Medicare change tied to safer weight loss surgery

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After Medicare changed its rules regarding coverage for weight loss surgeries in 2006, the cost for the procedures went down while safety measures increased, according to a new study.

Researchers found that the benefits were primarily due to a rules change that allowed Medicare to pay for a newer, less invasive procedure called laparoscopic adjustable banding.

Prior to the 2006 changes, Medicare, the federally-funded health insurance for older or disabled people, only reimbursed doctors for performing gastric bypass surgeries.

"This is one of the more recent natural experiments by Medicare to try and change the health care system for the better,” said Dr. David Flum, the study’s lead author and a professor at the University of Washington. “The message is, it worked.”

Laparoscopic gastric banding helps people lose weight by squeezing off a portion of the stomach into a small pouch that can handle only limited amounts of food.

Gastric bypass also makes the stomach smaller, while detouring food around part of the small intestine.

Flum and his team gathered data from the Centers for Medicare and Medicaid Services (CMS) on people with Medicare insurance who underwent weight loss surgery between 2004 and 2008.

Throughout the study period, more than 47,000 people had weight loss surgery.

Before the 2006 rules changes, no one in this group received laparoscopic banding. After the changes, that procedure made up more than a third of the weight loss surgeries.

As “lap banding” was introduced, the number of people who died after surgery fell by more than half.

Fifteen out of every 1,000 people who had weight loss surgery before Medicare changed its rules died within 90 days of the procedure. After the rules change, seven out of every 1,000 people died after the surgery.

Readmissions to the hospital also dropped, from 19 patients out of every 100 before Medicare changed its rules, to 15 out of every 100 patients after the changes.

The cost of the procedures also decreased over time.

Before 2006, Medicare paid roughly $24,000 for each procedure. Afterward, it paid about $20,000.

From Flum’s study it appears that another part of the rules change, which limited reimbursements only to hospitals that receive a particular accreditation, made little difference to the cost or safety of the procedures.

Hospitals receive accreditation through the American College of Surgeons or the American Society for Bariatric Surgery by performing a certain number of procedures each year and by having staff and facilities that meet certain standards.

Before Medicare’s new requirement for accreditation in 2006, patients received surgery at 928 sites. Afterward, patients went to 662 facilities for surgery.

“I think Medicare should get rid of that requirement,” said Dr. Edward Livingston, a professor at UT Southwestern Medical Center who was not involved in this study.

Livingston’s concern is that the changes to Medicare made it harder for some people to find an accredited facility in their area.

“This is a particular problem for rural America...where patients have to travel great distances” to locate a center that Medicare will reimburse, Livingston told Reuters Health.

He said that having facilities within easy reach is especially important for the growing proportion of people receiving laparoscopic banding, because the procedure requires frequent follow up care.

“One of the downsides (to Medicare’s coverage decision) is that access to care was decreased in places that were not accredited,” said Flum, “but I think that setting some accreditation standards around safety or volume makes a lot of sense.”

Other than to say CMS is pleased that the coverage decision appeared to improve health outcomes for people with Medicare, an official at CMS would not comment on the study because the agency is considering changing the rules again.

Medicare’s current coverage for weight loss surgery excludes one type, called sleeve gastrectomy, and officials are seeking input on whether there are enough data on its effects and safety to include the procedure.

Through the health care reform law passed in 2010, the federal government is making more efforts to steer patients toward the safest, most effective and cheapest procedures.

The law established the Patient-Centered Outcomes Research Institute, for instance, which funds comparisons of different approaches to preventing or treating diseases.

Flum said Medicare’s decision to change weight loss surgery coverage is the type of move he’d like to see shake out of the push to encourage more informed decisions about what procedures should be paid for.

“This is a model of how health care reform could play out to help people,” he said.

One of the lingering questions surrounding Medicare’s changes is whether the shift toward laparoscopic banding actually achieves better weight loss for patients compared to gastric bypass.

Recent studies have found that gastric bypass leads to faster weight loss and greater appetite control than the banding approach, making bypass potentially superior for some patients (see Reuters Health story of October 14, 2011). Others have found better diabetes control with bypass versus banding.

Flum is part of a group studying the long term outcomes of lap-banding, and whether it can also help stave off diabetes and heart disease as doctors hope. His study was funded by the National Institutes of Health and the Department of Defense

Livingston agreed that it will be important to determine if lap banding is as effective as other surgeries.

“You can do a safe operation, but if it doesn’t work you haven’t gained anything,” Livingston said.

SOURCE: Annals of Surgery, online October 4, 2011.

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