Bariatric surgery costs vs. benefits: Plan coverage considerations

Nearly 38% of adults in the United States are obese with almost 8% being extremely obese, according to the State of Obesity, a collaborative project of the Trust for America's Health and the Robert Wood Johnson Foundation designed to raise awareness of the disease. The growing epidemic has serious physical, psychological, and economic impacts on the U.S. population, including the increased likelihood of other conditions such as type 2 diabetes, heart disease, and osteoarthritis.

Ernest

From a healthcare perspective, bariatric surgery is considered one of the most effective options for short term and sustained weight loss, says Opella Ernest, MD, senior vice president and chief clinical officer, Health Care Service Corporation, which operates Blue Cross and Blue Shield plans in Illinois, Texas, Oklahoma, New Mexico, and Montana. Patients opting for this surgery can experience comorbidity resolution, improved quality of life, and decreased mortality, she says.

Furthermore, a 2016 study in American Family Physician comparing obese patients who opt for bariatric surgery to those who don’t show that the procedure reduces mortality by 30% to 50% seven years to 15 years after surgery.

“While the exact mechanisms for the surgery’s effectiveness aren’t completely understood, it seems to be more than simply limiting oral intake and/or reducing the gut’s absorptive capacity,” says Rich Snyder, MD, chief medical officer, Independence Blue Cross. “Almost immediate improvements in glycemic metabolism can affect the entire body. Significant benefits include reducing or eliminating obstructive sleep apnea, better control of high blood pressure, and reducing risk for degenerative arthritis.”

Cost reductions questionable

Having bariatric surgery to improve weight management and wellness may help health plan members reduce their medical costs. One 2015 study in JAMA Surgery suggests that after three years there are reduced cost benefits to individuals who have had bariatric surgery. This is because sstudies show that inpatient and pharmacy costs initially decrease, however inpatient admission costs are higher which can impact total savings, Ernest says.

It’s notable, however, that certain lifestyle changes, such as consuming protein first at every meal and regular physical activity, can help sustain health improvement, Ernest says. Bariatric surgery patients can also benefit from enrolling in a health management program to help maintain their increased quality of life.

Snyder

But Snyder has different sentiments regarding the total cost of care for recipients of the surgery. “While the health-promoting benefits of bariatric surgery seem clear, the cost of the procedure and perioperative management is significant and currently little evidence exists to show that the benefits lead to a net reduction in overall healthcare costs,” he says. “Further, additional costs might be incurred as a result of bariatric surgery, such as those related to surgical procedures to remove excess skin after significant weight loss.”

Reimbursement questions

Despite this, Snyder says that some of Independence’s health insurance plans provide coverage for bariatric surgery, and it has become an important service line for some of the hospitals and health systems that care for its members.

From an employer standpoint, Snyder notes that the cost-benefit dynamic may differ from employer to employer, especially for companies with employees that tend to retain employment for long periods of time.

“In addition to benefiting from avoided costs due to the comorbidities of obesity, after successful bariatric surgery, individuals are likely to be more productive and experience fewer medical complications that keep them out of work and on disability,” Snyder says. “A similar dynamic may be applicable to individual exchange plans and group health plans in which individuals may change plans every year while groups tend to be more stable. The risk for adverse selection is substantial for a plan that offers coverage for bariatric surgery on an exchange when other plans do not offer it.”

Along these lines, Ernest says benefit plans continue to be an integral strategy in employer retention of talent. “Coverage of bariatric surgery, along with other disease management services, can help attract and retain talented employees who are looking for a culture that embraces their attempts to manage their diseases and become healthier,” she says.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.