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Bariatric Surgery and the Obesity Battle

May 06, 2014

Hospital and ambulatory settings are finding that weight loss surgery can reduce the risk of cancer, cardiac disease, and diabetes in morbidly obese patients.

This article appears in the April 2014 issue of HealthLeaders magazine.

Mounting concern over obesity in America has put the spotlight on bariatric surgery. Interest in this approach to weight-loss spiked between 2000 and 2004. The number of inpatient surgeries then began to decline from a high of 130,158 in 2004, according to the Agency for Health Quality Research.

Still, many hospitals and health systems find it important to offer the service for patients who cannot lose weight through diet and lifestyle changes.

Bariatric programs can be high volume or low volume, with annual surgeries ranging from a handful to more than 800. Community hospitals offer the service, as do academic medical centers. Some service lines try nonsurgical approaches first, putting patients on medical weight management programs. Others begin educating patients about surgery from the start.

Many bariatric programs share one key element—they are built around multidisciplinary teams that include surgeons, nurses, nutritionists, endocrinologists, psychologists, and other specialists. These teams are at the core of the thorough presurgery prep and follow-up treatment considered vital to the success of bariatric surgery.

Some hospitals see the potential for growth. Weight-loss surgery is becoming more accepted, and indications for the procedure are shifting. And there is a large unmet need for care, according to the American Society for Metabolic and Bariatric Surgery. The group says that though 15 million people are classified as morbidly obese, only 1% of the clinically eligible population is treated through bariatric surgery.

For now, programs are dealing with declining demand, changes in certification rules, and complex, spotty insurance coverage. But last year, the American Medical Association declared obesity a disease. And data is accumulating on the health benefits of bariatric surgery as a treatment for diabetes and heart disease. So bariatric surgery programs are likely to continue to mature and evolve.

Bariatric surgery reduces a patient's risk of cancer, cardiac disease, and diabetes, says Daniel B. Jones, MD, chief of minimally invasive and bariatric surgery at Beth Israel Deaconess Medical Center in Boston.

"We get real results for most people," says Jones. "We're getting them off insulin when they are diabetic, getting them off breathing machines when they have sleep apnea. We get them walking or skiing. The list goes on and on. We can make an impact by getting 100 pounds off somebody."

Still, like other centers, BIDMC saw a drop in volume after 2008, when the hospital performed 288 procedures. By 2010, the number was down to 267 and the hospital made some changes. The program made it easier to schedule appointments and improved both its application process and education programs. The 649-bed teaching hospital started its program 15 years ago.

Across the river in Cambridge, Mass., Mount Auburn Hospital's program is only three years old. Mount Auburn contracts for two surgeons from the Tufts University Medical School–affiliated New England Medical Center. They offer the surgery as part of a two-track weight-management program. The procedures take place at the 220-bed hospital. Patients can get follow-up care either in Cambridge or at a satellite center in suburban Waltham, Mass.

Chuck Lukasik, the COO of Mount Auburn Professional Services, which employs the physicians at Mount Auburn Hospital, says it is a very competitive field. The hospital didn't launch the program as a profit center, but is mindful of the program's revenues.

"It rounds out what we do," he says. "We wanted to be a full-service provider, knowing that almost any time we fill a bed, it's profitable."

The plan, Lukasik says, was to start slowly and gradually build up the service. The program is still in a "growth mode." Surgeons working for Mount Auburn performed about 100 operations in 2013; they hope to get up to 200. "We're looking to the future to make sure we grow it enough to make it viable," he says.

The success of a bariatric surgery program can be measured by either quantity or quality, says Wanda Holderman, RN, CEO of the Fresno (Calif.) Heart and Surgical Hospital, a 57-licensed-bed facility that performed 3,201 cardiovascular and bariatric surgical procedures in FY 2012.

"I feel that investing in quality will result in continued growth and market share," she says. The hospital staff meets with program doctors monthly to review business strategies, costs, and outcomes. The surgeons "recognize the importance of quality outcomes as well as cost containment and efficiency," Holderman says. Currently, the hospital bariatric program has a 9.4% margin; also, its 3.5% readmission rate is below the ASMBS 2005 benchmark of 5%. 

Bariatric surgery has been around for decades, and despite changes in volume, technology, and reimbursement, many now consider the approach a mainstream treatment for morbid obesity. That wasn't so when the National Institutes of Health published a consensus statement on "Gastrointestinal Surgery for Severe Obesity" in 1991.

