A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
22
ASMBS Update
ASMBS News and Update
SEPTEMBER 2011 by ROBIN L. BLACKSTONE, MD, FACS, FASMBS
Robin L. Blackstone,MD, FACS,
FASMBS Dr. Blackstone is President of the American Society for Metabolic and Bariatric Surgery and Medical Director, Scottsdale Healthcare Bariatric Center, Scottsdale, Arizona.
ASMBS Mission Statement
The American Society for Metabolic and Bariatric Surgery was founded in 1983 to establish educational and support programs for surgeons and integrated health professionals. Our mission is to improve the care and treatment of people with obesity and related disease; to advance the science and understanding of metabolic surgery; to advocate for health care policy that ensures patient access to high-quality prevention and treatment of obesity. For more information, visit www. ASMBS.org. If you are interested in becoming a member or have questions about ASMBS, please contact Georgeann Mallory, the ASMBS Executive Director, via phone: (352)-331-4900 or e-mail: info@asmbs.org.
Important upcoming dates. September 23–24, 2011. American Society for Metabolic and Bariatric Surgery (ASMBS) Fall Education Event, Hyatt Regency, Chicago, Illinois. For more information, visit www.fall2011.asmbs.org October 31, 2011. Abstract deadline for ASMBS Annual Meeting 2012.
Obesity still not declared a disease by the Centers for Medicare and Medicaid Services. Obesity is still not classified as a disease by the Center for Medicare and Medicaid Services (CMS). In 2004, CMS actually took obesity off of the list of "conditions," allowing consideration of reimbursement for the treatment of obesity. In what has become one of the most important moments in our field, a Medicare committee met and evaluated the evidence supporting the treatment of obesity with surgery and the National Coverage Decision (NCD) was made effective February of 2006. The decision by Medicare established an important beachhead for access to care for patients with obesity. In 2009, CMS again examined the evidence and strengthened the NCD by adding type 2 diabetes mellitus (T2DM) as an indication for surgery. An additional part of the NCD was that it supported the ASMBS Bariatric Centers of Excellence program and the American College of Surgeons (ACS) Bariatric Surgery Network level 1 program as the chosen sites for performance of surgery. While limiting the coverage to only these designated centers initially decreased access, within a few years access rebounded.
Why did Medicare cover the treatment of obesity? The final decision was about the data, but the impetus was, and is, financial. Data available from the Centers for Disease Control and Prevention (CDC) outline cost differences between a patient with obesity versus the patient without obesity.1
According to the data, for each
obese beneficiary, Medicare, Medicaid, and private insurers pay $1,723, $1,021, and $1,140, respecitively, more than they do for "normal-weight beneficiaries.
In 2010, Thorpe and Yang2 reported
the impact of weight loss on lifetime medical care spending among Medicare beneficiaries.2
They found that weight
losses of 5, 10, and 15 percent are associated with substantial Medicare savings. For example, a 15-percent weight loss in the first year of Medicare enrollement among beneficiaries with Class II/III obesity confers a 15 percent lifetime Medicare savings of $60 million. Medicare/Medicaid is suffering from adverse selection. The government provides coverage to a disproportionate share of the population with obesity in some estimates of more than 38 percent.3
One strategy CMS could
employ would be to support obesity as a disease, which would mean it would be covered within the Essential Health Benefit. With this one intervention, the government would spread the adverse selection bias among all insured patients in the United States. The ASMBS Leadership and Access Team is encouraging CMS to declare obesity as a disease and ensure coverage in the Essential Health Benefit.
The difficulty in estimating the number of bariatric procedures performed per year. One of the questions most often asked of the ASMBS is, "How many procedures were done last year?" followed by, "How many adjustable gastric bands versus gastric bypass procedures were done?" and, "What is the percent increase in the sleeve gastrectomy over last year?" Unfortunately, these questions are more difficult to answer than you would think. First, there is no global source that gives both inpatient and outpatient cases. Often, cases performed in ambulatory centers are simply not captured even if all the correct Current Procedural Terminology (CPT) codes are defined. Attempts at surveys of our membership are often not well subscribed to and thus do not provide enough credible data. Finally, estimates from industry may reflect a bias. Last year, Bruce Wolfe, MD, appointed a task force, led by Anita Courcoulas, MD, MPH, FACS, an investigator from the Longitudinal Assessment of Bariatric Surgery to develop a methodology to estimate the numbers that could be repeated annually and published. The task force report should be available early 2012.
In the meantime, a report has emerged that shows bariatric surgery has plateaued in volume since 2004.4 The new report from lead author Ninh Nguyen, MD, FACS, Secretary-Treasurer of the ASMBS, and his colleagues at University of California, Irvine, California, showed that using the National Inpatient Sample (NIS) data, the number of bariatric surgery peaked in 2004 at 63.9 procedures per 10,000 adults and decreased to 54.2 procedures in 2008. In-hospital mortality decreased from 0.21 percent in 2003 to 0.10 percent in 2008, and the percentage of procedures performed laparoscopically was 90.2 percent in 2008, up from 20.1 percent in 2003.
In a separate report, Edward Livingston, MD,5
used the 2006 National
Hospital Discharge Survey (NHDS), the NIS, and the Survey of Ambulatory Surgery and found that the number of primary procedures, including outpatient bands, was 112,999 cases in 2006 with 91,289 inpatient cases. Nguyen et al4
estimated 92,147 in 2006;
remarkably similar to Dr. Livingston's estimate. Both studies show a peak in
procedures in 2004.
The major event that occurred between 2004 and subsequent years is that insurance policies dropped bariatric surgery coverage as a standard benefit included within the general surgery procedures. This change in insurance coverage, which was completed by January 2005, was most dramatically seen in Florida. Although many have cited the economy as the reason for the decline in numbers of cases, this first effort by insurance companies to control what they viewed as uncontrolled and uncontrollable use of surgery to treat a disorder that was a cosmetic problem was the real cause of the decline as these numbers show.
The bottom line is that according to the National Health and Nutrition Examination Survey 2010,6
patients
affected by severe obesity (BMI >40kg/m2
) equal 5.7 percent of the
population of 312,163,474 people in the United States. That means 17,793,318 patients are affected; however, only 0.7 percent of these patients are receiving this life-saving treatment. The continuing battle to gain universal and standard coverage through the Essential Health Benefit is important to open access of these life-saving treatments to patients.
Prevention of osteoporosis—is your program doing enough? In 2008, the ASMBS Integrated Health team published guidelines for nutritional supplementation of the post-bariatric patient.7
This was followed by the
publication of guidelines for nutritional management of the post-bariatric patient.8
Both publications discuss the management of calcium and vitamin D in the bariatric patient undergoing a malabsorptive procedure in regards to their risk for osteoporosis and fracture. At a recent meeting, some new data was presented that indicate that the risk of bone loss and fracture in the patient after gastric bypass may be higher. A 2011 study9
not yet published by
the Mayo Clinic, Rochester, Minnesota, compared fracture rates in 277 patients undergoing bariatric surgery with local age- and sex-matched fracture rates. The surgeries occurred between 1985 and 2004, and 94 percent were gastric bypasses. The retrospective chart study found 138 fractures in 82 patients since the surgery, with a standardized
Bariatric Times • September 2011