December 07, 2022
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: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 is 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
- 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:3,4
- BMI ≥ 40 or more than 100 pounds overweight; and
- BMI ≥ 35 and at least one or more obesityrelated 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 new 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. While these new criteria may be adopted by employers and their partners to determine bariatric surgery eligibility, it’s too early to determine how quickly or widespread they will be used.
Why Should Employers Cover Bariatric Surgery?
According to a review of the clinical evidence on the risks and benefits of bariatric surgery in adults published in 2020, “there is now strong evidence from [randomized control trials] and observational studies that bariatric surgery results in greater long-term weight loss than the best available nonsurgical interventions for obesity, regardless of the bariatric procedure used.”5 In addition to weight loss, bariatric procedures improve obesity-related comorbidities, as well as quality of life.
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.
While weight loss varies by procedure, evidence indicates similar results for sleeve gastrectomy – the most commonly performed bariatric procedure in the U.S. in 2020 – 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).5 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.6
Importantly, experts note that bariatric surgery patients will regain some weight over time although estimates vary widely.5 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.5
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.”5 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.5,7 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.7
- 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.8-11
- 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.12
- 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.13-17
- Quality of life improvement: A systematic review and meta-analysis of the literature found that bariatric surgery has a positive impact on quality life, but more so on physical quality of life than psychological quality of life.18
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.5 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.5
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% (oneanastomosis gastric bypass), 0.09% (RYGB), and 0.41% (duodenal switch).19
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.20,21 As a result of these findings, it is indicated that patients receive pre- and postoperative mental health evaluation and support.20,21
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.5
How Often Is Bariatric Surgery Performed?
In 2020 (the latest data available), an estimated 198,651 bariatric surgery procedures were performed in the U.S., a decrease from 2019 and 2018, possibly due to the COVID-19 pandemic.22 The two most common procedures performed in 2020 were sleeve gastrectomy (122,056 procedures) and Roux-en-Y gastric bypass (41,280).13 The same year, just over 22,000 revisions were performed (corrective surgeries due to complications or “incomplete treatment effect,” conversions from one type of bariatric surgery to a different type or a reversal restored to original anatomy), although data did not indicate surgery-specific revision rates.22,23
These data indicate that bariatric surgery is underutilized, with about 1% of the eligible population undergoing bariatric procedures.24 Reasons identified for this underutilization include patient and physician views and attitudes about bariatric surgery, as well as lack of knowledge or concerns about safety and efficacy; lack of discussion among providers and patients about bariatric surgery as a treatment option; and lack of knowledge among providers about bariatric surgery benefits coverage.24
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 or 13 studies) and a reduction in mortality (6 of 8 studies) among those who received bariatric surgery at a COE compared to those who did not.25
How Many Employers Provide Coverage for Bariatric Surgery COEs and How Do They Encourage Their Utilization?
In 2022, 72% of employers offer COEs for bariatric surgery; 69% plan to offer them in 2023 and 77% in 2024/2025.90 Fifty-four percent of employers will use their health plan(s) to contract with bariatric surgery COEs in 2023, while 13% will use a specialty COE network and 6% will have direct contracts.
In 2023, employers will encourage the use of bariatric surgery COEs in the following ways:26
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 new guidelines. 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
- 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.
- Will coverage be restricted to COEs? Limit coverage to facilities designated as COEs and have experienced, high-volume surgeons who demonstrate a minimal number of postoperative hospitalizations and mortality rates. Request definitive proof of performance to confirm superior outcomes.
- What kind of pre- and postsurgical support will be offered? Identify programs or services that can improve patient success, such as bariatric surgery navigators or coaches whose role is to support the employee through the entire surgical journey. As recommended above, provide psychological/mental support for employees pre- and post-surgery, along with financial and nutritional resources.
* Bariatric Surgery COEs are certified by the American College of Surgeons and the American Society for Bariatric and Metabolic Surgery. Many major health plans also designate COEs for bariatric surgery. Example criteria for COE accreditation can be found on the American College of Surgeons website.
- 1 | American Society for Metabolic and Bariatric Surgery. Bariatric surgery procedures. https://asmbs.org/patients/bariatric-surgery-procedures. Accessed September 21, 2022.
- 2 | Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surg Obes Relat Dis. 2022.
- 3 | American Society for Metabolic and Bariatric Surgery. Who is a candidate for bariatric surgery? https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery. Accessed September 23, 2022.
- 4 | Concensus Development Conference Panel. NIH conference: gastrointestinal surgery for severe obesity. Ann Intern Med. 1991;115(12):956-961.
- 5 | Arterburn DE, Telem DA, Kushner RF, Courcoulas AP. Benefits and risks of bariatric surgery in adults: A review. JAMA. 2020;324(9)
- 6 | O'Brien PE, Hindle A, Brennan L, et al. Long-term outcomes after bariatric surgery: a systematic review and meta-analysis of weight loss at 10 or more years for all bariatric procedures and a single-centre review of 20-year outcomes after adjustable gastric banding. Obes Surg. 2019;29(1):3-14.
