Bariatric surgery maintains, doesn't gain

In a way, bariatric surgery is like the member of the chorus who spent years waiting for a big break, got it, became a star, and then found out that success was harder than it looked.

After decades of slow growth since the first procedure was performed in 1954, rates escalated rapidly in the first few years of the 2000s but hit a wall recently. That wall may not be so easy to get past, even if the economy fully recovers.

A total of 36,700 bariatric surgeries were carried out in 2000, and then jumped 29% to 47,200 in 2001, according to the American Society for Metabolic & Bariatric Surgery. An additional 63,100 were carried out in 2002, an increase of 34% from the previous year. In 2003, 103,200 procedures were performed for an annual growth rate of 64%, the biggest increase in the previous decade. Hospitals and large health systems opened bariatric surgery centers as revenue builders and to serve their communities. General surgeons started specializing in the procedure.

“At the time, general surgery was taking a huge hit,” said Ken Champion, MD, a bariatric surgeon in Atlanta who performed the procedure for 35 years until he retired a few months ago because of medical issues. “A lot of people speculated that general surgery wouldn’t exist in 10 years because different operations were being picked off by the specialists. Adding a bariatric surgery center to a hospital meant they could add 200, 300 or 400 cases a year to their volume. It could be profitable. General surgery could be a revenue source.”

This growth was partly due to new techniques and medical devices that made the procedure safer. The Food and Drug Administration approved the first lap band product in June 2001. Several celebrities, including Carnie Wilson, Roseanne Barr and Al Roker, spoke publicly about their experiences with bariatric surgery. Awareness grew that obesity was a serious health issue rather than a failure of will. More insurers started covering it.

An Agency for Healthcare Research and Quality article in the July 2005 Health Affairs analyzing bariatric surgery trends stated: “As bariatric surgeons perform more surgeries and outcomes continue to improve, it is likely that more people will opt for the surgery. The potential demand may be quite large.”

Effect of the recession

Bariatric surgery growth rates started to slow significantly in 2006, when 177,600 were performed, an increase of only 4% from the previous year. By 2008, the number hit 220,000 and stayed there for 2009. Numbers for subsequent years are not available, but experts believe they are staying flat or even declining.

“It’s definitely plateaued,” said Robin Blackstone, MD, ASMBS president. “I would say there may even be a small downturn in the numbers based on what we are hearing from around the country.”

This is in part because the recession from December 2007 to June 2009 left patients deferring or delaying many elective procedures. While no organization tracks a national number of elective surgeries, hospitals across the country have reported declines over the past five years. They have cited the drop in elective surgeries as a major inhibitor of their bottom lines.

“Patients are worried about their economic stability,” said Scott Cunneen, MD, director of bariatric surgery at Cedars-Sinai Medical Center in Los Angeles. “They’re worried about paying rent and providing food for their families. Weight-loss surgery is elective. It’s a good investment for both the insurance company as well as the individual, but they have more immediate concerns.”

Even those who are insured and employed may be holding back, because coverage is no guarantee these bills will get paid. Twenty-five percent of patients considering bariatric surgery are denied coverage three times before approval, according to the ASMBS.

Once the surgery is approved, the out-of-pocket costs for it and related care can still be considerable. The procedure itself costs between $18,000 and $35,000 without insurance, but for those with coverage, $5,000 deductibles are common.

Patients may end up needing cosmetic surgeries, usually to remove excess skin, that usually are not covered. Pre- and post-surgery nutrition and other counseling can get expensive. Those costs can equal the price tag of the surgery itself.

“Patients are holding back because they are uncertain about their future, and they don’t want to take time off work when their employers are trimming back personnel,” said Kevin Huffman, DO, president and medical director of American Bariatric Consultants based in Vermilion, Ohio. He advised about 40 institutions about setting up new bariatric surgery programs in 2005. That number dipped to around 20 in 2011.

Surgery seen differently

But it’s not just the economy that is affecting bariatric surgery trends. The patient view of the procedure has changed. It’s still seen as effective, but the very public struggles of some celebrities to maintain weight losses has sent the message that this is not an easy way out. Patients still need to make difficult changes in diet and physical activity.

It never really was the easy way out, but that was how some perceived it.

“People want a magic pill to address obesity, but it’s just not out there,” Dr. Champion said.

The growth in bariatric surgery means that more people know others who have had the procedure and could see its pluses and minuses.

“I talk to patients every day,” said Ed J. Hendricks, MD, a trustee of the American Society of Bariatric Physicians. “They tell me, ‘My friend had bariatric surgery. Things are not going too well.’ People are beginning to realize it’s not a cure. It’s really just a tool.”

There also has been heavy media coverage of several scandals, some linked to patient deaths, associated with questionable bariatric surgery clinics. In December 2011 the FDA issued warning letters to several such clinics for false advertising. Some are under other federal, state or local scrutiny. That has affected even those clinics that have a clean record.

“We will never know who didn’t even walk through the doors because of those incidents,” said Jeremy Korman, MD, a bariatric surgeon with LA Bariatric Center in Marina Del Ray, Calif.

But bariatric surgery and surgeons are not down and out. Centers are not closing. Surgeons still are busy, but they are expanding into nonsurgical weight loss medicine and other health care services to keep going and better serve patients.

“From a complete care standpoint, that’s a good idea,” Dr. Korman said. “From a business standpoint, it’s a tremendous platform.”

There also is some work to expand the list of those eligible for this procedure in hopes numbers will go up again. Numerous studies have looked at the surgery’s impact on other health conditions.

Most recently, a paper in the March 26 New England Journal of Medicine compared patients with diabetes receiving bariatric surgery with those who got medical treatment for excess weight. After two years, 75% of those who received gastric bypass, and 95% getting biliopancreatic diversion, achieved glycemic control. All the patients in the medical treatment group did not.

Some experts believe that bariatric surgery numbers will continue to grow again when the economy fully recovers and various policy changes are implemented. Few, however, believe that explosive increases will happen again. Bariatric surgery most likely will retain some of its star status, but it has lost some of the novelty that gave it its luster.

“Bariatric surgery used to be kind of exotic,” said Dr. Blackstone, who is also medical director of the Scottsdale Healthcare Bariatric Center in Arizona. “Now it’s more of a standard service. Hospitals can still do well and get quality results with low complication rates, but you have to have a robust program and give solid service.”