Managing Overweight and Obesity: Bariatric Surgery

What Is It? Surgical procedures on the stomach or intestines to produce weight loss. Surgery enables the body to start losing weight but diet and behavior modification are important determinants of long-term success.

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January 09, 2020

For employers seeking to align their weight management strategy with the latest evidence, this resource offers recommendations on creating a comprehensive benefits package to treat obesity, including behavior-based interventions and pharmacological and surgical treatment.

What Is It?

Surgical procedures on the stomach or intestines to produce weight loss. Surgery enables the body to start losing weight but diet and behavior modification are important determinants of long-term success.

Who Is Bariatric Surgery Indicated For?

92% of large employers cover bariatric surgery.42

Qualifications for bariatric surgery include:62

  • BMI ≥40 (or more than 100 pounds overweight).
  • BMI ≥35 with a weight-related comorbidity, such as hypertension, dyslipidemia, diabetes or osteoarthritis.
  • Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.

Eligibility for surgery is also based on a medical evaluation to determine acceptable operative risks, which procedure to apply and how to manage coexisting conditions throughout the surgical treatment process. Candidates also undergo an evaluation by a multidisciplinary team, including a psychological assessment of mental health or substance abuse conditions, as well as a nutritional assessment to educate the patient and implement needed pre-and post-surgical lifestyle changes.

Why Should Employers Cover It?

Bariatric surgery is the most effective treatment to date for significant and sustained weight loss in people with severe obesity.63 Data show that bariatric surgery patients achieve greater weight loss than those following a regimen of diet, exercise and/or prescription medications. In addition to facilitating weight loss, bariatric procedures improve or resolve obesity-related comorbidities.64-69

 

Bariatric Surgery Efficacy

Weight Loss

Evidence shows that bariatric surgery results in substantially greater weight loss than non-surgical therapy. According to a 2018 evidence review of the three most commonly performed bariatric procedures, at five years follow-up the average total weight loss was 25.5% for Roux-en-Y gastric bypass, 18.8% for sleeve gastrectomy and 11.75% for adjustable gastric band.70

Health Outcomes

Research demonstrates that bariatric surgery is associated with improvements in mortality, diabetes, cardiovascular risk factors, sleep apnea and quality of life. According to the largest comparative study to date, at 10 years follow-up, bariatric surgery was associated with the following outcomes:65-69

  • Significant improvement in glucose control for people with diabetes and reduced incidence of new cases of diabetes.
  • Reduction in cardiovascular risk factors (e.g., hypertension, high cholesterol).
  • Mortality was reduced by 29% after a mean follow-up of 10.9 years.
  • Quality of life improvement in the 2- to10-year follow-up period, with the degree of improvement correlating with the amount of weight loss.

Weight loss is not the only factor that patients and providers should consider when discussing bariatric procedure options. Because each surgery has advantages and disadvantages, shared-decision making conversations should include information on the risks, and potential changes in comorbid conditions with each procedure.


Safety

Short-term Complications

The incidence of complications from surgery is increased in patients with obesity, particularly related to thromboembolism and wound healing. Other complications of bariatric surgery may include bleeding, bowel obstruction and cardiopulmonary complications (e.g., pneumonia, heart attack).64

According to one study, 30-day rates of major adverse events (death; percutaneous, operative, or endoscopic intervention; venous thromboembolism and failure to discharge the hospital within 30 days) were 5.0% for Roux-en-Y gastric bypass patients, 2.6% for sleeve gastrectomy patients and 2.9% for adjustable gastric band patients.70

Another analysis of 74,774 bariatric procedures performed between 2011 and 2014 found that the in-hospital mortality rate was 0.29% and the average length of hospital stay was 2.55 days. In 2014, the percentage of in-hospital systemic complications was 2.94% and the percentage of hemorrhagic complication was 2.36%.71

Longer-term Complications

While longer-term complications vary based on the type of bariatric procedure (e.g. complications from the adjustable gastric band may relate to the presence of a foreign object in the patient’s body), adverse events can include ulcers, esophagitis and less severe issues related to dumping syndrome, vomiting and diarrhea.64

Because of complications and rehospitalizations from bariatric surgery, some research suggests that bariatric surgery may not be a cost-saving intervention.* For example, a six-year study of 30,000 Blue Cross Blue Shield beneficiaries found that average pharmaceutical costs and office-based services declined post-surgery; however, higher inpatient costs due to complications negated any savings. The average annual post-surgery costs never dipped below pre-surgery costs ($8,850) for the six years studied, and were no lower than costs for a comparison group of patients with obesity who did not undergo surgery.72

Despite this, when factors other than direct health care costs are considered, bariatric surgery can be cost-effective. For example, bariatric surgery can positively impact length and quality of life. It may also benefit employers through increased productivity, decreased workers’ compensation and decreased disability.73

* Cost savings indicates an intervention that is more effective and less costly than an alternative course of action. Cost-effective means an intervention is more effective than an alternative, but has equal costs; or, has equal effectiveness but lower costs. Cost-effectiveness is generally expressed as a gain in health outcomes at a predetermined reasonable cost.