- 7 | Chen Y, Corsino L, Shantavasinkul PC, et al. Gastric bypass surgery leads to long-term remission or improvement of type 2 diabetes and significant decrease of microvascular and macrovascular complications. Ann Surg. 2016;263(6):1138-42.
- 8 | Pareek M, Bhatt DL, Schiavon CA, Schauer PR. Metabolic surgery for hypertension in patients with obesity. Circ Res. 2019;124(7):1009-1024.
- 9 | Climent E, Goday A, Pedro-Botet J, et al. Laparoscopic roux-en-y gastric bypass versus laparoscopic sleeve gastrectomy for 5-year hypertension remission in obese patients: a systematic review and meta-analysis. J Hypertens. 2020;38(2):185-195.
- 10 | Schauer PR, Bhatt DL, Kirwan JP, al; e. STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes— 5-year outcomes. NEJM. 2017;376(7):641-651.
- 11 | Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic surgery versus conventional edical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label,single-centre, randomised controlled trial. Lancet. 2015;386(9997):964- 973.
- 12 | Aminian A, Wilson R, Al-Kurd A, et al. Association of bariatric surgery with cancer risk and mortality in adults with obesity. JAMA. 2022;327(24):2423-2433.
- 13 | Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnea: a review. JAMA. 2020;323(14):1389- 1400.
- 14 | Wong AM, Barnes HN, Joosten SA, et al. The effect of surgical weight loss on obstructive sleep apnoea: a systematic review and meta-analysis. Sleep Med Rev. 2018;42:85-99.
- 15 | Greenburg DL, Lettieri CJ, Eliasson AH. Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis. Am J Med. 2009;122(6):535-542.
- 16 | Groen VA, van de Graaf VA, Scholtes VA, Sprague S, vanWagensveld BA, Poolman RW. Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients: a systematic review. Obes Rev. 2015;16(2):161-170.
- 17 | Subak LL, King WC, Belle SH, et al. Urinary incontinence before and after bariatric surgery. JAMA Intern Med. 2015;175(8):1378- 1387.
- 18 | Lindekilde N, Gladstone BP, Lübeck M, et al. The impact of bariatric surgery on quality of life: a systematic review and meta-analysis. Obesity Reviews. 2015;16(8):639-651.
- 19 | Robertson AGN, Wiggins T, Robertson FP, et al. Perioperative mortality in bariatric surgery: meta-analysis. Br J Surg. 2021;108(8):892-897.
- 20 | Neovius M, Bruze G, Jacobson P, et al. Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6(3):197-207.
- 21 | Stenberg E, Bruze G, Sundström J, et al. Comparison of sleeve gastrectomy vs intensive lifestyle modification in patients with a BMI of 30 to less than 35. JAMA Network Open. 2022;5(7):e2223927-e2223927.
- 22 | American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011-2020. https://asmbs.org/ resources/estimate-of-bariatric-surgery-numbers. Accessed September 23, 2022.
- 23 | Blue Cross Blue Shield Association. Bariatric Surgery Evidence Review. March 2018.
- 24 | Gasoyan H, Tajeu G, Halpern MT, Sarwer DB. Reasons for underutilization of bariatric surgery: The role of insurance benefit design. Surg Obes Relat Dis. 2019;15(1):146-151.
- 25 | Azagury D, Morton JM. Bariatric surgery outcomes in US accredited vs non-accredited centers: A systematic review. Journal of the American College of Surgeons. 2016;223(3)
- 26 | Business Group on Health. 2022 Large Employers’ Health Care Strategy and Plan Design Survey. https://www.businessgrouphealth.org/resources/2022-large-employers-health-care-strategy-and-plan-design-survey. Accessed September 21, 2022.
- 27 | American Society for Metabolic and Bariatric Surgery. Updated Position Statement on Insurance Mandated Preoperative Supervised Weight Loss Requirements. April 2016. https://asmbs.org/resources/preoperative-supervised-weight-loss-requirements. Accessed August 2022.
- 28 | Krimpuri RD, Yokley JM, Seeholzer EL, Horwath EL, Thomas CL, Bardaro SJ. Qualifying for bariatric surgery: is preoperative weight loss a reliable predictor of postoperative weight loss? Surg Obes Relat Dis. 2018;14(1):60-64.
- 29 | STOP Obesity Alliance. Developing a Comprehensive Benefit for Outcomes-based Obesity Treatment in Adults. https://stop.publichealth.gwu.edu/sites/g/files/zaxdzs4356/files/2022-02/comprehensive_obesity_care_v._9.1.21.pdf. Accessed July 28, 2022.
More TopicsArticles & Guides Pharmacy Plan Design & Administration Cost Management
Part 1: IntroductionAn Employer's Practical Playbook for Treating Obesity
Part 2Obesity Playbook: Intensive Behavioral Interventions
Part 3Obesity Playbook: Antiobesity Medications
Part 4Obesity Playbook: Bariatric Surgery
Part 5Obesity Playbook: Workplace Culture and Design
Part 6: AppendixObesity Playbook: Appendix
Full GuideObesity Playbook: Full Guide
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