February 26, 2024

An Employer's Practical Playbook for Treating Obesity

For employers seeking to align their weight management strategy with the latest evidence, this resource offers recommendations on creating a comprehensive benefits package to treat obesity, including behavior-based interventions and pharmacological and surgical treatment.

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What Is Bariatric Surgery?

Bariatric surgery refers to surgical procedures on the stomach or intestines to induce weight loss. The procedures are indicated in cases where other methods for losing weight have been unsuccessful.

Procedures include:

• Sleeve gastrectomy;
• Roux-en-Y Gastric Bypass (RYGB);
• Biliopancreatic diversion with duodenal switch;
• Gastric balloons; and
• Adjustable gastric bands.¹

Bariatric surgery procedures enable the body to start losing weight, but diet and behavior modification are important to long-term success.

Who Is a Candidate for Bariatric Surgery?

In October 2022, the American Society for Metabolic and Bariatric Surgery and International Federation for the Surgery of Obesity and Metabolic Disorders released a joint statement on the indications for bariatric surgery.² This was the first update to guidelines since 1991 when the National Institutes of Health issued a consensus statement that has since been used by clinicians and payers as criteria for bariatric surgery eligibility. Based on studies demonstrating the long-term safety and efficacy of bariatric surgery, the new guidelines:^2,3

• Recommend surgery for people with BMI ≥35, regardless of whether they have co-morbidities; and
• Suggest surgery be considered for people with metabolic disease and BMI of 30-34.9.

Furthermore, the guidelines recommend that BMI thresholds be adjusted in the Asian population so that those with BMI ≥27.5 are offered bariatric surgery.²

For 31 years leading up to this update, the guidelines for bariatric surgery were:^4,5

• BMI ≥ 40 or more than 100 pounds overweight; and
• BMI ≥ 35 and at least one or more obesity-related comorbidities such as type 2 diabetes, hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.

Employers should review the updated guidelines with their health plans and vendor partners and determine any impact they may have on program eligibility criteria, steerage to Centers of Excellence, and patient communications.

What Is the Efficacy of Bariatric Surgery?

Bariatric surgery leads to sustained weight loss, as well as numerous positive health outcomes, including lower mortality risk.⁷

Weight Loss

While weight loss varies by procedure, evidence indicates similar results for sleeve gastrectomy – the most commonly performed bariatric procedure in North America in 2022 – and RYGB, although there are slight differences when the procedures are compared in randomized clinical trials vs. observational studies (observational studies show greater weight loss among patients who receive RYGB than sleeve gastrectomy).^6,8 According to a systematic review and meta-analysis, the average percent excess weight loss at or beyond 10 years follow-up for patients who underwent bariatric surgery was 57% for sleeve gastrectomy, 60% for RYGB and 49% for gastric band.⁹

Importantly, experts note that bariatric surgery patients will regain some weight over time although estimates vary widely.⁶ Studies indicate that “the proportion of people who regain weight to the point that they are within 5% or less of their preoperative weight” is the least common with RYGB, followed by those who received sleeve gastrectomy, and more common with the gastric band.⁶

Health Outcomes

Bariatric surgery is associated with a host of positive health outcomes, and according to a clinical review, “multiple observational studies have suggested that patients who undergo bariatric surgery are associated with a lower long-term risk of all-cause mortality compared with matched non-surgical patients.”⁶ Specific health outcomes associated with bariatric surgery include but aren’t limited to the following:

• Diabetes control and remission: Numerous studies have shown that people with diabetes who underwent bariatric surgery experienced improvement in glucose control and long term-remission of type 2 diabetes years after follow-up and that these outcomes were better for those who underwent surgery compared to medical therapy.^6,10 Patients who underwent bariatric surgery were also less likely to experience microvascular and macrovascular complications associated with type 2 diabetes (e.g., retinopathy, coronary artery disease, peripheral arterial disease and stroke) compared to those who did not but received usual care.¹⁰
• Reduced risk of heart failure: A study published in 2017 found that patients who had undergone bariatric surgery had a significantly decreased risk of heart failure in comparison to patients with obesity who had not underwent surgery.¹¹
• Dyslipidemia improvement and hypertension remission: Short- and long-term studies show improvements in dyslipidemia among patients who undergo bariatric surgery. Studies also show that bariatric surgery is associated with hypertension remission (rates range from 43% to 83% at 1 year). Furthermore, patients who undergo bariatric surgery have higher rates of remission and lower rates of use of antihypertensive medication compared to those who participate in intensive lifestyle interventions.^12-15
• Reduced cancer risk and mortality: A retrospective study published in 2022 found that there was a significantly lower incidence of obesity-associated cancer and mortality among adults with obesity who underwent bariatric surgery compared to those who didn’t.¹⁶
• Sleep apnea, osteoarthritis and urinary incontinence improvement: Studies indicate that bariatric surgery can improves daytime sleepiness, severity of obstructive sleep apnea and knee pain and functional status, along with urinary continence.^17-21
• Quality of life improvement: A systematic review and meta-analysis of the literature found that bariatric surgery has a positive impact on quality of life, though this is associated mostly with an improvement in a patient’s physical quality of life more so than mental quality of life.²²

What Is the Safety Profile of Bariatric Surgery?

