Obesity is a Disease – it Should be Treated Like OneDecember 8, 2021
If you have high blood pressure and it does not improve with diet and exercise, you are started on medication. This course of action is what the medical community refers to as “the standard of care”.
Treating high blood pressure is important, because of the risk of heart disease, stroke, and death if left untreated. We have this concept of standard of care, to ensure that people get treated the same.
This concept is important for many reasons, but the most important reason is it’s the right thing to do.
Obesity Is A Disease
When it comes to obesity, the standard of care is not always met. This is because obesity is not treated as a chronic disease. We, as a community, do not treat obesity like we do high blood pressure or diabetes. Some would argue, we do not treat obesity very much at all.
Approximately 90 million U.S. adults (42%) now live with obesity (1). In 2017, 228,000 patients received bariatric surgery in the USA which represents only 1% of the clinically eligible population (2). This is a problem as struggling with obesity puts a person at risk for several other diseases: cardiovascular disease, diabetes, cancer, and a diminished quality of life.
More recently, we are starting to understand how patients with COVID-19 fair worse, if they also have obesity. Only in the past decade has obesity been formally recognized as a disease rather than a perceived lifestyle choice (1).
Combating the origin story of obesity has been difficult and slow. We, as a scientific community, are starting to understand the interplay between environment, genetics, and epigenetics, all of which have a role in the development of obesity. The notion that obesity is a personal choice, plays a part in disease management.
Let’s say a patient goes to see their primary care provider (PCP) for a new diagnosis of diabetes and they also happen to suffer from obesity. The PCP starts a diet and exercise plan to treat diabetes, which inherently targets excess weight. If the patient does not reach the mutually agreed upon goal, they are referred to a bariatric surgeon. This is my vision of what the standard of care should be.
There are countless times my own patients have shared that they have put off surgical discussions for years or had to convince their PCP that bariatric surgery was the next step. The reasons for this are multifactorial. What is concerning, is that even if a patient receives a referral, they may not actually receive treatment.
Insurance May Not Cover Treatments
As obesity is not perceived as a disease, the treatments for it are not recognized as indispensable either. Unfortunately, exercise programs and anti-obesity medication are expensive. Reimbursement of behavioral and pharmacologic therapies for weight management is generally limited (1). Additionally, if a patient chooses to pursue surgery, their insurance policy may not cover it.
In a study of insurance policy coverage of private insurance, 95% of plans had defined medical policies for coverage of bariatric surgery (2). 4.6% did not provide any coverage (2). Of these plans, several policies had criteria for eligibility. Plans may state mandatory periods of documented obesity and/or have specific criteria on which comorbidities are obesity-related and therefore qualify the patient for surgery. Some of these requirements are not based on evidence.
87% of policies in the same research study required the completion of a supervised medical weight management program lasting at least six months. The ASMBS (American Society for Metabolic and Bariatric Surgery) examined the evidence for a supervised weight management program and recommended abandoning this practice as there is no evidence to support it (2).
Participating in a program prior to surgery does not change the outcome and it often serves as a barrier to surgery and imposes an unnecessary delay in treatment of the disease.
If a patient meets the minimum criteria for bariatric surgery, their procedure choice may be limited. For example, some may not be a candidate for sleeve gastrectomy unless their BMI is greater than 60 (3).
The decision-making on procedure type should be had by the patient and the physician, not the insurance company.
Type Of Payor And Type Of Plan Matters
Type of payor and the type of plan matter. Insurance companies are the primary funding entity, covering costs for 63-74% of bariatric procedures performed each year (3). High deductible plans are popular as co-payments tend to be less. These plans shift costs onto the patient.
They discourage patients and providers from utilizing services to minimize cost. They encourage patients to delay “non-essential” health expenses until their deductibles have been met (4). This represents a delay in the most effective treatment of obesity.
There is also a substantial difference between state insurance and private insurance for bariatrics. Since the implementation of the Affordable Care Act, mandates for reimbursement of bariatric surgery under any insurance premium have been created by states to provide wider access to those procedures and regular insurance practices.
However, most states do not consider bariatric surgery an essential health benefit and therefore have limited to no coverage options (3). Previous studies have shown that publicly insured patients are less likely to undergo bariatric surgery (3). It is, therefore, no wonder that most patients who undergo bariatric surgery have private insurance and higher median incomes (3) as they are the ones who can afford to meet these deductibles.
Bariatric surgery should be covered because it improves overall burden of disease.
The landmark STAMPEDE trial followed diabetics for three years after bariatric surgery compared to patients who underwent medical treatment alone. The results were significantly in favor of surgery. Five separate clinical trials showed that standard bariatric procedures, as compared with medical treatment alone, were associated with few major complications and resulted in superior glycemic control, weight reduction, and reduction in cardiovascular risk factors (5).
