The Role of Commercial Health Insurance Characteristics in Bariatric Surgery Utilization

Abstract

Objective:The aim of this study was to understand relationships among insurance plan type, out-of-pocket cost sharing, and the utilization of bariatric surgery among commercially insured patients.Background:Only 1% of eligible persons undergo bariatric operations, and this underutilization is often attributed to lack of insurance coverage. But even among the insured, underinsurance is now recognized as a major barrier to accessing medical care. The relationships among commercial insurance design, out-of-pocket cost sharing, and elective surgery utilization, particularly in bariatrics, are not well understood.Methods:Retrospective review of 73,002 commercially insured members of the IBM MarketScan commercial claims database who underwent bariatric surgery from 2014 to 2017. The exposure variables were insurance plan type and out-of-pocket cost sharing. The outcome was utilization of bariatric surgery. We also examined seasonal trends in bariatric surgery utilization stratified by average levels of cost sharing.Results:Utilization of bariatric surgery was higher in plans with lower cost sharing, such as PPOs (20 operations/100,000 enrollees) than in HDHPs (high-deductible health plans, 12.1 operations/100,000 enrollees). Overall, every $1000 increase in cost sharing was associated with 5 fewer bariatric operations per 100,000 insured lives; this association was strongest in plans with high cost sharing (high-deductible and consumer-directed health plans). Members of all plan types had higher surgical utilization in quarter 4 relative to quarter 1 of each year; these seasonal variations were also most pronounced in plans with high cost sharing.Conclusions:Insurance plan types with higher cost sharing have lower utilization of bariatric surgery. Underinsurance may represent a newly identified barrier to surgical care that should be addressed by advocates and policymakers.

Patient‐provider discussions of bariatric surgery and subsequent weight changes and receipt of bariatric surgery

“…Studies have identified a number of barriers to bariatric surgery. Insurance coverage and pre‐bariatric insurance requirements, such as adherence to a stringent diet for a particular period of time, weight loss, primary care physician letter of necessity, and laboratory testing remain significant impediments (18‐21). However, other common barriers include patient concerns about the risk of death and complications, a misperception that they would not qualify for the procedure, or a complete unawareness of the procedure altogether (5,22‐24).…”

Do Insurance-mandated Precertification Criteria and Insurance Plan Type Determine the Utilization of Bariatric Surgery Among Individuals With Private Insurance?

“…16 A 2019 study by Chhabra et al found that individuals with more generous plans such as preferred provider organization have a higher rate of bariatric surgery utilization (20 per 100,000 insured lives), compared to those in high-deductible health plans (12 per 100,000 insured lives). 23 For most patients, the route to surgery typically involves several steps, including attending an initial information/orientation session with the bariatric surgery program, as well as completing nutritional, psychological, pulmonary, and cardiology evaluations. These evaluations, whether coupled with a preoperative medical weight management requirement or not, can take patients approximately 6 months to complete.…”

“…Preferred provider organization and fee-for-service plans are less restrictive in allowing enrollees to select a doctor or hospital and do not require referral for specialized care by primary care providers. 21,23 Although, beneficiaries with preferred provider organization plans incur lower cost-sharing when using in-network providers. 21,23 The fee-for-service payment mechanism has been described as a contributor to the overuse of health services and the use of high-cost specialized care since it bases the payments on volume and not the value of provided services.…”

“…21,23 Although, beneficiaries with preferred provider organization plans incur lower cost-sharing when using in-network providers. 21,23 The fee-for-service payment mechanism has been described as a contributor to the overuse of health services and the use of high-cost specialized care since it bases the payments on volume and not the value of provided services. 24 In contrast, health maintenance organization plans are generally more restrictive and are more likely to limit enrollees to in-network providers.…”

“…They also require a referral by a primary care provider for specialty care visits. 21,23 The intent of the health maintenance plans to restrict the overutilization of health services could have been too restrictive in the case of bariatric surgery. This could explain the associations seen in this study, especially considering the number of pre-operative specialized services that bariatric surgery patients utilize to meet the precertification criteria.…”