Bariatric Surgery Utilization

In 2017, an estimated 228,000 bariatric surgery procedures were performed in the United States. Sleeve gastrectomy was performed most commonly (59%), followed by Roux-en-Y gastric bypass (17.8%) and adjustable gastric band (2.77%).74

A longitudinal analysis of bariatric surgery rates among privately insured adults showed a gradual increase in utilization from 2006 to 2009 (43.5 per 1000 patients in 2006 to 70.6 per 1000 in 2009). This increasing trend plateaued from 2010 to 2015.75

Type of Procedure Percentage of All Procedures
Sleeve gastrectomy 59%
Roux-en-Y gastric bypass 17.8%
Adjustable gastric band 2.77%
Balloons 2.75%
Other 2.46%
Biliopancreatic diversion with duodenal switch 0.7%
Revision*
Revisions include corrective surgeries (due to complications or “incomplete treatment effect”)
or conversions (when a bariatric surgery is changed to a different type of bariatric operation or a reversal restored original anatomy).64
14.14% %

*Data are from the best available inpatient and outpatient datasets. Although this data did not indicate surgery-specific revision rates, studies show that revisions vary by procedure type. For example, one study indicated that subsequent bariatric surgeries (revision or reversal) were required in 0.3% of the Roux-en-Y gastric bypass patients and in 17.5% of laparoscopic adjustable gastric band.64, 76

Bariatric Surgery Centers of Excellence

Ninety-two percent of large employers cover bariatric surgery.42 Among those, 56% require employees and dependents to use an accredited center of excellence (COE).77 Bariatric Surgery COEs are certified by the American College of Surgeons and the American Society for Bariatric and Metabolic Surgery. Many major health plans also designate COEs for obesity surgery. Example criteria for COE designation can be found on the Center of Excellence in Metabolic & Bariatric Surgery website.

Studies indicate that bariatric surgery patients have better outcomes, as well as a better experience, at centers accredited as COEs.78 For example, one study showed high-quality facilities had half the complications during the initial hospital stay as compared to low-quality facilities. Over the 14-month post-surgery period, complications for laparoscopic surgeries were 30% less likely when the procedure was performed at a high-quality facility. Complications after gastric banding surgeries were 50% less likely when performed at high-quality facilities.79

58% of employers use their health plan(s) to contract with bariatric surgery COEs, while just 4% have developed direct contracts.77

Requirement that Bariatric Procedures are Performed at a COE, 2018 
Figure 1: Requirement that Bariatric Procedures are Performed at a COE, 2018

70% of employers with bariatric surgery COEs have a traditional fee-for-service payment structure, 25% have a bundled payment model and 5% have an alternative payment model in place.77

Bariatric Surgery Coverage Checklist

  • Define eligibility criteria for bariatric surgery. Only patients who meet recommended criteria, whose physicians have indicated that weight loss surgery is medically necessary, and who are likely to benefit from the procedure should be approved for surgery. Although some employers may seek documentation of a patient’s agreement to comply with pre- and post-procedure treatment recommendations, or may institute pre-surgery weight loss requirements (e.g. a structured diet program for a minimum of 6 months) before a patient is eligible for surgery, evidence indicates that pre-operative weight loss does not have a clear impact on post-surgical outcomes or weight loss. While individual surgeons may recommend pre-operative weight loss based on the specific needs and circumstances of a patient, mandating this may unnecessarily delay or divert patients from surgery.80,81
  • Specify the procedures covered. Work with your health plan(s) to verify that only bariatric procedures with evidence of effectiveness and low-complication rates are covered.
  • Restrict coverage to qualified providers and facilities. Limit coverage to facilities designated as COEs and experienced, high-volume surgeons who demonstrate a minimal number of post-operative hospitalizations and mortality rates. Request definitive proof of performance as a way to confirm superior outcomes.
  • Provide patients with pre- and post-surgical support. Identify programs or services that can improve patient success, such as bariatric surgery navigators or coaches whose role is to support the employee through the entire surgical journey.
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TABLE OF CONTENTS

  1. What Is It?
  2. Who Is Bariatric Surgery Indicated For?
  3. Why Should Employers Cover It?
  4. Bariatric Surgery Efficacy
  5. Safety
  6. Bariatric Surgery Utilization
  7. Bariatric Surgery Centers of Excellence
  8. Bariatric Surgery Coverage Checklist