Abstract
Despite the effectiveness of bariatric surgery, both with respect to weight loss and
improvements in obesity-related co-morbidities, it remains underused. Only 1% of the
currently eligible population undergoes surgical treatment for obesity, with roughly
228,000 individuals receiving bariatric surgery in the United States each year. Several
barriers to bariatric surgery have been identified, including limited patient and
referring physician knowledge and attitudes regarding the effectiveness and safety
of bariatric surgery. However, the role of insurance coverage and benefit design as
a barrier to access to care has received less attention to date. Bariatric surgery
is cost-effective compared with nonsurgical treatments among individuals with extreme
obesity and type 2 diabetes. While it may not result in cost savings among all bariatric
surgery eligible patients, for certain patient subgroups, bariatric surgery may be
cost neutral compared with traditional treatment options. In addition, longer-term
outcomes of bariatric surgery suggest decreased or stable costs in the long run. The
purpose of this review paper was to synthesize the existing knowledge on why bariatric
surgery remains largely underused in the United States with a focus on health insurance
benefits and design. In addition, the review discusses the applicability of value-based
insurance design to bariatric surgery. Value-based insurance design has been previously
applied to bariatric surgery coverage with use of incentive-based cost-sharing adjustments.
Its application could be further extended because the postoperative clinical outcomes
and costs vary among the different subgroups of bariatric surgery eligible patients.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Surgery for Obesity and Related DiseasesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Trends in obesity among adults in the United States, 2005 to 2014.JAMA. 2016; 315: 2284-2291
- Body mass index and the prevalence of hypertension and dyslipidemia.Obes Res. 2000; 8: 605-619
- The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis.BMC Public Health. 2009; 9: 88
- Estimating the medical care costs of obesity in the United States: systematic review, meta-analysis, and empirical analysis.Value Heal. 2016; 19: 602-613
- Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient–2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery.Surg Obes Relat Dis. 2013; 9: 159-191
- Surgery for weight loss in adults.Cochrane Database Syst Rev. 2014; CD003641
- Comparative effectiveness of 3 bariatric surgery procedures: Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy.Surg Obes Relat Dis. 2016; 12: 997-1002
Estimate of bariatric surgery numbers, 2011-2017 [homepage on the Internet]. Gainesville, American Society for Metabolic & Bariatric Surgery; c2018 [updated 2018 Jun; cited 2018 September 10]. Available from: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers.
- Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.N Engl J Med. 2004; 351: 2683-2693
- Weight loss and health status 3 years after bariatric surgery in adolescents.N Engl J Med. 2016; 374: 113-123
- Bariatric surgery and long-term durability of weight loss.JAMA Surg. 2016; 151: 1046-1055
- Weight and metabolic outcomes 12 years after gastric bypass.N Engl J Med. 2017; 377: 1143-1155
- Long-term effects of bariatric surgery in patients with insulin-treated type 2 diabetes: 44% at glycemic target without insulin use.Surg Obes Relat Dis. 2017; 13: S5-S6
- Remission of type 2 diabetes mellitus in patients after different types of bariatric surgery.JAMA Surg. 2015; 150: 1126-1133
- Effects of bariatric surgery on mortality, cardiovascular events, and cancer outcomes in obese patients: systematic review and meta-analysis.Obes Surg. 2016; 26: 2590-2601
- All-cause and cause-specific mortality associated with bariatric surgery: a review.Curr Atheroscler Rep. 2015; 17: 74
- A nationwide safety analysis of bariatric surgery in nonseverely obese patients with type 2 diabetes.Surg Obes Relat Dis. 2016; 12: 1163-1170
- Bariatric surgery barriers: a review using Andersen's Model of Health Services Use.Surg Obes Relat Dis. 2018; 14: 404-412
- Decreased access to bariatric care: an analysis of referral practices to bariatric specialists.Surg Obes Relat Dis. 2016; 12: 1725-1730
