February 27, 2007 in City

Long wait to lose weight

By The Spokesman-Review
 
JESSE TINSLEY i photo

Brent Bruns, of Rathdrum, holding his daughter, Florence, has been hobbled by a heart ailment that leaves him gasping for breath after a few minutes of walking. The former scuba diver, who weighs more than 350 pounds, is awaiting gastric bypass surgery.
(Full-size photo)

At a glance

•To be considered medically eligible for weight-loss surgery, a patient must have a BMI – body mass index – of greater than 40, or greater than 35 with at least one serious weight-related illness.

•A BMI of 35 is the equivalent of 70 to 80 pounds over ideal body weight, while a BMI of 40 is about 100 pounds overweight.

•The number of Americans having weight-loss surgery more than quadrupled between 1998 and 2002, from less than 13,500 to nearly 72,000.

– Source: Agency for Healthcare Research and Quality, Rockville, Md.

Nearly 100 morbidly obese people approved for Medicare-funded weight loss surgery are lining up for the operations after being forced to wait a year for their Inland Northwest doctors to gain federally required certification.

Clinics in Post Falls and Spokane were among the first in the nation to attain new “center of excellence” status that verifies their procedures – and allows the government to foot the bill for the $25,000 surgeries.

Some patients, like Brent Bruns, 36, of Rathdrum, were within weeks or even days of the life-altering surgery last February, when Medicare officials abruptly changed the rules.

“It was the day before my appointment to set the actual date. I was pretty devastated,” said Bruns, who lost his job and gained more than 100 pounds after developing life-threatening heart trouble nine years ago.

With his weight topping 357 pounds on a 6-foot-3 frame, he was counting on gastric bypass surgery performed by Dr. John Pennings, of Post Falls, to more or less save his life.

Instead, Bruns spent the year watching his serious illnesses – high blood pressure, sleep apnea, type 2 diabetes, gall bladder disease – get worse.

“Now, my liver is bad, too,” said Bruns, the father of an 11-month-old daughter and another baby on the way. “It’s frustrating to think that if I would have had it done a year ago, I wouldn’t have been in such bad shape.”

Bruns tried to lose weight through dieting but found his efforts limited by illness – and the sheer magnitude of the bulk.

“You think you can do it on your own,” he said. “You think you should be able to do it on your own.”

The 2006 Medicare mandates were aimed at ensuring government-funded weight loss surgeries were performed only in centers with enough volume, experience, equipment and patient support to predict success, said Michael Marchand, regional spokesman for the federal program.

They were echoed last week by a Medicare ruling that expands the surgical option to all clients, including those over 65 – but only in a center that has gained approval by the American Society for Bariatric Surgery.

The operations are not just weight-loss treatment. Clients also must have a life-threatening illness such as diabetes or heart disease, Marchand said. “This is not a cure for obesity,” he said.

Last year’s ruling sent bariatric surgeons, centers and hospitals scrambling for the certification, which costs $10,000 and requires a stringent review of everything from death rates to the number of heavy-duty commodes, wide beds and large surgical tools adapted for patients up to 600 pounds.

“This all of a sudden became very important to 500 hospitals and 900 surgeons,” said Pennings, the Post Falls doctor. Some 223 hospitals and 403 surgeons have been approved so far, according to the Surgical Review Corporation Web site.

Pennings’ clinic, Surgical Bariatrics Northwest, received simultaneous certification Feb. 1 with Northwest Specialty Hospital, where he performs 125 weight-loss surgeries a year.

A few days later, Dr. Matt Rawlins and Dr. R. Andrew Bright, of Spokane’s Rockwood Bariatrics Clinic, were certified along with Sacred Heart Medical Center. Together, Rawlins and Bright have performed more than 700 bariatric surgeries since 2001.

Rockwood Clinic applied for the certification in late 2005, well before Medicare’s ruling, but it still took more than a year to gain approval.

“It was a pretty extensive process,” said Tena Cramer, service line director at Sacred Heart. “I think we felt comfortable that we had procedures in place. But the staff, they were pretty excited. There was some sense of relief that we had done well.”

Pennings and Rawlins said the certification confirmed but did not change their existing procedures. Both estimated that Medicare clients make up about 20 percent of their practices; both said they have plenty of business from private-pay clients as well.

As obesity rates in the United States have ballooned to encompass more than a quarter of the adult population and more than 15 percent of youth, the number of so-called super-obese people has risen as well. About 11.5 million people, 5 percent of the population, are now candidates for surgery typically limited to people 80 to 100 pounds overweight, Pennings said.

Those approved for surgery typically have tried every other option – and failed, the doctors said.

“It’s a vicious thing. The more weight you gain, the less able you are to take it off,” Rawlins said. “This always has to be a last resort.”

The tipping point for surgery comes when the risks of the operation are outweighed by the risks of remaining obese. Only then, the doctors said, will they operate.

Critics asked whether the government should spend money for gastric banding, gastric bypass and other weight-loss surgeries, but the doctors who perform them don’t see the debate.

“If we don’t use government money for weight-loss surgery, we’ll use more government money for other services,” said Rawlins, who views the surgery as treatment for disease, with weight loss as a side effect.

At least one Washington state expert criticized the “center for excellence” certification as a way of keeping information from patients and insurance companies.

Dr. Jeffery Thompson, chief medical officer for Washington state Medicaid, said he won’t require the new designation because the $10,000 fee creates a proprietary relationship that allows the bariatric group and those certified to keep their information private. Once a surgeon or center is certified, they no longer are required to report their outcomes to the federal government.

“I am frustrated by the lack of transparency to both the payer and the client for the risk of any surgery in hospital or outpatient settings,” Thompson said.

Since August 2004, Washington Medicaid has paid about $22,000 apiece – about the same rate as Medicare – for 50 or 60 surgeries a year that meet the same standards as the Medicare requirements, he said.

Though Pennings and Rawlins spend three-quarters of their professional lives performing weight-loss surgeries, both said they’re dismayed at the growing glut of obesity in this country.

The problem is largely a clash between genetics that evolved to cope with famine and a society that has become one constant feast.

“The thing that’s really tripped the trigger is the affluence of our environment, fast-food energy and the speed of our society,” said Pennings, who said he’s bothered by commercials for 99-cent hamburgers: “It’s like corruption to me.”

For patients like Brent Bruns, all this theoretical talk is mostly beside the point. He’s got an appointment with Pennings this week to reschedule the surgery that he believes will give him back his life.

“My ideal weight would be 220,” said Pennings, who was in high school the last time he saw that number of a scale. He figures he’ll even be happy to get down to 250 or 260 pounds.

Right now, the condition of his heart and joints means he can’t walk on a treadmill for more than four or five minutes at a time. With an expected weight loss of at least 50 or 60 pounds within the first several months, he’ll be able to accelerate that decline with more exercise.

He probably won’t return to his former job as pastry chef at the Coeur d’Alene Resort or as a local scuba instructor, but, with weight loss, he might be able to find work as an accountant – and to play softball or basketball or go hunting again.

He’ll definitely be able to play longer and harder with Florence, his hazel-eyed 11-month-old and with the baby who’ll arrive in September.

Bruns knows it won’t be easy. He knows some people have the surgery, lose the weight – and then gain most of it back. He also knows he’s determined to be different.

“It’s got to be a conscious effort, but in my case it’ll give me the footing that I need,” he said. “I have so much to gain by not doing that.”


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