DALLAS – June 7, 2022 – Many insurance companies require patients to complete a medically supervised weight management program before they approve them for weight-loss surgery, but new data shows this controversial requirement does nothing to improve treatment or safety outcomes, and may actually hinder weight loss success.
The study*, presented here today at the American Society for Metabolic and Bariatric Surgery (ASMBS) Annual Meeting (#ASMBS2022), adds to a growing body of evidence that calls into question the clinical rationale for delaying weight-loss surgery to fulfill this requirement imposed by insurers.
Weight management program requirements vary among insurers. Some require patients to simply complete a program; others expect patients to maintain weight within a defined period; others may deny payment for surgery if patients gain or even lose weight. The duration of these programs range from three to 12 months.
Many insurance companies believe that participation in a weight management program preoperatively results in patients with fewer complications, better health outcomes and decreased healthcare costs.
“Believing is one thing, proving is another. Patients in the insurance-mandated weight management programs did not achieve greater weight loss before or after bariatric surgery, did not have fewer post-operative complications, and did not have better resolution of obesity-related diseases when compared to patients who had no such insurance requirement,” said study-co-author Deborah Hutcheon, Doctor of Clinical Nutrition (DCN) and RD, Prisma Health, Greenville, SC. “The data shows the requirement only served to diminish outcomes and unnessarily delay patient access to a life-saving medical intervention.”
In the single-institution retrospective study, researchers reviewed the weight loss and safety outcomes of 1,056 patients who had either laparoscopic gastric bypass surgery (572) or sleeve gastrectomy (484) from 2014 to 2019. A total of 779 patients completed a medically supervised weight management program as mandated by their insurance company. Patients were followed for up to five years, which researchers note, to their knowledge, is the longest duration of follow-up to date for a study of this kind.
Patients not required to complete the weight management program prior to surgery had, on average, greater weight loss (1% to 5% more) in both the short- and long-term, and had better resolution or improvement of obesity-related diseases including hypertension, diabetes, and hyperlipidemia. No differences were seen in the rate of complications. However, weight management program patients who received gastric bypass had a significantly higher reoperation rate 13 months after surgery (3.8%), while gastric bypass patients who did not participate in the program did not require any reoperations.
Patients with the weight management program requirement waited an extra two months on average to have surgery, which researchers theorize may have resulted in a reduced long-term commitment to diet, exercise, and lifestyle modification after surgery, contributing to less weight loss.
In a 2016 position statement, the ASMBS called for an end to insurance mandated preoperative supervised weight loss requirements and mandates, stating, "The discriminatory, arbitrary, and scientifically unfounded practice of insurance-mandated preoperative weight loss contributes to patient attrition, causes unnecessary delay of lifesaving treatment, leads to the progression of life-threatening comorbid conditions, is unethical, and should be abandoned."
“Some insurers are following the data and discontinuing their mandates, but many still cling to the misguided assumption that requiring completion of a weight loss management program before bariatric surgery improves results. There is simply no scientific basis to this assumption and this practice has to stop,” said bariatric surgeon Teresa LaMasters, MD, ASMBS President-Elect, who was not involved in the study. “Every day delayed is another day denied access to the most effective long-term treatment for obesity. The preparation of the patient for metabolic bariatric surgery rests with the surgeon in collaboration with a multidisciplinary team. Arbitrary barriers should not stand in the way of these life-saving procedures.”
About Weight-Loss Surgery
Metabolic/bariatric or weight-loss surgery such as gastric bypass and sleeve gastrectomy have been shown to be the most effective and long-lasting treatment for severe obesity. The operations improve or resolve diseases including type 2 diabetes, heart disease and high blood pressure and leads to significant and durable weight loss. Its safety profile is comparable to some of the safest and most commonly performed surgeries in the U.S., including gallbladder surgery, appendectomy and knee replacement. Weight-loss surgery is generally reserved for people with severe obesity, which means about 75 to 100 pounds overweight or having a BMI of 35 or higher with an obesity-related disease. Obesity is linked to early death and more than 40 diseases including type 2 diabetes, hypertension, heart disease, stroke, osteoarthritis and at least 13 different types of cancer.[i],[ii],[iii] According to the ASMBS, less than 1% of those eligible for weight-loss surgery currently have it in any given year -- about 256,000 bariatric surgeries were performed in 2019, the latest estimates available.
The ASMBS is the largest organization for bariatric surgeons in the nation. It is a non-profit organization that works to advance the art and science of bariatric surgery and is committed to educating medical professionals and the lay public about bariatric surgery as an option for the treatment of severe obesity, as well as the associated risks and benefits. It encourages its members to investigate and discover new advances in bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved surgical outcomes for patients with severe obesity. For more information, visit www.asmbs.org.
*Insurance-Mandated Weight Management Program Completion Prior to Bariatric Surgery Provides No Long-Term Clinical Benefit
Deborah Hutcheon1, Greenville, SC; Joseph Ewing1, Greenville, SC; Madeleine St. Ville2, Clemson, SC; Megan Miller1, Greenville, SC; Lindsay Kirkland1, Greenville, SC; Shanu Kothari1, Greenville, SC; John Scott,1 Greenville, SC. Affiliations: Prisma Health,1 South Carolina; Clemson University2
[i] The Effectiveness and Risks of Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2003-2012. Accessed from: https://jamanetwork.com/journals/jamasurgery/fullarticle/1790378
[ii] Steele CB, Thomas CC, Henley SJ, et al. Vital Signs: Trends in Incidence of Cancers Associated with Overweight and Obesity — United States, 2005–2014. MMWR Morb Mortal Wkly Rep 2017;66:1052–1058. DOI: http://dx.doi.org/10.15585/mmwr.mm6639e1
[iii] Centers for Disease Control and Prevention. (2015) The Health Effects of Overweight and Obesity. Accessed from: https://www.cdc.gov/healthyweight/effects/index.html