Original Article |

Impact of Bariatric Surgery on Health Care Costs of Obese Persons:  A 6-Year Follow-up of Surgical and Comparison Cohorts Using Health Plan Data

Jonathan P. Weiner, DrPH; Suzanne M. Goodwin, PhD; Hsien-Yen Chang, PhD, MHS; Shari D. Bolen, MD, MPH; Thomas M. Richards, MSEE; Roger A. Johns, MD, MHS; Soyal R. Momin, MS, MBA; Jeanne M. Clark, MD, MPH
JAMA Surg. 2013;148(6):555-561. doi:10.1001/jamasurg.2013.1504.
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Importance Bariatric surgery is a well-documented treatment for obesity, but there are uncertainties about the degree to which such surgery is associated with health care cost reductions that are sustained over time.

Objective To provide a comprehensive, multiyear analysis of health care costs by type of procedure within a large cohort of privately insured persons who underwent bariatric surgery compared with a matched nonsurgical cohort.

Design Longitudinal analysis of 2002-2008 claims data comparing a bariatric surgery cohort with a matched nonsurgical cohort.

Setting Seven BlueCross BlueShield health insurance plans with a total enrollment of more than 18 million persons.

Participants A total of 29 820 plan members who underwent bariatric surgery between January 1, 2002, and December 31, 2008, and a 1:1 matched comparison group of persons not undergoing surgery but with diagnoses closely associated with obesity.

Main Outcome Measures Standardized costs (overall and by type of care) and adjusted ratios of the surgical group's costs relative to those of the comparison group.

Results Total costs were greater in the bariatric surgery group during the second and third years following surgery but were similar in the later years. However, the bariatric group's prescription and office visit costs were lower and their inpatient costs were higher. Those undergoing laparoscopic surgery had lower costs in the first few years after surgery, but these differences did not persist.

Conclusions and Relevance Bariatric surgery does not reduce overall health care costs in the long term. Also, there is no evidence that any one type of surgery is more likely to reduce long-term health care costs. To assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings.

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Figure. Regression-adjusted ratios of surgery group costs to comparison group costs by time and expenditure category, including total cost (A), inpatient cost (B), professional office cost (C), and pharmacy cost (D). Ratios higher than 1.00 indicate that the annual costs are greater among the surgical cohort compared with the comparison group for that period. Ratios in which the 95% CI does not cross 1.00 are statistically significant at the P = .05 level. This analysis adjusted for the matching design of the study and the following covariates: person's baseline cost in the preoperative/preindex period, age, obesity propensity score during the preoperative/preindex period, and 32 morbidity groups (aggregated diagnosis groups) based on all diagnoses found in the claims during the preoperative/preindex year. Total cost includes inpatient, professional office, outpatient/other, and pharmacy costs.




