally lose significant amounts of weight. But about 25 percent of gastric banding patients have not lost weight two years after surgery, Dr. Blackstone said. That’s in part because those patients fail to revamp their diet and exercise patterns.

“When it comes to adjustable banding procedures, the surgery is not the intervention,” Dr. Flum said. “It’s the lifestyle changes and the adjustments that come after it.”

No matter what type of procedure you undergo, be prepared to pay for services like a nutritional counselor and personal trainer, as well as a gym membership, all of which can help keep you motivated over the long haul.

Some insurers will also stipulate that you join a care-management program, which could cost $1,500 or more out of pocket, Dr. Flum said. Most doctors will insist that you quit smoking before you have surgery.

Once you lose the excess weight, you’ll have excess skin, and this may require another unforeseen expense: cosmetic surgery. Most insurers don’t cover surgery to remove sagging and excess skin after weight loss, unless it is considered medically necessary — if the skin is causing rashes, for instance, or infections.

Some patients need more than one procedure to remove skin from the abdomen, thighs and upper arms. The bills can reach $20,000, Dr. Flum said.

Ms. Warnock-Morgan worries that her cosmetic surgery bills could go still higher, perhaps to $30,000. “I might have to tap my 401k or work out some kind of payment plan with a surgeon,” she said. “I would go on a reality show if they would pick up the cost of the surgery.”

Another cost that many bariatric patients do not consider: a new wardrobe, or several new wardrobes, as weight falls off.

But the expense that most frequently blindsides patients is, oddly, perhaps the most obvious. “The most expensive thing is if the surgery is unsuccessful,” Dr. Blackstone said.

If you are not prepared to make the necessary lifestyle changes as well, then surgery is likely to be a waste of your time and money.