The safety of bariatric surgery is assessed through short- and longer-term complications, which can vary based on the procedure. Complications within the first 30 days may include wound infection, gastrointestinal or intra-abdominal bleeding, venous thromboembolism and hemorrhage.⁶ The 30-day risk of serious adverse events, reoperation and readmission are lower for sleeve gastrectomy than RYGB, but one literature review points out that the rate of serious events is generally lower than 6% across studies/procedures.⁶

Despite possible complications, the mortality rate from bariatric surgeries is relatively low. A meta-analysis published in 2021 found that among the 3.6 million patients who underwent bariatric surgery, 4,707 deaths occurred. The mortality rates for each kind of procedure were: 0.03% (gastric band), 0.05% (sleeve gastrectomy), 0.09% (one-anastomosis gastric bypass), 0.09% (RYGB), and 0.41% (duodenal switch).²³

Longer-term complications may include but aren’t limited to esophagitis and less severe issues related to dumping syndrome, vomiting and diarrhea. Studies also indicate higher rates of behavioral health issues, including substance use disorders, depression, anxiety and self-harm, among those who undergo bariatric surgery compared to those who participate in intensive-lifestyle interventions.^24,25 As a result of these findings, it is indicated that patients receive pre- and post-operative mental health evaluation and support. ^24,25

According to a review of the evidence, long-term term rates of reoperation range from 5% to 22.1%, with lower rates for sleeve gastrectomy than for RYGB.⁶

Should Bariatric Surgery Be Performed at Centers of Excellence?

Research indicates that patients undergoing bariatric surgery have better outcomes and a better experience at surgical centers accredited as Centers of Excellence (COE). A systematic review of studies found a reduction in risk-adjusted outcomes (10 of 13 studies) and a reduction in mortality (six of eight studies) among those who received bariatric surgery at a COE compared to those who did not.²⁷

How Many Employers Provide Coverage for Bariatric Surgery COEs and How Do They Encourage Their Utilization?

In 2023, 69% of employers offer COEs for bariatric surgery; 72% plan to offer them in 2024 and 81% in 2025/2026.²⁸ Fifty-nine percent of employers will use their health plan(s) to contract with bariatric surgery COEs in 2024, while 13% will use a specialty COE network and 6% will have direct contracts.²⁸

In 2024, employers will encourage the use of bariatric surgery COEs in the following ways:

• 42% of employers will require the use of a bariatric COE to obtain coverage;
• 41% will provide travel and accommodation coverage/reimbursement;
• 25% will offer reduced or no cost share if surgery is conducted through a COE;
• 8% will require or incentivize use of a second-opinion service; and
• 22% won’t offer an incentive to encourage use.²⁸

What Should Employers Consider When Covering Bariatric Surgery?

• What are the eligibility criteria for patients to qualify for bariatric surgery? Work with health plans and/or other vendor partners to review existing criteria (if applicable) and determine if revisions are warranted based on the guidelines published in 2022. Only patients who meet recommended criteria, whose physicians have indicated that weight loss surgery is medically necessary, and who are likely to benefit from the procedure should be approved for surgery. Although some employers may institute presurgery weight loss requirements (e.g., a structured diet program for a minimum of 6 months) before a patient is eligible for surgery, evidence indicates that preoperative weight loss does not have a clear impact on postsurgical outcomes or weight loss. While individual surgeons may recommend preoperative weight loss based on the specific needs and circumstances of a patient, mandating this may unnecessarily delay or divert patients from surgery.^29,30
• How might anti-obesity medications, including GLP-1s, impact bariatric surgery criteria? Speak with vendor partners, including bariatric surgery CEOs, about if and how anti-obesity medications should be incorporated into pre-authorization guidelines for bariatric surgery.
• What procedures will be covered? Work with existing or prospective partners to verify that only bariatric procedures with evidence of effectiveness and low complication rates are covered as a part of the surgery benefit. Also, determine coverage for revisional procedures, which may be needed in the case of surgical complications or inadequate weight loss even when patients adhere to the treatment regimen.³¹

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