Challenges to Overcome for Long Term Success

Obese patients who qualify for bariatric surgery have major challenges to conquer to achieve long-term weight loss success. Not every patient who initially wants the surgery should have it. Patients must address a lot of issues before the surgery and a number of changes after the surgery. Prior to surgery, patients must evaluate their perceptions as to how dramatic weight loss will impact their life. The physician should frankly discuss whether a patient is capable of handling the experience of losing 50% or more of weight. If a patient has always been obese, how will that individual adjust emotionally to being in literally a new body? Operative risk stratification is always important, and patients must understand the potential for both complications and death as a result of the surgery. With a low mortality rate for all the bariatric procedures, selecting appropriate candidates for bariatric surgery is more about how the patient intends to live after the operation than it is about the operation itself. Just like outpatients treated successfully for obesity, successful surgical patients must have the determination to adopt more healthful behavior. They must be realistic about their weight loss goal and daily focus on a gradual but cumulative process that leads to that goal. As one bariatric surgeon states regarding patient selection, "We are looking for only a few good patients."

This criterion is met by those patients who passionately want to gain control of their obesity and are determined to use dietary, behavioral, and surgical means to do so. For patients who do not want to change their eating patterns, are apprehensive about seeing themselves as physically different, or find unacceptable the potential surgical complications, this form of treatment for obesity is not an appropriate option.

The second challenge for an obese patient is the need to obtain social support or at least to understand how lack of social support can hamper the patient's weight loss success. How will significant persons in the patient's life respond to a thinner, typically more energetic, and frequently more attractive individual in place of the person who was obese, especially if the significant other person is obese as well? It is not unusual for an obese spouse or key family member to become jealous or envious of the person who lost a large amount of weight. The significant person may be threatened by the patient's increase in self-esteem or the way others respond to that person as they lose weight. Either consciously or unconsciously, an individual may try to sabotage the patient's weight loss efforts. Statements like, "I loved you just the way you were," or buying the patient foods high in calories as an expression of caring might be sending a message that change is threatening to the key support person. Family conflict or jealousy including marital discord and divorce can occur if the patient's family and friends are not supportive of the patient losing a dramatic amount of weight. This challenge must be addressed prior to surgery and reassessed by the primary care physician following the operation for at least 1 to 2 years.

The third challenge severely obese patients face when they consider surgery is payment for the procedure. For many patients this challenge is insurmountable. Severely obese patients motivated to make permanent behavior changes, who understand and accept the risks of the surgery, and have a positive support system still may not qualify for the operation. In situations where third party payment is not covered, the patient's primary care physician can be an advocate to appeal the patient's case. To be an effective advocate, the physician needs to understand the complexity of payment for bariatric surgery.

The rationale for reimbursement for bariatric surgery may appear straightforward to both the patient and the primary care physician in terms of both the amount of weight lost by the majority of patients and improvement in comorbid conditions. A meta-analysis by Buchwald et al. involving 22,094 postoperative obese patients highlights this point. Their study reported a mean postoperative weight loss of 61.2% for all patients. For specific procedures, gastric banding had a mean weight loss of 47.5%, gastric bypass 61.6%, gastroplasty 68.2%, and biliopancreatic diversion 70.1% [11].

The majority of morbidly obese patients who lose 25% to 50% of their weight frequently experience a remarkable improvement in other chronic disease conditions. Buchwald et al. also reported that postoperatively diabetes completely resolved or improved in 86.0% of the patients, hyperlipidemia improved in 70%, hypertension in 61.7%, and sleep apnea in 83.6% [11]. These data are consistent with the findings from the Swedish Obese Subjects (SOS) prospective study showing that at 2 years after operation, patients maintained a mean weight loss of 61.6lb compared to the control group who lost 1 lb [12]. Postsurgical patients experienced improvement in hypertension, diabetes, hyperinsulinemia, hypercholesterolemia, hypertriglyceridemia and low HDL cholesterol compared to controls [12].

