Bariatric Surgery—A Review for Physician Organizations

By Pete Fronte, MBA, President, Altura

According to the medical literature, a person is classified as "overweight" if their body mass index (BMI) is >25 kg/m2, "obese" if their BMI ≥30 kg/m2, and "morbidly obese" if their BMI ≥40 kg/m2 or 35 to 39.0kg/m2 with associated, severe, co-morbidities. Currently, it is estimated that more than half of all adults in the U.S. are overweight (i). The prevalence of obesity in U.S. adults increased by 8% over the last decade, and is now the second most common cause of preventable death (300,000/yr) in the country next to cigarette smoking.

People who are either overweight or obese are at an increased risk for several diseases (ii) (iii) including cardiovascular disorders, psychiatric disorders and endocrine disorders (iv) (v). The overweight patient has several options to pursue in an effort to reduce their weight. These options include health and health risk evaluations by a physician with recommendations for diet and exercise, pharmacotherapy, psychotherapy, and in the case of morbidly obese patients, bariatric surgery.

National Institutes of Health Guidelines

In 1978, the National Institutes of Health (NIH) held a consensus conference to discuss surgery for obesity. Another consensus conference was held in 1985 where health implications of obesity were established. By 1991, new surgical procedures had been developed with varying success rates which led NIH to convene yet another conference to evaluate the objective evidence for the new surgical therapies and to make the following recommendations:

  • Patients should first be considered for treatment in a nonsurgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral support and modification.
  • Patients whose BMI exceeds 40 are potential candidates for surgery if they strongly desire substantial weight loss.
  • In certain instances, less severely obese patients (with BMI’s between 35 and 40) also may be considered for surgery. Included in this category are patients with high-risk co-morbid conditions.

Procedures

There are currently three categories of surgical procedures available: restrictive, malabsorbtive, and combination. Restrictive procedures (e.g. stapled gastroplasty, gastric banding) produce weight loss by limiting one's ability to ingest large quantities of food. These procedures are thought to result in poor weight loss maintenance and a 15% to 20% rate of re-operation (vi). Malabsorbtive procedures produce weight loss by limiting the body's ability to extract nutrients from the ingested food (with little or no restriction). Due to some of the side effects of this type of surgery, dysfunctional bowel movements and risk of malnutrition, these procedures are less commonly performed in the United States. Combination procedures, like the Roux-en-Y Gastric Bypass, take features from both restrictive and malabsorbtive procedures. The resulting procedure produces better weight loss than that seen with purely restrictive procedures, and milder side effects when compared to purely malabsorbtive procedures. The cost range for bariatric surgery (hospital and surgery fees) is $15,000 - $30,000 per procedure according to the American Society for Bariatric Surgery (ASBS).

A December 11, 2002 JAMA article, which reviewed studies and literature on bariatric surgery, indicates that the mean excess weight loss in gastric bypass patients typically ranges from 65% to 75%, which corresponds to loss of approximately 35% of initial weight. According to this article, morbidity and mortality rates reported in the range of 10% and 1% or less, respectively. Additionally, early complications of gastric bypass include deep venous thrombosis or pulmonary embolism (1%-2%), anastomotic leaks (1%-2%) and wound infection (1%-5%). Iron and vitamin B12 deficiency occur in more than 30% of patients and half of the patients with iron deficiency develop a microcytic anemia. Note: ASBS maintains data from the International Bariatric Surgery Registry on their web site www.ASBS.org (see rational for surgery ‡ international bariatric surgery registry).

California View

ASBS estimates approximately 12,000 and 96,000 bariatric surgeries will be conducted in the California and the United States respectively, this year. These numbers are growing at a rate of approximately 39% per year. Based on its member base, ASBS estimates approximately 100 surgeons in California and 800 surgeons nationally conduct these surgeries.

The criteria for coverage of bariatric surgery by health plans in California seem to follow the NIH guidelines closely according to Stan Padilla, MD, of Brown & Toland Medical Group. All seven plans that Brown & Toland contracts with cover the Roux-en-Y procedure provided that the patients have failed a managed weight loss program. Dr. Padilla also mentions a disturbing trend amongst young adults and teens seeking consultation for bariatric surgery before seriously considering non-surgical options.

According to Greater Newport Physicians’ Doug Allen, MD, physician groups have seen an exponential rise in requests for bariatric surgery and with the increasing requests for skin removal and the payment for complications of both, the resultant financial impact on groups has outpaced the ability of premium increases to compensate. There appears to be no counterbalance to this trend which has led, according to CAPG’s Dirk Thornley, to CAPG’s position in requesting that health plans define a significant co-pay structure for these procedures and their sequelae.