- Weight control practices of severely obese patients who are not seeking bariatric surgery.Obesity. 2013; 21: 1509-1513
- Factors influencing primary care physicians’ referral for bariatric surgery.JSLS J Soc Laparoendosc Surg. 2015; 19
- Physicians’ attitudes about referring their type 2 diabetes patients for bariatric surgery.Surg Obes Relat Dis. 2012; 8: 381-386
- Patient and referring practitioner characteristics associated with the likelihood of undergoing bariatric surgery.JAMA Surg. 2015; 150: 999-1005
- Primary care physician decision making regarding severe obesity treatment and bariatric surgery: a qualitative study.Surg Obes Relat Dis. 2016; 12: 893-901
- Attitudes about the safety and efficacy of bariatric surgery among patients with type 2 diabetes and a body mass index of 30-40 kg/m2.Surg Obes Relat Dis. 2013; 9: 630-635
- Perceived barriers to bariatric surgery among morbidly obese patients.Surg Obes Relat Dis. 2010; 6: 16-21
- Predictors of patient selection in bariatric surgery.Ann Surg. 2007; 245: 59-67
- Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis.Surg Obes Relat Dis. 2010; 6: 8-15
- Inpatient bariatric surgery among eligible black and white men and women in the United States, 1999–2010.Am J Gastroenterol. 2013; 108: 1218-1223
- Trends in utilization of bariatric surgery, 2009–2012.Surg Endosc. 2016; 30: 2723-2727
- Patient race and the likelihood of undergoing bariatric surgery among patients seeking surgery.Surg Endosc. 2015; 29: 2794-2799
- Economic value of greater access to bariatric procedures for patients with severe obesity and diabetes.Med Care. 2018; 56: 583-588
- Applying value-based insurance design to low-value health services.Health Aff. 2010; 29: 2017-2021
- Using clinically nuanced cost sharing to enhance consumer access to specialty medications.Am J Manag Care. 2014; 20: e242-e244
- Connecticut's value-based insurance plan increased the use of targeted services and medication adherence.Health Aff. 2016; 35: 637-646
- Value-based insurance design in cardiology.J Am Coll Cardiol. 2012; 60: 1825-1827
- Reducing copayments for essential cardiovascular medications: evaluation of a natural experiment.Gen Intern Med. 2010; 25: S381-S382
- The impact of reducing cardiovascular medication copayments on health spending and resource utilization.J Am Coll Cardiol. 2012; 60: 1817-1824
- Applying value-based insurance design to high-cost health services.Health Aff. 2010; 29: 2009-2016
- Value-based insurance design for diagnostics, devices, and procedures: a novel approach to better recognize the effectiveness and value of medical technology [monograph on the Internet].Institute for Health Technology Studies, Washington, DC2012 ([cited 2018 August 1]. Available from:)
- Obesity in the workplace: impact, outcomes, and recommendations.J Occup Environ Med. 2018; 60: 97-107
- Healthcare costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Patients study.Lancet Diabetes Endocrinol. 2015; 3: 855-865
- Cost-effectiveness of bariatric surgery for severely obese adults with diabetes.Diabetes Care. 2010; 33: 1933-1939
- Audit shows that bariatric surgery is cost-effective.BMJ. 2014; 349: g6735
- Cost-effectiveness of bariatric surgery.JAMA. 2013; 310: 742-743
- Healthcare use during 20 years following bariatric surgery.JAMA. 2012; 308: 1132-1141
- Impact of bariatric surgery on healthcare costs of obese persons.JAMA Surg. 2013; 148: 555-562
- Why readmissions matter….Surg Obes Relat Dis. 2014; 10: 379-381
- Agenda item 9 pension and health benefits committe: exploring opportunities in value-based insurance design [monograph on the Internet].CalPERS, Sacramento2016 ([cited 2018 August 1]. Available from:)
- The first metabolic and bariatric surgery accreditation and quality improvement program quality initiative: decreasing readmissions through opportunities provided.Surg Obes Relat Dis. 2014; 10: 377-378
Article info
Publication history
Published online: October 12, 2018
Accepted:
October 6,
2018
Received in revised form:
September 12,
2018
Received:
August 10,
2018
Footnotes
Supported, in part, by Grant R01-DK108628-01 from the National Institute of Diabetes, Digestive, and Kidney Disease as well as PA CURE funds from the Commonwealth of Pennsylvania (DBS), and NIH/NIDDK 3 R01 DK108628-05 S1 (GT).
Identification
Copyright
© 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