Bariatric surgery is an effective treatment for obesity and the treatment effect lasts. Patients who underwent Roux-en-y Gastric Bypass (RYGB) were followed for 12 years in one study. Patients who underwent surgery had fewer obesity-related coexisting conditions than patients who did not undergo RYGB twelve years later (6). Additionally, of patients who had diabetes before surgery, the majority remained in remission at twelve years (6). Remission of type 2 diabetes was much more likely if the RYGB occurred before the onset of treatment with insulin. (6) This speaks to the importance of referring patients to surgeons earlier. A delay in treatment reduces the chance to cure disease.
Bariatric surgery should be covered because it will save health care dollars.
U.S. expenditures on health care in 2006 were an estimated 2.1 trillion, accounting for 16% of our gross domestic product (7). An estimated 168$ billion (16.5% of Us health expenditures) is spent annually to treat obesity and obesity-associated comorbid conditions (8). Bariatric surgery itself is expensive, $28,000 on average (8) and there have been arguments about cost savings in studies of comorbidity resolution after surgery.
During a study of six-year follow-up after surgery, the authors were unable to identify any short- or long-term reductions in overall health care costs. They noted fewer prescription and office-based visit costs, but these savings were offset by inpatient services (8). Other studies have suggested there may be a return on investment in 3 to 7 years (9).
We have documented cost savings and improvement in health outcomes in certain patient populations, notably diabetics (2). As obesity is intimately associated with many co-morbidities, it will be difficult to ascertain true cost savings. Arguably, there are indirect savings that may be difficult to measure but remain valuable.
We can expect as patients are become healthier; some will return to work. As they are healthier, they will live longer, and will not utilize the healthcare system in the way they did before surgery.
Recent studies have shown that the risk of death over time was approximately 35% lower among extremely obese patients who underwent bariatric surgery than among those who did not. (NEJM Longitudinal assessment of bariatric surgery consortium.)
It is difficult to measure cost savings over a patient’s lifetime, but as bariatric surgery has been shown to reduce overall mortality and improve obesity-related comorbidities, it is reasonable to infer there would be cost savings even if we have not demonstrated it in shorter follow up studies.
Bariatric surgery should be covered because it is the right thing to do.
Bariatric surgery is an effective treatment for a disease that wreaks havoc on the individual as well as our community. Patients deserve access to effective and evidence-based care. This treatment has long-term effects that the individual and community will benefit from. As we have evolved in our understanding of obesity, it is time we also evolve in our treatment of it.
- Thomas A. Wadden and Adam G. Tsai. Addressing Disparities in the Management of Obesity in Primary Care Settings. The New England Journal of Medicine 282;10 (2020) 977-978
- Selim G. Gebran, Brooks Kighton, Ledibabari M. Ngaage et al. Insurance Coverage Criteria for Bariatric Surgery: A survey of Policies. Obesity Surgery (2020) 30: 707-713
- Hamlet Gasoyan, Michael T. Halpern, Gabriel Tajeu et al. Impact of Insurance plan design on bariatric surgery utilization. Surgery for Obesity and Related Diseases 15 (2019) 1812-1821
- Chhabra, Karan R., Dimick, Justin B., Fendrick, A. Mark. Value-based insurance coverage for bariatric surgery: time for surgeons to lead the change. Surgery for Obesity and Related Diseases 15 (2019) 152-154
- Philip R. Schauer, Deepak K. Bhatt, John P. Kirwan et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes- 3 year outcomes. The New England Journal of Medicine 372; 21. May 2014. 2002-2013
- Ted D. Adams, Lance E. Davidson, Sheldon E. Litwin et al. Weight and Metabolic Outcomes 12 years after Gastric Bypass. The New England Journal of Medicine 377; 12. September 2007. 1143-1155
- Steven A. Schroeder. We Can Do Better- Improving the Health of the American People. The New England Journal of Medicine 357; 12. September 2007. 1221-1228
- Jonathan P. Weiner, Suzanne M. Goodwin, Hsien-Yen Chang et al. Impact of Bariatric Surgery on Health Care Costs of Obese Persons. JAMA Surgery. Vol 148 (No. 6), June 2013. 555-562
- Cremiew PY, Buchwald H Shikora SA, et al. A study on the economic impact of bariatric surgery. Am J Manag Care. 2008; 14(9):589-596
- The Longitudinal Assessment of Bariatric Surgery Consortium (LABS). Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery. The New England Journal of Surgery 2361;15. July 2009. 445-454
- Natalie Liu and Luke Funk. Bariatric Surgery and Diabetes Treatment- Finding the Sweet Spot. JAMA Surgery. May 2020; Vol 155 (No. 5) 1
- David e. Arterburn, Dana A. Telem, Robert Kushner, Anita P. Courcoulas. Benefits and Risks of Bariatric Surgery in Adults: A review. JAMA Surgery. September 2020. Vol 324 (No. 9) 879-887
ABOUT THE AUTHORMacKenzie Landin, MD, FASMBS is a board-certified general surgeon specializing in advanced/minimally invasive general and bariatric surgery at Banner University Medical Center in Phoenix, Arizona. She practices at the Banner University Medicine Obesity and Bariatric Surgery Center She is an assistant professor at Banner University Medical Center-Phoenix/University of Arizona-Phoenix.