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Effective Health Care Program

Data Points #17: Trends in bariatric surgery in Medicare beneficiaries

Research Report

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This report is from AHRQ's Data Points Publication Series.

Overview

Use of bariatric surgery increased dramatically in Medicare beneficiaries from 2006 through 2009.

Procedure mix varies by age and region and changed over the period of analysis as laparoscopic operations became more common.

Most Medicare bariatric surgery recipients are under age 65 (eligible due to disability), but the proportion of recipients over 65 has increased over time.

Rehospitalization rates are moderate and relatively stable over time. Postoperative mortality is low.

Bariatric surgery is not associated with disenrollment from the Medicare program among working age disabled beneficiaries. Only about one percent of disabled people who received bariatric surgery disenrolled within five years of the procedure.

Obesity has been associated with a number of comorbidities and adverse health outcomes and is considered one of the major challenges facing the health care system today. In 2008, more than one-third of the adult population was obese, defined as having a body mass index (BMI) of 30 kg/m2 or higher. Research has shown surgical treatments to be more effective for weight loss than nonsurgical strategies such as diet and exercise or pharmacotherapy.

Bariatric procedures result in weight loss by modifying the size of the stomach (restriction) or the anatomy of the small intestine (malabsorption). The most common operation for weight loss performed in the United States, the Roux-en-Y gastric bypass (RYGB), is both a restrictive and a malabsorptive operation. RYGB is performed by creating a small gastric pouch, usually <30 mL, and rerouting the intestine such that the duodenum and proximal jejunum are bypassed. It is most often performed laparoscopically (LRYGB) but can also be carried out with an open approach (ORYGB) when indicated. Another option is the adjustable gastric band (AGB), a purely restrictive approach. It reduces stomach size through the use of a mechanical device placed over the proximal portion of the stomach. Finally, biliopancreatic diversion with duodenal switch (DS), the most malabsorptive operation, bypasses most of the duodenum and all of the jejunum, and provides only about a 100 cm common channel in the distal ileum for both consumed nutrients and biliopancreatic secretions to mix and be absorbed.

Each operation provides different but significant degrees of weight loss. In addition, studies have demonstrated significant improvements in medical comorbidities such as type 2 diabetes, obstructive sleep apnea, and hypertension following bariatric surgeries. Bariatric surgery is not risk free, however. Morbidity and mortality rates following bariatric surgery continue to be a major concern.

Medicare provides health insurance to people over age 65 and to working-age disabled people. As observed in the general population, obesity is common in Medicare beneficiaries. In 2002, 21.4 percent of older beneficiaries and 39.3 percent of disabled beneficiaries were considered obese. These numbers have likely increased over time. As the number of obese Medicare beneficiaries increases, so does the number eligible for bariatric surgery.

Beginning in February 2006, the Centers for Medicare & Medicaid Services (CMS) expanded coverage of bariatric operations. Beneficiaries with a BMI of 35 kg/m2 or greater and at least one obesity-related comorbidity who have documented unsuccessful medical treatment for their obesity become eligible to receive bariatric surgery. Medicare covers ORYGB or LRYGB, open or laparoscopic DS, or laparoscopic adjustable gastric banding in an inpatient (IPLAGB) or outpatient (OPLAGB) setting at a Level 1 Bariatric Surgery Center or Bariatric Surgery Center of Excellence. This report describes the use and associated outcomes of bariatric surgery by Medicare beneficiaries from 2006 through 2009.

Conclusion

Use of bariatric surgery in Medicare patients has dramatically increased since its expansion of coverage in 2006. We observed increases in operations in both the age-eligible and working-age disabled groups. Most operations were performed on disabled beneficiaries, but the proportion of age-eligible operations increased over time. While mortality was relatively low and rehospitalization rates moderate, it did not appear that bariatric surgery was associated with health status improvements great enough to warrant return to the workforce.