From a health plan perspective, Jeff Kamil, MD, Corporate Medical Director at Blue Cross of California (BCC) feels that they will continue to follow the government (NIH) guidelines because these guidelines are based on the most recent and best clinical evidence. Beginning in 2001, health plan denials of services were submitted to an Independent Medical Review (IMR) system which is administered through the DMHC. In its first year, the IMR process overturned 100% of health plan denials for bariatric surgery that were submitted for a determination of medically necessity. The reversal rate dropped to 50% in the second year as HMOs began to adopt the NIH guidelines. Denials of investigational procedures appeared to be upheld most of the time. Additionally, lack of a weight loss program alone will not justify a denial especially if a co- morbid condition exists. According to DMHC’s Tom Gilevich, HMOs and groups should collaborate more on the prevention side of obesity. Most patients are making these decisions in discussion with surgeons, not their primary physicians, says Gilevich.

Impact on Physician Groups

Dr. Allen has created a financial model that can estimate the financial burden of bariatric surgery on the health system. This spreadsheet allows input of assumptions to drive estimated costs to the California health care system (to request a copy please email Dirk Thornley at dthornley@capg.org). A few groups have mentioned that this surgery is carved out of physician organization risk for some health plans while a majority of groups maintain a risk position in some form. Regardless of hospital risk position, groups can expect an impact on the professional capitation side of the equation, especially if patients experience difficulties post-surgery.

Paniculectomy procedures provide an example of the financial issues. The removal of excess skin was historically covered under HMO insurance only when it resulted in frequent infections or other medical problems. According to Dr. Allen, what is increasingly occurring now, however, is a decision by the independent medical reviewers or DMHC that removal of this excess skin must be covered as the surgery that created the problem was a covered service. With the current co-pay structure this service is offered to the member with little in the way of out of pocket expenses.

According to Dan Temianka, MD, of HealthCare Partners Medical Group, any new technology that has not been appropriately considered in risk agreements can have a detrimental financial impact on physician groups. "It’s the outliers that can hurt you with this surgery since the potential for complications and lengthened hospital stays are fairly high", says Dr. Temianka. Dr. Temianka adds that patients must adhere to a strict diet post surgery and that the surgery is not a panacea that allows for continued eating of large quantities of food.

Scripps Clinic’s Ken Fujioka, MD, has seen many successes with the surgery but the jury is still out on long-term weight loss and the appropriate selection of patients for surgery. Dr. Fujioka has conducted two managed care based studies on bariaitrc surgery. One 46 patient retrospective study demonstrated that non-depressed patients had lower healthcare utilization when compared to depressed patients who remained high utilizers of care two years post-surgery. The number of prescription medications utilized for both groups, however, decreased during the same time frame (vii). Another retrospective study with 46 patients demonstrated a maximum weight loss of 36.1% at 18 months. At 36 months, patients regained 13% of their total weight loss. Additionally, utilization of healthcare resources was slightly higher during the second year after surgery. (viii)

What’s Next?

As the number of bariatric surgeries increase, health plans and physician groups are beginning to seek more objective data and best practices to ensure successful pre-surgical preparation and post-surgical outcomes. The two key impacts are to the patient’s long-term weight loss (including improvement the improvement of health status) and the financial impact to the health system. Patients have significant needs post-surgically and groups are seeing increased utilization without a plan for dealing with this patient base. Therefore, it is important that groups and plans individually, or preferably collectively, put into place initiatives and/or studies in an attempt to capture information surrounding bariatric surgery costs, utilization, health outcomes and best practices. Additionally, health system constituents must reconsider the economic structure surrounding this procedure to ensure its viability and success.

(i) Kuczmarski RJ, Carrol MD, Flegal KM et al. Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994). Obes Res.1997;5:542-548

(ii) Stampfer MJ, Maclure KM, Coldita GA, et al. Risk of symptomatic gallstones in women with severe obesity. Am J Clin Nutr. 1992;55:652-658

(iii) Hochberg MC, Lethbridge-Cejku M, Scott WW, et al. The association of body weight, body fatness and body fat distribution with osteoarthritis of the knee: data from the Baltimore Longitudinal Study of Ageing. J Rheumatol. 1995;22:488-493

(iv) Ford ES, Williamson DF, Liu S Weight change and diabetes incidence: findings from a national cohort of U.S. adults. Am J Epidemiol. 1997;146:214-222

(v) Lipton RB, Liao Y, Cao G, et al. Determinants of incident non-insulin-dependent diabetes mellitus among blacks and white in a national sample. The NHANES I Epidemiologic Follow-up Study. Am J Epidemiol. 1993;138:826-839

(vi) Balsiger BM, Poggio JL, Mai J, et al.Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity.Gastrointest Surg.2000;4:598-605

(vii) K.Fujioka, RH Toussi, ME Brunson, RA Mendes Health care utilization before and after Bariatric surgery, the Mangaged care experience, Obesity Research Vol. 9S3:2001

(viii) RH Toussi, J. Sheard, K.Fujioka Comparison of Depressed Versus Non-Depressed Patients undergoing Bariatric surgery, Am J of Clinc. Nutriton Vol 75 #2,;2002

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