Bypassed surgeries

Obese patients seeking treatment locally are left without Medicare or Medicaid coverage

» ‘Drastic’ gastric procedure got nurse off cycle of obesity

STORY SUMMARY »

Surgical treatments touted as lifesavers for obese people are out of reach for Medicaid and Medicare patients in Hawaii.

That's because the federal government won't cover bariatric surgeries, such as a gastric bypass, unless it is done at a facility designated as a Bariatric Center of Excellence. To get the designation, the facility must do 125 bariatric cases a year, and no hospital in the islands does that many.

The requirement is preventing patients from treatment that one doctor says gives "them part of their life back."

One health care professional who would agree with that assessment is Michelle Garson, an intensive care nurse at the Queen's Medical Center.

Garson once weighed as much as 500 pounds but has lost about half her weight since gastric bypass in 2006. She's no longer in a wheelchair, on oxygen, or taking insulin for diabetes.

Garson, 46, says she's enjoying little things people take for granted, such as walking across the sand at Waimea Bay.

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Medicare and Medicaid recipients in Hawaii are being denied access to a life-extending obesity surgery because of a federal program intended to ensure such patients get the best care.

Medicare, Medicaid and many major insurance carriers will only allow patients to go to designated Bariatric Surgical Centers of Excellence being established across the country, said Dr. Alyssa Chapital, former University of Hawaii researcher.

Bariatric surgery and follow-up care in Hawaii are excellent, said Chapital, now a trauma surgeon at Mayo Clinic. But no medical center here does enough obesity surgeries -- 125 a year -- to qualify for the designation, she said.

Unless that number is reached or some exemptions are granted, many obese isle patients will have difficulty getting bariatric surgery, she said. They would have to go to a designated center on the mainland, and "there is no way people can afford it," she said.

"It's a relatively arbitrary number -- it's not fair," said Dr. Kenric Murayama, program director and chief surgeon at the Queen's Comprehensive Weight Management Program.

His program is doing about 100 bariatric procedures a year, he said. Straub Clinic & Hospital is doing 90 to 100, according to a spokeswoman. Castle Medical Center has had 76 bariatric surgery cases since it established a Surgical Weight Loss Institute in April 2006, and it averages 10 to 15 cases a month, a spokesman said. Kapiolani Medical Center at Pali Momi also is doing some bariatric surgery.

"All (insurance) providers here cover bariatric surgery to some degree," Murayama said. But the U.S. Centers for Medicare and Medicaid Services ruled in February 2006 that Medicare and Medicaid patients can only go to Bariatric Centers of Excellence, he said. "So, in Hawaii we cannot operate on any Medicare or Medicaid patients and have it be a covered benefit."

Half of Hawaii's residents were classified as obese in 2005, with native Hawaiians making up a disproportionate percentage, according to state health statistics.

Chapital, in a telephone interview from the Mayo Clinic, said obesity surgery is extending lives in the United States and that she wanted to see if complications and mortality rates in Hawaii are similar to the rest of the nation.

She evaluated administrative claims data from the Hawaii Medical Service Association from December 1999 to December 2005 while at the John A. Burns School of Medicine.

She said the outcomes were similar to national averages, and there is no medical reason why a Bariatric Center of Excellence should not be designated here.

Five hospitals were performing surgery for morbid obesity during her study over five years, with 396 patients ranging from 14 years old to 69.

"Obesity or a weight problem is just the visible tip of the iceberg," Murayama said. "The real problem is all the co-morbid illnesses -- adult onset diabetes, sleep apnea, heartburn disease, female infertility and that's just the beginning of it."

Two-thirds of Americans are overweight, with a body mass index (weight relative to height) of more than 25, Murayama said. Someone with a BMI of 30 to 40 is considered obese, and more than 40 is morbidly obese, he said.

Among options are gastric bypass surgery, which separates the stomach into two sections, with a tiny pouch for food, and a LAP-BAND or adjustable gastric band that encircles the stomach and restricts food intake.

Patients must be cleared psychologically "to make sure they understand the implications of a life-threatening operation to treat weight," Murayama said. It is a lifelong commitment that requires lifestyle changes with diet and exercise, he stressed.

Describing dramatic changes in some of his patients, Murayama said, "It's the single most rewarding thing I've ever done, because people appreciate that we gave them part of their life back."

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‘Drastic’ gastric procedure got nurse off cycle of obesity

Michelle Garson came to Hawaii as a traveling nurse in 1990 but says she hasn't been off the island in 10 years "because my butt wouldn't fit in an airplane seat."

Gastric bypass surgery in February 2006 changed her life "in many directions," the 46-year-old woman said recently.

She is taking her mother to New York this month and plans to go on a 3.1-mile Thanksgiving Turkey Trot with her husband and family members in Portland, Ore.

"They might be able to trot, but I'm walking," she laughed. "But it's better than rolling."

Garson weighed 500 pounds when Dr. Kenric Murayama, program director and chief surgeon for the Queen's Comprehensive Weight Management Program, performed the minimally invasive gastric bypass.

She said she had been in a wheelchair for about three years and was on continuous oxygen.

"I had a lot of health problems associated with morbid obesity," she said, including insulin-dependent diabetes, sleep apnea, esophageal reflux and a heart attack over three years before 2006.

Garson, 5 feet 8 inches tall, said she gained most of her weight between 2004 and 2006 because of eating habits, a sedentary lifestyle and inability to sleep at night. "The heavier I got, the more I didn't sleep and the more weight I gained. It's a vicious cycle, and there's depression in there, feeling like I can't lose this so why bother."

She did research on the gastric bypass procedure for four or five years, she said. "I decided it was drastic, but at the point I was at, I needed drastic." She was enjoying life, she said, "but it was watching instead of doing."

Garson said her husband, Wally, was supportive, and her employer, the Queen's Medical Center, made accommodations allowing her to continue working.

Unable to walk around as a staff nurse in the cardiac intensive care unit, she transferred to the education department in the intensive care unit, training other nurses.

With her weight reduced to about 268 and dropping, she's excited about returning to the ICU as a staff nurse. "It means I can be active enough to be out there."

Her goal is 211 pounds: "I walk, I swim, I do things I haven't been able to do for years."

She's out of the wheelchair, off oxygen and insulin, she said. "I'm a nurse and I hardly believe it myself. Two days after surgery, I was off insulin and haven't been back on it."

She takes some medicine for diabetes and blood pressure, and all gastric bypass patients have to take multivitamins and calcium, she said. "But I went from 27 prescriptions a day to fewer than 10. It's way incredible."

Garson is thrilled to be able to buy clothes that fit without having to mail-order them, but says the surgery "isn't about looking good." It's about things people take for granted, she said.

"For me it was about mobility, being able to work and reducing health risks. But it is not a magic thing. It is hard work. You have to lose weight before surgery to prove you are committed."

Garson said she has two brothers and comes from a family of marathon and ultramarathon runners. "My mom is very fit and trim," she said. "I'm not fit and trim but I'm better."

Her mother and brothers will join her and her husband for the Thanksgiving Turkey Trot, she said. "This is like a celebration trip for all of us."