In 1998, there were 12,777 surgeries nationwide, according to the latest data from ASMBS. That number climbed annually, reaching 135,985 in 2004. (The group's most recent inpatient numbers are higher than AHRQ estimates, but show similar trends.) Awareness grew as celebrities slimmed down after surgery, including weather forecaster Al Roker, comedian Roseanne Barr, and, more recently, New Jersey Governor Chris Christie. To date, approximately 700 hospitals have reached the minimum volume of 125 cases to gain accreditation, according to ASMBS.

The inpatient number began to decline in 2005, but began climbing again in 2008, reaching 124,838 annual surgeries for that year. For 2010—with the addition of the organization's anecdotal estimate of outpatient procedures—ASMBS estimates that there were approximately 160,000 such operations.

"There were numerous events during the 2008 time frame impacting decisions of consumers," Holderman says. She sees several factors—including the recession—that worked to keep consumers from seeking weight-loss surgery. Limits on insurance coverage and the impression that bariatric surgery is "discretionary" played into the drop in volume, Holderman says.

At the same time, insurance coverage and quality measures are evolving. Despite opposition from providers and their professional associations, the Centers for Medicare & Medicaid Services dropped a requirement that patients be treated only at accredited hospitals—which must treat at least 125 patients each year. That volume requirement may change as the American College of Surgeons and ASMBS work to merge their accreditation programs, a process that is ongoing.

Still, the market remains underserved and new indications for the surgery may bring changes. The ECRI Institute, a nonprofit based in Plymouth Meeting, Pa., put bariatric surgery for type 2 diabetes on its "Annual Top 10 C-Suite Watch List." Although the mechanism is unclear, doctors are seeing type 2 diabetes resolve after surgery, but before significant weight loss.

"Clinicians are asking whether an early surgical intervention in patients with moderate obesity and type 2 diabetes may prove to be more cost-effective in the long run compared with the normal care practice of pharmaceutical management and lifestyle changes," according to the ECRI report.

Despite challenges, many providers are committed to offering bariatric surgery.

Success key No. 1: Multidisciplinary team

The term multidisciplinary is practically an understatement in the context of bariatric surgery. The range of specialties involved in the BIDMC program is typical: cardiology, pulmonology, anesthesiology, hepatology, hematology, pharmacology, and plastic surgery. In addition, program staff includes nurses, socials workers, psychologists, and nutritionists. And an important component of that team: two dedicated surgeons, Jones says.

"Two working together is much better than one. You have that extra set of hands and extra set of eyeballs looking at things," he says.

For patients, dealing with so many different providers can mean multiple trips to the hospital and complicated scheduling. When the Mayo Clinic in Arizona examined the time needed to complete the program before surgery, it pulled together a team to look at ways to improve the viability of the program by making it more efficient.

What they found was that even the initial evaluations could take months because of scheduling conflicts among multiple providers.

"We said, 'Let's harness the fact that we are an integrated center and have people come for one day and see all of their providers in their initial visits,' " says Operations Administrator Kripa Krishnan. "We like to call it kick-starting their entry into the program. It knocked out a lot of visits."

As a result, the average time from evaluation to surgery dropped from six months to four months, according to a report Krishnan and her team presented during the American College of Health Care Executives' 2013 meeting.

Success key No. 2: Pre- and postoperative care

Highland Hospital in Rochester, N.Y., has a high-volume program, logging between 600 and 700 bariatric surgeries per year. Andrea Zimmerli, the bariatric program coordinator at the 261-bed hospital, which posted a 5.1% operating margin in FY 2013, says pre- and postoperative counseling and support are essential to the success of their program. Many patients come unprepared for the dietary and lifestyle changes they will need to make, she said.

"They just want the surgery," says Zimmerli. "They don't want to go through three months of this and three months of that."

But if, for example, they won't follow the meal plan before surgery, they won't follow it after, she says. Preparation includes an intensive education program and a psychological evaluation to help prepare patients for the stress and changes that come with surgery.

"It increases the postoperation success rate because we work with them so much preoperatively," Zimmerli says, noting that 80% of their patients keep their weight off.  

Postoperative care is important, too, Zimmerli says. The patients come back for return visits several times within the first six months and then annually. About 50 to 60 patients attend monthly support-group sessions. The bariatric center also has a Facebook page that patients can access for questions, comments, and to keep in touch with the center.

