Nation Weighs Value of Obesity Surgery

Photo by Graham Ramsay Erica Seiguer

One third of Americans are obese, and about two thirds are overweight. The rate of obesity among the young has tripled since 1980; 16 percent of children from 6 to 19 years old are now considered overweight.

This growth in America’s waistline has consequences for individual and public health, as well as social and economic repercussions. Obesity increases the risk of a host of health conditions, including hypertension, dyslipidemia, type 2 diabetes, heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers, including endometrial, breast, and colon cancers. These conditions cause increased morbidity and mortality and result in large costs for the health care system and society in general. Some estimates put the annual cost of the extra pounds at $123 billion, including $64 billion in direct costs and $59 billion in indirect costs, such as those incurred due to decreased labor market participation and lower lifetime earnings due to premature death.

The Surgery Option
In addition to diet and exercise, surgery is becoming an increasingly popular approach to dealing with obesity. Gastric bypass, gastric adjustable banding, biliopancreatic diversion, and duodenal switch are all surgical techniques aimed at weight loss. In fact, the Centers for Medicare and Medicaid Services (CMS), the agency that runs the Medicare program, recently announced a national coverage decision to provide nationally uniform insurance coverage for beneficiaries undergoing bariatric surgery to address morbid obesity. Eight to 12 million Americans qualify as morbidly obese, having a body mass index greater than 35.

The first proposal from CMS, however, had advocated against coverage, in part because of published data showing a greater mortality risk from bariatric surgery for Medicare beneficiaries. In the 30-day period for public comment on the proposal, several national organizations, research groups, and individuals lobbied against the draft non-coverage decision. Eventually, the agency decided to cover the procedure for its beneficiaries, which include elderly and disabled populations.

Mixed Results
As part of Medicare’s decision, coverage will be provided only if the surgery is performed at a center accredited by either the American Society for Bariatric Surgery (ASBS) or the American College of Surgeons (ACS). Matthew Hutter, HMS instructor in surgery at Massachusetts General Hospital, who has been involved in the American College of Surgeons accreditation program and conducts health services research in this area, believes that while the Medicare decision is a step toward ensuring quality care, it may restrict access to care for many Medicare beneficiaries in the near future.

“I think that the centers of excellence or accreditation programs that have been set up are quite commendable,” Hutter said. “My concern is access to care.... Very few centers are presently accredited by either the ACS or ASBS. Thus, many Medicare patients do not have access to bariatric surgery right now.” In Hutter’s own practice, many surgeries have had to be postponed because of the coverage decision. He worries that patients in rural areas, which may be unlikely to host a center of excellence program, will not have access to the treatment.

Some believe that the wider use of bariatric surgery in morbidly obese individuals will have significant economic and social impacts. Harvey Sugerman, immediate past president of the American Society for Bariatric Surgery, has claimed that expanding access to bariatric surgery will allow many who are disabled to improve past the point of disability, resulting in cost savings to Medicare and society in general.

Hutter believes that measuring the effects of such interventions on health care and other costs, as well as quality of life, will be technically difficult; however, he is engaged with researchers in the HMS Department of Health Care Policy to assess some of the implications of obesity for the Medicare program. While Hutter was not part of the decision-making process at CMS, he did provide preliminary data from his research to the agency during the 30-day comment period after the first non-coverage decision was proposed.

The Medicare decision does recognize obesity as a disease and bariatric surgery as an effective treatment. Hutter said that this formulation has important consequences. “It’s fairly critical and, at first, earlier in my career, I did not appreciate the significance,” he said. “Obesity to some people is thought of as a cosmetic thing or as a result of a lack of willpower. That is definitely not the case.” In his experience, bariatric surgery can have an enormous impact on the lives of patients, ridding them of hypertension, hyperlipidemia, diabetes, sleep apnea, and joint pain. Yet the improvement in quality of life is something that, according to Hutter, has been difficult to quantify, a factor that has made cost–benefit analyses more limited.

—Erica Seiguer is an MD–PhD student studying economics in Harvard’s Doctoral Program in Health Policy.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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