Despite the effectiveness of bariatric surgery, both with respect to weight loss and improvements in obesity-related comorbidities, it remains underutilized. 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 as well 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 to non-surgical treatments among individuals with extreme obesity and type II diabetes mellitus. 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 is to synthetize the existing knowledge on why bariatric surgery remains largely underutilized 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 (VBID) to bariatric surgery.
VBID has been previously applied to bariatric surgery coverage with a use of incentive-based cost-sharing adjustments. Its application could be further extended, since the postoperative clinical outcomes and costs vary among the different sub-groups of bariatric surgery eligible patients.
The past decade has witnessed significant progress in the development of new antiobesity medications, with several having greater efficacy than pharmacological agents previously approved by the Food and Drug Administration (FDA). Despite the potential of new medications to combat America's obesity crisis, access to these
Background: Access to bariatric surgery is restricted by insurers in numerous ways, including by precertification criteria such as 3-6 months preoperative supervised medical weight management and documented 2-year weight history.
Objectives:To investigate if there is an association between the aforementioned precertification criteria, insurance plan type, and the likelihood of undergoing bariatric surgery, after controlling for potential sociodemographic confounders.Research Design-The study was conducted using the Pennsylvania Health Care Cost Containment Council's data in 5 counties of Pennsylvania in 2016 and records of preoperative insurance requirements maintained by the Temple University Bariatric Surgery Program.Privately insured bariatric surgery patients and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched by sex, race, age group, and zip code (n = 1,054). Univariate tests and logistic regression analysis were utilized for data analysis.Results-The insurance requirement for 3-6 months preoperative supervised medical weight management was associated with smaller odds of undergoing surgery (odds ratio [OR] = 0.459, 95% confidence interval [CI] 0.253-0.832, P = 0.010), after controlling for insurance plan type and the requirement for documented weight history.Preferred provider organization (OR = 1.422, 95% CI 1.063-1.902, P = 0.018) and fee-for-service (OR = 1.447, 95% CI 1.021-2.050, P = 0.038) plans were associated with greater odds of undergoing surgery, compared with health maintenance organization plans, after controlling for the studied precertification requirements. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P = 0.132).
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