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9 minute read |

Bariatric Surgery: The Dollars and Sense of Health Plan Coverage

Obesity is a significant driver of chronic disease and health care cost. Morbid obesity is an advanced form of obesity that is even more significantly linked to disease and poor health outcomes. Given the significance and growing prevalence of morbid obesity, treatment for it deserves attention and informed decision-making.

We sat down with John Dawson, Healthstat Chief Actuary, to discuss key concepts in benefit design for one of the more controversial interventions employers are under increasing demand to cover – bariatric surgery.

Bariatric surgery seems like a drastic intervention. Shouldn’t we be promoting behavior change and healthier lifestyles instead?

It’s truly not an either-or question. Diet and exercise are appropriate and sufficient for most of us with a little extra weight to lose. But morbid obesity is a serious health condition that changes body chemistry and biology to the point that diet and exercise typically are not enough. And while we’ve seen miraculous weight loss on shows like The Biggest Loser, the conditions under which those contestants lived are not realistic for most people, and the sad truth is, most of the contestants were not able to sustain their weight loss.

When it comes to bariatric surgery, the first thing to know is that it is not a cosmetic procedure. It is an intervention for a serious chronic disease. But you cannot look at bariatric surgery as a shortcut to get around the work of behavior change. In fact, the surgery is only effective in conjunction with lifestyle and behavior change. That’s why it’s important to build the elements for success into your coverage.

The right plan design should create an enabling environment, yielding health benefits to the employee and as a result, financial return to the employer. Bariatric surgery is an important tool that helps people with morbid obesity reduce excess weight, and more importantly, reduce health risks as well as future healthcare costs associated with obesity-related comorbidities. The goal is to offer coverage that’s both financially responsible for the employer and accessible for the employee. That means including enough parameters to favor successful outcomes, but not so many requirements that you build up barriers to patient success.

Should bariatric surgery be covered under our benefits plan?

There is enough evidence from peer reviewed literature about the clinical and financial efficacy of bariatric surgery that coverage is justified. So, I would say, emphatically, “Yes. Your health plans should cover bariatric surgery.”

But which surgeries should we cover? Not all procedure types are currently recommended, and best practice will almost certainly change over time. So, rather than trying to specify each procedure, a more durable strategy to keep up with changes is to use plan document language that follows standards of medical practice specified by the American Society for Metabolic and Bariatric Surgery (ASMBS).

Regardless of procedure type, the most important thing to know is that bariatric surgery is never a standalone procedure. Success requires many support components, such as nutrition counseling, exercise counseling, psychological evaluation, psychological counseling and much more. Without the full complement of care, you’re not providing the standard of care that makes it likely they’ll achieve the desired outcomes.

As a consultant, I would have several goals for a bariatric surgery benefit:

  • Have a good ROI
  • Hold down costs
  • Improve outcomes
  • Promote access and reduce barriers
  • Cover the full range of services required

Who should be covered under this benefit? Are there reasonable patient qualifications?

NIH Guidelines recommend that surgery only be considered for patients with a BMI of 40+, or for those with a BMI of 35+ with obesity-related comorbidities. There are providers who advocate extending coverage to patients with comorbidities at a BMI of 30+. I haven’t seen economic data to rationalize that approach in the US, and that threshold would comprise about 40% of the US adult population.

BMI criteria are also just one aspect of patient qualification. To have a good probability of success, a patient needs to understand the procedure and be physically and emotionally prepared for the rigors of recovering from the surgery and keeping up new nutrition and exercise habits. In this context, there’s a balance to strike between creating an enabling benefit design that will provide improved access vs. increasing barriers to a medically necessary procedure because you’re trying to avoid having people undergo a surgery when they’re not ready for it. Patients have a lot of pre-work and post-work to do to achieve the desired outcomes. That means having access to the necessary complement of services, but also being ready to make the most of those services.

