Treating Obesity - Does It Pay?

Questions and Answers

Philip Schauer, MD   September 29, 2009

1. If the health plan doesn't pay for bariatric surgery, what are your best recommendations?
   
2. Do you recommend bariatric surgery for people with a BMI < 35?
   
3. How do you recoup costs with turnover of employees?
   
4. How do you determine which type of procedure to do?
   
5. Do you think that employers will recognize obesity as an issue in the workforce in the near future and, therefore, begin to institute coverage (especially with all of the recent national media attention)?
   
6. You spoke a little about the long term success of these treatments at about 10 years out as far as maintaining weight loss. But are there any additional implications for these treatment options 20 or 30+ years out?
   
7. What are the long term consequences or risks of gastric bypass surgery?
   
8. How do you manage patient expectations? For instance, a patient views surgery as the appropriate course of action, without a willingness to make any accompanying lifestyle changes?
   
9. Do you have a sense of the split between self-pay and insurance pay clients in your program?
   
10. What are the attributes of quality for bariatric surgery program?
    
11. The NIH consensus conference on obesity surgery was held in 1991 and the report is out of date as noted on their web page. Are any new guidelines in the works from the NIH?
    
12. Do you support any of the dietary programs such as Atkins, Weight Watchers, and Jenny Craig?
    
13. What is your opinion as far as the continuous rise in the epidemic of obesity? You mentioned your patient that is 16 that has "tried everything" to lose weight over the past 5-6 years. Why do you feel that obesity is continuing to worsen rather than improve?

If the health plan doesn't pay for bariatric surgery, what are your best recommendations?

On a big picture level, education is critical. Bariatric surgery has consistently been shown to improve people’s health and lengthen their lives. Insurance companies that deny bariatric coverage need to be aware of this as well. Though national organizations like the American Society for Metabolic and Bariatric Surgery continue to lobby for improved insurance access for patients, it is important that individual patients to challenge existing exclusion clauses as well. To make these operations available to patients who cannot obtain coverage, some programs have instituted financing programs to make payment easier as well.

Do you recommend bariatric surgery for people with a BMI < 35?

NIH guidelines have dictated appropriate BMI guidelines for performing bariatric surgery. These include BMI >35 with weight-related co-morbidities, or > 40. These guidelines are now over 15 years old and excellent data has come out since then that has demonstrated both improvements in medical co-morbidities and mortality after bariatric surgery. Presumably these benefits could also be applied to patients with weight-related co-morbidities and BMI less than 35. However, bariatric procedures performed on patients with a BMI less than 35 should be performed with Institutional Review Board approval only.

How do you recoup costs with turnover of employees?

The up-front cost of bariatric surgery may seem significant. The operations typically require hospitalization for 1 to 4 days, and recovery periods range from 4 to 6 weeks. However, after bariatric surgery, patients and therefore employees have significantly improved health. As we have discussed, improvement in diabetes, hypertension, and high cholesterol all translate into healthier employees and this decreases the long term cost as care for these chronic health conditions may become unnecessary. Also, after significant weight loss, patients' physical stamina improves and this translates into a healthier, more efficient employee.

How do you determine which type of procedure to do?

Many patients have done significant research prior to enrolling in our program and they often feel strongly about a particular procedure. The reasons for their decision are then discussed in the context of their medical burden with our physicians, and collectively a decision is made as to what procedure will benefit a particular patient the most. For this reason, I believe it is imperative that bariatric surgery programs be able to offer all currently approved surgical options for their patients, as no one procedure is appropriate for all patients.

Do you think that employers will recognize obesity as an issue in the workforce in the near future and, therefore, begin to institute coverage (especially with all of the recent national media attention)?