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Bariatric Surgery is Cost-Effective
Posted on March 15, 2013
Luke M. Funk MD MPH, Bradley J. Needleman MD, W. Scott Melvin MD
Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University Medical Center
Conflict of Interest: -Dr. Funk performs bariatric surgery. He has no other conflicts of interest or financial ties to disclose. -Dr. Needleman performs bariatric surgery and is the Director of the Bariatric Surgery program at the Ohio State University Medical Center. He has received honoraria for serving as a speaker for Covidien. -Dr. Melvin performs bariatric surgery. He has no other conflicts of interest or financial ties to disclose.
We read with interest the article by Weiner and colleagues which was published online on February 20 in JAMA Surgery (1). Their study concluded that bariatric surgery did not reduce overall health care costs over a 4-7 year period. Although there were methodological limitations – a large percentage underwent open gastric bypass, an operation that is performed rarely in modern day bariatric surgery and nearly one-third had four years or less follow-up time, the study was rigorously conducted and the authors used numerous matching and adjustment methods to account for confounding. We especially commend the authors for addressing two critical topics – the obesity epidemic and the exploding cost of the healthcare. Our country must find solutions to both as we moved forward. What can we conclude from this study? Perhaps as important, what can’t we conclude? One thing that we cannot determine from this study is anything about the cost-effectiveness of bariatric surgery. This study examined only a portion of the numerator of this ratio: short term costs. The authors acknowledge this in their comments, as performing a cost-effectiveness analysis was not the intent of their study. However, shifting the discussion from bariatric surgery being “costly” to “not cost-effective” is a slippery slope, as the accompanying invited critique by Livingston illustrated (2). To examine whether bariatric surgery is cost-effective, one must study the denominator as well: the effectiveness. One of the true pioneers in the field of decision science, Dr. Milton Weinstein, did just this in 2010 using a Markov model to predict the cost-effectiveness of bariatric surgery over the lifetime of the patient (3). Weinstein and colleagues found that bariatric surgery was well below $25,000 per quality-adjusted life years gained, a threshold commonly used to establish whether an intervention is worthy of investment. The United Kingdom – which has one of the most advanced cost-effectiveness analysis programs in the world at its National Institute for Health and Clinical Evidence (NICE) – has concluded the same (4). Though its per capita health expenditures are less than half of what ours are in the U.S. (5), the National Health Service in the U.K. covers bariatric surgery. Given these data, and the recent findings from randomized trials confirming that bariatric surgery has a profound impact on diabetes prevalence, among other comorbidities, the question is not “Is bariatric surgery worth it?” The question is really, “Why is only 1% of the morbidly obese population in the U.S. undergoing the gold standard therapy - surgery? Would we tolerate this for any other disease process? What are we going to do about it?”References1. Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg 2013;Feb 20:1-8.2. Livingston EH. Is bariatric surgery worth it? JAMA Surg 2013;Feb 20:1.3. Campbell J, McGarry LA, Shikora SA, Hale BC, Lee JT, Weinstein WC. Cost-effectiveness of laparoscopic gastric banding and bypass for morbid obesity. Am J Manag Care 2010;16(7):e174-87.4. CG43 Obesity: full guideline, section 6 – health economics: evidence statements and reviews. NHS National Institute for Health and Clinical Excellence. Available at: www.nice.org.uk/guidance/index.jsp?action=download&o=38268. Accessed March 12, 2013.5. Health expenditures per capita. The World Bank. Available at: data.worldbank.org/indicator/SH.XPD.PCAP. Accessed on March 12, 2013.
Payor outcomes versus Patient Outcomes - Impact of Bariatric Surgery on Health Care Costs of Obese Persons
Posted on February 21, 2013
Glenn M Ihde MD
President, Texas Association for Bariatric Surgery
Conflict of Interest: None Declared
In this study there are several variables overlooked. With an average age of 45 years, there is no reference to how long the patients had suffered from obesity prior to entering the study. Only approximately 7% of the patient population was under age 30, and since obesity is a lifelong disease, one has to assume that the vast majority of these patients had been accumulating disease damage for at least 10 or more years. In that perspective, this study is really a view of life salvage then it is on disease prevention or improvement. The statistical analysis portion of the article also indicates that non-obesity related morbidities were intentionally included in the study population, which makes it difficult to determine whether costs were related to obesity or affected by surgery. Pharmacy costs, which decreased for the surgical cohort may be a rough estimate of disease improvement, it would overall indicate a healthier population if not a less expensive one. No mortality data is reported, and since it would cost the payor nothing to treat any of those unfortunate patients, it would skew the cost data in favor of not having surgery.An increase in digestive disease related costs was seen, requiring a high inpatient stay and associated costs, but the authors can only assume that these are “complications” associated with bariatric surgery. Since there is no data to support that assumption it is unfortunate that the opinion was allowed in the article. In contrast, the increase costs in the non-surgical cohort were cardiovascular and respiratory related, conceivably more serious conditions and again raising the question of mortality as a factor in the analysis, and costs related to increased clinic visits for postoperative follow-up should have been expected.The article provides a single analysis over a tumultuous time in history for bariatric surgery. The spectrum of surgery went from almost completely open to almost completely laparoscopic. The banding procedures underwent multiple revisions of the prosthetic device. Gastric sleeve was introduced around 2005 and rapidly became a common procedure which the study cannot account for. Bariatric surgery was promoted as a dangerous and last resort therapy of desperation, leading only the sickest of patients to seek surgery. Most importantly, bariatric surgery was still in its infancy. By the end of the study in 2008 the learning curve was just leveling off for most of the discipline. The longitudinal study of bariatric surgery outcomes shows how much change occurred in those years. Perhaps, after these improvements, the high inpatient costs would no longer be present in the first two years after surgery, markedly changing the outcomes of this type of study.This study, which examines costs in the obese population by one payor, really only tells us one thing. That the payor did not realize a financial gain by providing bariatric surgery benefits to its clients, and at worst came out even in the deal.
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