That said, some health plans impose excessive standards to qualify for the surgery. For example, they may require the patient to demonstrate over long time periods that they’re unable to lose weight through diet and exercise – but that inability is already in evidence. On the other hand, they may require the patient to show they can lose 5-10% of their bodyweight before the surgery, with the likelihood of being able to control their weight after surgery. How could a patient show this? By demonstrating adherence through a long qualification period – 6 to 12 months before surgery.

And the most egregious plans make the patient start their qualification period over if they miss any of their visits, or if their weight loss stalls. I think that is incredibly misguided – these patients are on a trajectory to have some really bad health events in the future. They’re at risk for heart attacks, strokes, cancers, double knee replacements, etc. Delaying the care they need makes it more likely that the health plan will pay claims for these bad health events instead of the much smaller, more manageable cost of bariatric surgery treatment.

Inappropriate barriers can block an otherwise appropriate and motivated patient from qualifying for surgery. It sets up the reality that the patient will not pursue bariatric surgery treatment, and instead continue on the path towards incurring other, more costly healthcare complications related to their chronic obesity.

Should coverage be limited to certain providers?

There are several advantages to limiting coverage to surgeries performed in a Bariatric Surgery Center of Excellence.

Back to patient qualification for a moment, a Center of Excellence is in the best position to determine when an individual is fully fit for surgery. Their expert teams are designed to be able to evaluate and select patients for whom bariatric surgery is both appropriate and timely. That removes the onus of determining patient qualification from the health plan. In addition to the surgical team, the multidisciplinary team assembled at a Bariatric Surgery Center of Excellence generally includes nutritionists, psychologists, pulmonologists, cardiologists and other medical specialists who are trained in bariatric care. They can evaluate and support the physical, psychological and social factors that will improve the likelihood of positive outcomes.

Regarding provider qualification, designation as a Bariatric Surgery Center of Excellence indicates the facility has met standards that consider policies and procedures, as well as evaluating metrics such as number of surgeries performed, complication rates, quality and outcomes. The actions required to maintain Center of Excellence designation are consistent with the criteria health plans would deem appropriate for ensuring consistent quality.

5. What about the scope of services? How does an employer decide what to cover?

As an employer, my first thought might be, I’m self-funded so I can offer whatever coverage I choose. And in theory, employers do control that decision. However, how coverage is administered depends largely on the TPA or carrier’s values and protocols around bariatric surgery. If an employer chooses to provide this important coverage, the employer must be very clear and direct with the TPA or carrier on how that coverage should be administered.

There are several things an employer needs to help make a bariatric surgery program successful:

  • A TPA that understands its wishes and will carry them out
  • Expertise from a Bariatric Surgery Center of Excellence
  • Patients who are ready to change their lives
  • Accessibility of supportive care before and after surgery

Pre-surgery and post-surgery care are critical to successful outcomes. Prior to healthcare reform, it was relatively uncommon for insurance to pay for things like nutrition counseling, or anything related to exercise, etc. Now, under the Affordable Care Act, a more comprehensive range of prevention services are considered “essential benefits.” Meaningful coverage for nutrition counseling, exercise counseling, psychological evaluation and psychological counseling lowers the cost barriers of these critical services for patients.

Psychological services are particularly important because of the high association of morbid obesity and depression. Whether obesity leads to depression, or depression predisposes to obesity, addressing the underlying depressive disorder is key to achieving long-term health improvement and lasting lifestyle changes.

What if my employee doesn’t live near a Bariatric Surgery Center of Excellence?

Recovery from bariatric surgery does require access to specialists. Remember that the internal anatomy of bariatric patients is very different from a typical person’s anatomy. Bariatric surgery patients should also be under the care of accredited specialists who can recognize post-surgical complications more readily.

In addition, post-surgery care involves learning how to eat during the different phases of recovery and how to exercise properly. Regular follow-up visits are key to success.

