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Should Medicare's Bariatric Surgery Coverage Policy Be Extended To Obese Individuals Without Pre-Existing Comorbidities? Open Access

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Background In a February 2006 policy decision, the Centers for Medicare & Medicaid Services (CMS) determined that evidence was sufficient for CMS to cover certain types of bariatric surgeries for Medicare beneficiaries. Under this new policy, CMS modified its long-standing position on the classification of obesity as an illness. The modified obesity policy allows for coverage of certain designated surgical services for the treatment of obesity for Medicare beneficiaries who 1) have a BMI > 35, 2) have at least one co-morbidity related to obesity and 3) have been previously unsuccessful with the medical treatment of obesity. Under the current Medicare policy, those obese beneficiaries who have not developed a secondary obesity-related condition, such as diabetes and/or hypertension, are not eligible for the surgery. Specific AimsThe objective of this study was to investigate whether sufficient evidence exists for Medicare to consider an expansion of the bariatric surgery NCD to prediabetic obese beneficiaries. Specifically, this research 1) investigated the outcomes of bariatric surgery on obese individuals with and without CMS-defined comorbidities, 2) estimated the increase in the eligible Medicare population if the bariatric surgery NCD was broadened to include obese prediabetics, and 3) estimated the cost implications of a Medicare policy change to cover bariatric surgery for obese patients without co-existing comorbidities.MethodsThe study design was a cross sectional analysis that relied on secondary data sources, such as hospital administrative data and publicly-available survey results. The two main data sources included the 1) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) and 2) Behavioral Risk Factor Surveillance System (BRFSS) databases. Univariate, bivariate, and multivariate analyses were conducted to determine the impact of specific obesity-related comorbidities on short-term bariatric surgery outcomes, such as length of stay, hospital cost, complications, and in-hospital mortality. The models specifically focused on the impact of prediabetes on resource and complications outcomes. Additionally, the eligibility and cost impact of expanding the bariatric surgery NCD to the Medicare program was estimated. ResultsStudy results indicated that while patient characteristics varied greatly between the two study groups (beneficiaries with comorbidities versus without comorbidities), resource outcomes and complications rates did not vary significantly between the groups. Specially, prediabetic patients did not have significantly different short-term outcomes relative to other bariatric surgery patients. If CMS expanded coverage of bariatric surgery to obese prediabetes, an additional 108,961 Medicare beneficiaries would be eligible and the expansion would cost CMS $21.9M to $54.8M for a given year. (Note: this does not account for costs averted due to reduced future hospitalizations.)Policy RecommendationsA set of policy recommendations and options designed to increase access to bariatric surgery among the currently eligible Medicare population, as well as a new category of patients (prediabetic obese individuals) are provided. The key policy recommendations include:*CMS should clarify NCD language for contractors by enumerating what constitutes an obesity-related condition.*CMS should expand the current bariatric surgery NCD to establish prediabetes as a qualifier for the surgery.*CMS should classify obesity as an illness. ConclusionsThis research focused on one important societal factor in addressing obesity and its related comorbidities, public health insurance coverage of obesity treatments. Study findings suggest that there is evidence to support expanding Medicare's bariatric surgery coverage to beneficiaries without existing comorbidities, specifically to pre-diabetic obese beneficiaries. The findings from this dissertation provide the foundation for future research that can consider more comprehensive long-term outcomes of bariatric surgery - such as post-discharge medical complications, health-related quality of life trade-offs, and life expectancy gains - on obese patients without existing comorbidities.

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