Bariatric Times

MAY 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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12 Brief Report Bariatric Times • May 2017 BACKGROUND After a year and a half of concentrated lobbying on multiple fronts, the South Carolina Department of Health and Human Services (SCDHHS) has expanded program coverage for bariatric surgery to include sleeve gastrectomy for approximately 890,000 South Carolinians with fee- for-service Medicaid benefits. This decision, which took effect July 1, 2016, marked a significant turning point in obesity treatment access for Medicaid patients in South Carolina, who previously only had coverage for Roux-en-Y gastric bypass (RYGB). This story is one of victory in which advocates fought against the rising tide of obesity, where economic and clinical barriers are still slow to fall and allow access for patients to the proven treatment of bariatric surgery. COLLABORATIVE ADVOCACY AND STAYING POWER We have been separately active in the long history of advocacy for bariatric surgery coverage in South Carolina. By 2010, when laparoscopic sleeve gastrectomy had been added to bariatric procedure options, we broadened our advocacy targets and joined forces. We put our combined efforts to work to play a key role in the Centers for Medicare & Medicaid Services (CMS) approving Medicare members' access to bariatric surgery. However, the question of expanding that coverage to include laparoscopic sleeve gastrectomy brought new hurdles to clear. In mid-2012, CMS delegated that decision to each regional Medicare Administrative Contractor. In response, our advocacy movement launched a multi-year, grassroots lobbying campaign to approach each separate regional Medicare administrative contractor (MAC) and complete their lengthy processes to change the rules. With that successful campaign behind us in 2014, we realized that South Carolina—our shared home state—denied its Medicaid patients the same bariatric surgery benefits that were available to every Medicare patient in the country and to most commercially insured members. Every day we were seeing residents living with the burden of obesity and type 2 diabetes mellitus (T2DM). To us, this was an issue of fairness as well as economics. As taxpayers, we understand the state's challenges in offering universal access, but we believe that if we cannot begin to prevent obesity and treat those already dealing with it, the health impact to our residents and financial impact to our state will be devastating. THREE ESSENTIAL STRATEGIES FOR WINNING We began discussions with SCDHHS in earnest in 2014 to p ursue Medicaid coverage for the sleeve procedure. Our efforts prompted some high-profile resistance. Politicians wrote editorials in the state's newspapers, arguing against spending taxpayer money on what they termed elective weight-loss surgery. Other opponents feared a rush to surgery that would drain Medicaid funds. It is critical in advocating for obesity treatment to turn those perceptions about bariatric surgery from weight loss to health gain. We pursued three proven strategies to change hearts and minds. Successful advocacy needs lobbyists for access to decision makers. It needs doctors willing to present the devastating process of obesity and the science to support the benefits of treatment, including surgery. It also needs patients willing to make the emotional case. We recruited Dawn Gabriele, Senior Manager Ethicon HEMA; J.J. Darby with Johnson & Johnson State Government Affairs; Joe Nadglowski, President & CEO of the Obesity Action Coalition, and Christopher Gallagher, Washington Representative for the American Society for Metabolic and Bariatric Surgery (ASMBS). They helped open doors and prepare physicians to present the clinical case. Lobbyists know the policymakers and decision makers. They provide the insights to tailor every presentation to the individual's position in the decision process and where each stands on the issues. They "set the table" for clinicians to make their plea. Across the state, physicians such as South Carolina bariatric surgeons Marc Antonetti, MD; Glen Strickland, MD; Edward Rapp, MD; and T. Karl Byrne, MD, stepped up to present the scientific evidence and educate policy- and decision makers on the health risks of obesity, the costs of untreated disease, and the well-documented benefits of sleeve gastrectomy. Their platform drew from the l arge body of existing evidence linking obesity to an increased risk for T2DM, chronic heart disease, some cancers, stroke, hypertension, arthritis, and obstructive sleep apnea. 1 They presented results of studies showing that, in addition to weight loss after bariatric surgery, patients may also experience resolution or improvement of their obesity-related conditions. 2–7 They also provided data specific to South Carolina patients documenting fewer heart attacks and strokes following bariatric surgery (e.g., a 65 percent reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM). 8 They emphasized the disparity in excluding the Medicaid population from sleeve gastrectomy when SCDHHS was already offering the bypass option that carried higher costs and potentially higher risks and complication rates. In a hearts and minds battle, however, evidence alone does not always win the day. The physicians then invited their patients to share their stories in a grassroots letter- writing campaign. At first, we observed that patients with obesity were still attempting to find their voice. They were reluctant to come forward and hard-pressed to advocate for themselves because of obesity's lingering stigma. When completed, the heartfelt, personal letters from patients struggling with obesity gave a face and a voice to the issue. Those stories painted the very real picture of obesity's toll on South Carolina lives and it was ultimately those letters that turned the key and won the vote. As of July 1, 2016, we achieved victory when the SCDHHS expanded program coverage for bariatric surgery to include sleeve gastrectomy for approximately by JOHN D. SCOTT, MD, and NATALIE HEIDRICH Bariatric Times. 2017;14(5):12–14. COLLABORATIVE ADVOCACY AGAINST THE RISING TIDE OF OBESITY A Winning Strategy Pays Off in South Carolina ABSTRACT In mid-2012, the Centers for Medicare & Medicaid Services issued a decision stating that Medicare Administrative Contractors may determine coverage of stand-alone l aparoscopic sleeve gastrectomy for the treatment of comorbid conditions related to obesity in Medicare beneficiaries who met listed criteria. Until July 2016, Medicaid patients in South Carolina received coverage for Roux-en-Y gastric bypass but not sleeve gastrectomy. Here, the authors, who were involved in concentrated lobbying and advocacy efforts, describe the process that led the South Carolina Department of Health and Human Services to expand program coverage for bariatric surgery to include sleeve gastrectomy for South Carolinians with fee-for-service Medicaid benefits. KEYWORDS Obesity, obesity treatment, advocacy, access to care, insurance coverage, sleeve gastrectomy, South Carolina

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