At Mount Auburn in Massachusetts, its weight management center offers two tracks: medical and surgical weight loss. Some patients start in one track and end up in the other, Lukasik says.

In Fresno, it takes six to nine months of prep before a patient is ready for surgery, Holderman says. Still, at 878 procedures, Fresno hospital did more than any hospital in the state in 2009, according to a report from the California Office of Statewide Health Planning and Development.

New patients go through a psychological and physical evaluation, as well as cardiac stress testing, endoscopy, and sleep studies, as needed. A team of doctors meets twice weekly to discuss each case and find the right "treatment algorithm" for each patient, Holderman says. Some may need more counseling; in other cases, the care team may recommend a different procedure than the patient had in mind.

Postsurgical counseling is just as important. In some cases, physicians in Fresno see patients who had surgery elsewhere.

"It doesn't matter where their initial procedure was performed. All bariatric patients require lifelong care," Holderman says.

Part of that care needs to be nutrition counseling, says BIDMC's Jones. Patients who fail to take proper vitamin supplements can suffer from bone loss and cognitive problems.

"Especially with the gastric bypass, there are problems that occur because of malabsorption that are often preventable with multivitamins and supplements, and regular follow-up with a nutritionist," he says.

Success key No. 3: Accreditation and insurance coverage

For bariatric programs, accreditation and insurance are closely linked. Insurance coverage varies from patient to patient and payer to payer. In some cases insurers will cover care only at an accredited hospital. But those rules also vary—and are changing, at least for Medicare and Medicaid patients.

So bariatrics programs need to be adept at dealing with all payers, including CMS, where changes may benefit some hospitals at the expense of others. Until last year, CMS would cover care only at accredited hospitals. Some argue that accreditation criteria—such as volume requirements—ensure quality programs. Others say volume is not a good measure of quality. And those at smaller programs may argue that the accreditation process presents them with a catch-22. Some private insurers will only pay for care at accredited centers, also known as Centers of Excellence. With limits on insurance coverage, hospitals such as Mount Auburn and Mayo in Arizona say it is talking them longer to get volume up to the 125 annual cases needed to become a Center of Excellence.

At Mayo, Krishnan and her team realized that insurance issues were delaying surgery for qualified patients. In response, they added a bariatrics financial coordinator to the staff to help patients deal with insurers, a move in combination with other program enhancements that is credited with helping the hospital see volume go up from 55 cases in 2009 to 83 cases in 2012.

Success key No. 4: Buy-in

Lukasik of Mount Auburn says that part of the program's success has been support from physicians and administrators.

"We have a CEO who is pretty driven around new services and is not willing to go with the excuse that, 'We're not big hospitals; we shouldn't do that,' " he says. Physicians also need to buy in to the program, as they have in Michigan. Working under the auspices of Blue Cross and Blue Shield, the Michigan Bariatric Surgery Collaborative collects data from the 39 hospitals in the state offering bariatric surgery. Four times a year, about 27 surgeons meet to review reports based on the data. The data is deidentified, but the hospitals can compare their outcomes to those at other hospitals.

In one case, the collaborative was able to identify a small number of hospitals that were using inferior vena cava filters to prevent blot clots. However, the data showed that patients at those hospitals actually had a higher rate of blot clots to the lung. In response, use of the device dropped by 30% within three months, says Tom Leyden, director of the Value Partnerships Program at Blue Cross and Blue Shield of Michigan.

"The power of the consortium is evidenced by this significant drop in little over three months," he adds. "Literature supports that quality improvements take two to 15 years to produce similar results." Between 2007 and 2010, use of the preoperative IVC filter placement dropped from 5.2% of cases to 0.7%.

"Subsequently everyone stopped putting them in," he says. "It decreased the cost of care because they didn't do another procedure. And it improved the quality of care."

Since the program began, the consortium has collected data on 38,000 cases. An analysis of data from 2007 to 2010 found readmissions and emergency department visits both declined by 35% and overall complication rates decreased by 24%.

All of this adds up to lower health costs and better care for patients. For many of the hospitals, that's the definition of success.

"The primary goal is clinical excellence," says Zimmerli of Highland Hospital. "The business results will come from that."

Tinker Ready is a contributing writer for HealthLeaders Media.

Reprint HLR0414-7

This article appears in the April 2014 issue of HealthLeaders magazine.


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