While limiting coverage to Bariatric Surgery Centers of Excellence is generally appropriate, it can create access issues for patients who are geographically distant. Employers with effective onsite healthcare programs can address distance barriers through working relationships between their onsite healthcare providers and their Bariatric Surgery Center of Excellence teams, so patients receive appropriate pre- and post-surgery care.

Providers in workplace health and wellness centers (“onsite providers”) often establish strong, ongoing working relationships with patients. At first, the clinic’s draw may be based on convenience. But over time, the way that care delivery is structured gives the provider time to get to know a patient, making it easier for the patient to check in both physically and emotionally. Having a working relationship with an onsite provider especially helpful – many bariatric surgery patients can benefit from some extra support incorporating changes into their daily lives, work, family and social interactions.

What role can a workplace health center play in supportive local care?

For many employers, an onsite clinic is at the core of helping patients navigate the healthcare system well. Onsite clinicians can guide patients to Centers of Excellence. And the onsite clinic can play a crucial supportive role in before and after care for bariatric surgery.

Healthstat onsite clinicians engage patients in healthy behavior change across the spectrum of care. That includes a focus on weight loss goals for patients ranging from overweight to morbidly obese. For some patients, Healthstat weight management programs will be enough to make that healthy difference. For other patients, additional intervention is necessary. The onsite clinician can discuss both lifestyle interventions and treatment options, help each patient prepare for and make their own best decisions. And if the patient decides to pursue surgery, our onsite clinicians can help the patient choose a high-quality bariatric surgery team that is consistent with their employer’s health plan and network.

The onsite provider is in a great position to discuss these options because there’s trust they have no agenda to lean toward services that aren’t essential. Healthstat doesn’t work on a fee-for-service model, instead charging a flat fee per employee per year; it’s often linked to a performance guarantee for keeping people healthier. So, the onsite clinician’s only incentive is to provide the care that’s needed, and as much as is needed, to protect each person’s health.

The onsite clinician often plays a natural “advocate” role. That’s by program design, as well as to fulfill a professional calling that leads the clinician to this model of care. The structure of care delivery in the onsite setting allows ample time for a patient to talk with their clinician in greater depth. Together, they can work through a recap of a visit with the surgeon, discuss what was said, process the information and formulate the questions the patient wants to ask on their next visit. It’s empowering for the patient.

Healthstat providers establish ongoing relationships with patients because they have time to get to know them. They learn what their “real life” is like. They may have visibility to a range of socioeconomic determinants of health, which allows the Healthstat clinician to address potential barriers to success. At the heart of the Healthstat model is the recognition that our clinicians can drive behavior change by addressing roadblocks and moving a patient toward action.

What’s in it for the employer? Is there a positive ROI for covering bariatric surgery?

Bariatric surgery, in the context we’re discussing it, may cost $12K-$24. The return on investment has been estimated at 18-24 months in claim cost savings alone. Improved worker productivity bolsters the financial return. The financial impact continues to accrue thereafter. Particularly when we look at a patient who is morbidly obese with significant comorbidity, the return on investment can be substantial.

In some cases, turnover will prevent the employer from realizing the anticipated ROI. There are two turnover mitigation strategies employers might consider:

  • Impose a one- or two-year waiting period for new employees before they become eligible for coverage
  • Provide coverage for removing excess skin for patients that achieve weight loss when they’re still covered under the health plan one or two years after the surgery.

Medical evidence demonstrates the clinical efficacy of bariatric surgery. The surgery also makes financial sense for the employer as an intervention to prevent even higher claims costs in the future. It follows that consistent and universal coverage for bariatric surgery is appropriate. As the next step to designing an effective benefit, employers should consider the importance of continuity of care. Two provider types offer the ideal combination of specialist expertise and ongoing support close to home: a Bariatric Surgery Center of Excellence and a Healthstat workplace health and wellness center with providers that have the time and commitment to nurture a long term, caring relationship with the patient.

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