At a time when the public is becoming aware of the individual benefits bariatric surgery can produce, major insurance companies are eliminating financial coverage for such procedures. For instance, in early 2004, Blue Cross Blue Shield in Florida and Nebraska announced they no longer provide coverage for gastric bypass surgery, and CIGNA Corporation will eliminate this benefit in certain states as their contract expires [13].

Some insurance companies use a medical benefit Medicare provides as a guideline to determine their policy coverage. A lot of interest was generated on July 15, 2004 when Health and Human Services Secretary Tommy Thompson and Medicare administrator Mark McClellan announced Medicare's new policy on obesity. This policy change was the removal of the statement, "obesity is not considered an illness" from the Coverage Issues Manual (CMI) [14], which determines what care and services Medicare will pay. The Medicare National Coverage Determination on Obesity tracking notes state, "because CMI is intended to address the coverage of particular care and services, rather than the definition of illness, we do not believe it is appropriate for the manual to address this issue" [13]. Now the Coverage Issues Manual states in sections 35-26, "Services in connection with the treatment of obesity are covered services when such services are an integral and necessary part of a course of treatment." The only change in the CMI is deletion of the sentence stating obesity is not an illness. This is not a major policy change but a correction regarding the purpose of the CMI.

Discussion by the Medicare Coverage Advisory Committee regarding payment for certain types of bariatric surgery for obesity without covered comor-bidities is scheduled to occur in November 2004. Until a decision is determined, non-coverage for obesity without comorbidities is the policy, whether surgical or non-surgical. (For a specific answer to an obesity reimbursement question, it is possible to call Medicare's obesity lead analyst directly at 1-410-786-9252.)

Added to the fact that Medicare denies coverage for surgical treatment of obesity without comorbidities is the lack of data regarding the long-term economic benefits of bariatric surgery. In order to understand the medical benefit, The National Institutes of Health's National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) established the Longitudinal Assessment of Bariatric Surgery (LABS) consortium to collect data on clinical, epidemiological, and behavioral outcomes of bariatric surgery [15]. The LABS data, coupled with publications like that of Buchwald et al. [11] and the Swedish Obese Subjects study, will provide the outcome data needed to economically determine the value of a surgical intervention as part of the treatment for this chronic disease condition.

Further complicating the decision by third party payers is the cost of bariat-ric surgery, which ranges from $15,000 to over $25,000 with operative complications extending the cost to over $100,000 in certain situations [16]. With more people becoming severely obese, the demand by Americans for bariatric surgery is rapidly growing from 16,000 operations in the early 1990s to 103,000 in 2003 [17], with an estimated 140,000 operations projected in 2004, a 36% increase from 2003. This means the estimated cost of bariatric surgery in 2004 is between $250 million and $300 million. These figures do not account for the cost of both short- and long-term surgical complications, and long-term monitoring to make certain the patient does not develop certain deficiencies. Payers for the procedure want to see a comparable savings compared to the expenditures in healthcare costs in order to justify the procedure. With conclusive data still lacking that demonstrate the economic savings for third party payers, it is not difficult to understand the reluctance of third party payers to cover bariatric surgery operations.

Finally, the greatest risk a patient assumes by having the surgery is death. If there is an average mortality rate of 0% to 1.5%, possibly hundreds of patients will die in 2004 from either short-term or long-term surgical complications. The meta-analysis by Buchwald et al. demonstrated a 30-day mortality rate of 0.1% for restrictive procedures, 0.5% for gastric bypass, and 1.1% for biliopancreatic diversion or duodenal switch [11]. On the other hand, not all operative complications are experienced within 30 days of the procedure. Patients who present with possibly a greater risk of death are women of childbearing age, which reflects the highest proportion of patients who qualify for bariatric surgery. This risk was highlighted in an editorial case presentation where a morbidly obese patient who had had her bypass surgery 18 months previously presented at 31 weeks gestation with abdominal pain. Both the patient and her infant died as the result of gangrene that involved much of her small intestines that herniated through a tear in an adjacent membrane, a complication involving the intestines during gastric bypass surgery. Therefore, delaying pregnancy for a significant period of time after bypass surgery is recommended [18].

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