Yes. As the science of obesity is more clearly elucidated, it is becoming clear that many forces interact that are shaping our current epidemic. Genetics, environment, and behaviors all interact in a complex network and the end result is an increasingly large disease burden. As our population ages, the medical and financial impact of weight-related co-morbidities of diabetes, hypertension, high cholesterol, and ischemic heart disease will continue to burgeon. Obesity is central to this and I believe the scientific data we are generating will continue to make strong arguments to institute coverage.

You spoke a little about the long term success of these treatments at about 10 years out as far as maintaining weight loss. But are there any additional implications for these treatment options 20 or 30+ years out?

Yes, and thankfully we have some of that data available already. Roux-en-Y gastric bypass has been performed for decades and therefore, this data is available now. We perform nearly the same operation today, but now it is performed laparoscopically, in a less invasive way. Newer procedures including laparoscopic adjustable gastric banding and sleeve gastrectomy are continuing to gain longer term data that is quite encouraging.

What are the long term consequences or risks of gastric bypass surgery?

After the immediate post-operative period, there are several long term risks from gastric bypass surgery. Strictures at the gastro-jejunal anastomsis can occur, causing dysphagia or pain. These are usually secondary to patients smoking or NSAID use. Bowel obstructions can occur at any point, early or late from the time of operation and usually present with severe abdominal pain. Nutritional deficiencies are rare, but if patients do not follow up routinely in a comprehensive bariatric surgery program, can occur.

How do you manage patient expectations? For instance, a patient views surgery as the appropriate course of action, without a willingness to make any accompanying lifestyle changes?

Bariatric surgery is a lifelong commitment and should not be undertaken without a full commitment by the patient. In our program, this is stressed throughout the pre-operative period. If a patient does not or cannot understand the implications of a post-surgical lifestyle, they undergo further education to insure this understanding. Failure to have appropriate expectations can ultimately lead to poorer outcomes after bariatric surgery.

Do you have a sense of the split between self-pay and insurance pay clients in your program?

No. All patients receive the same care pathways and attention to individual patient needs.

What are the attributes of quality for bariatric surgery program?

A multi-disciplinary approach to treating patients is the key to high quality bariatric and metabolic programs. Excellent surgical results and experience are important, but this clearly is just one aspect. Medical specialists are needed to manage patients’ often significant co-morbidities and optimize them for possible operative intervention. A dedicated nutritional team is key to educating patients on appropriate eating habits at all points. Psychologists with a particular interest in the complex behavioral issues surrounding obesity are required. In addition, dedicated nurses, and facilities, including both inpatient and outpatient clinics, and updated operative suites make for a quality program.

The NIH consensus conference on obesity surgery was held in 1991 and the report is out of date as noted on their web page. Are any new guidelines in the works from the NIH?

Given the influx of compelling data detailing the beneficial effects of bariatric surgery in terms of both reducing co-morbidities and decreasing mortality, revision of the guidelines is likely indicated. Other countries around the world are expanding criteria with intervention in lower BMI populations and publishing their results in peer-reviewed journals.

Do you support any of the dietary programs such as Atkins, Weight Watchers, and Jenny Craig?

We generally encourage diet plans that the patient will tolerate best, which could include any of those you listed and more. Our patients typically will be scheduled for an appointment with our dietician who will review nutritional choices and portion sizes with them, as well as guide them along the best diet plan suited for the patient. Additionally, our patients will see any one of our two Obesity Medical Physicians if a supervised low calorie diet is being implemented and/or if medication enhancement is necessary.

What is your opinion as far as the continuous rise in the epidemic of obesity? You mentioned your patient that is 16 that has "tried everything" to lose weight over the past 5-6 years. Why do you feel that obesity is continuing to worsen rather than improve?

Obesity is a complex, medical problem. Its roots are in genetics, environmental influences, and behaviors. All of these factors coalesce in a complex way that has propelled this epidemic. Our scientific understanding of obesity is improving, but clearly there is much more to do. Education may be central to intervening sooner in younger patients to prevent them from developing severe obesity and its related diseases. At this point, the only long term, durable, and successful means to treat morbid obesity is surgery.