Healthcare flaw: Surgery is covered, counseling isn't

There are many problems with our healthcare system, but I think the frequent rejection of preventive services in favor of more complicated procedures that deliver more immediate results is a particularly egregious flaw. Case in point: Tennessee's Medicaid program, TennCare, covers bariatric surgery, but won't pay for a dietitian's counseling services.

TennCare isn't alone. Tennessee is one of 20 states explicitly barring reimbursements for dietitians. And private insurance coverage for dietitians is few and far between, If available, it often requires a high out-of-pocket payment.

I can't understand why an insurer would rather cover an expensive surgery procedure necessary when a patient becomes obese--and likely is already suffering from several co-morbid issues likes diabetes, high cholesterol and high blood pressure--but it won't pay for dietary counseling services that could help prevent patients from becoming overweight or obese and simultaneously help avoid spending additional precious healthcare dollars.

And it's not like Tennessee doesn't have to worry about overweight residents and health costs. It spends almost a half billion dollars annually on obesity-related health issues and was recently given the dubious honor of the second-fattest state in the nation. So why would they make such a nonsensical decision? TennCare officials said that since program recipients have access to nutritional counseling through primary care doctors, they opted not to reimburse dietitians as a money-saving measure.

However, the American Dietetic Association points out that nutritionists have the specific training to know what questions to ask and how to devise an eating plan based on someone's medical condition, cravings and daily habits. They also understand the metabolic interactions between specific foods and the body. In other words, primary care physicians can't properly do a dietitian's specialized job.

And bariatric surgery isn't cheap. It has averaged $1,900 per surgery over the last five years, and more complicated surgeries can incur much heftier price tags. TennCare has paid $23,716 for one such complex surgery. "Bariatric surgery is drastic and expensive and carries higher morbidity and mortality risks than lifestyle interventions or medication," the American Society of Bariatric Physicians has said.

Possible complications of gastric bypass surgery include vitamin and mineral deficiency, gallstones, bleeding stomach ulcer, hernia, food intolerance, kidney stones, blood clots, pneumonia and dumping syndrome. That last one is a condition where stomach contents move too quickly through the small intestine causing nausea, vomiting, diarrhea, dizziness and sweating. Doesn't sound like fun.

There are, of course, many success stories related to bariatric surgery that are available all over the Internet. Most patients who undergo gastric bypass typically lose up to 60 percent of their excess body weight. I'm happy for these people. However, many patients do regain weight between three and five years following surgery.

Perhaps more importantly, the Mayo Clinic notes that weight loss surgery isn't a miracle cure for overweight issues. "Weight-loss success after gastric bypass surgery depends on your commitment to making lifelong changes in your eating and exercise habits." Aha. So even if patients forgo a dietitian's services before undergoing bariatric surgery, they likely would require such counseling afterward. Will the insurers cover it then? Not TennCare.

Meanwhile, a dietician charges $100 to $150 for an hour-long session, which isn't accompanied by any of the previously mentioned side effects or potential complications. According to the American Dietetic Association, dietetic professionals have been successful in utilizing various combinations of dietary strategies, including healthy eating plans and meal replacements, to achieve a 5 to 10 percent reduction in body weight. All with no risk factors!

I'm not trying to advocate for insurers to stop covering weight loss surgeries. I recognize and appreciate their place in the healthcare industry for patients needing extreme weight management solutions. But I do think we should ensure that every other measure, including dietary counseling, has been explored before advising patients to undergo major surgery. The only way to accomplish that? Insurers must actually cover these healthcare services.

"I think the healthcare system is waking up to the fact that giving people some simple direction and some basic help with diet can really help save a lot of costs up front," says Nan Allison, a board member of the Tennessee Dietetic Association.

I can only hope. - Dina