Bariatric Trends May 2006

8/3/2019 Bariatric Trends May 2006

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Review of Trends in the Marketfor Bariatric Surgery

RESEARCH IN BRIEF

Driven largely by the rising obesity epidemic, the U.S. market for bariatricsurgery is undergoing exponential growth. However, lingering concernsabout quality and the high cost of bariatric proceduresespecially costsassociated with co-morbidities and a relatively high risk of mortalityhaveled many payers to resist or restrict reimbursement for bariatric surgery.Consequently, the market is currently constrained by the need to meetrequirements for centers of excellence (COEs) in bariatric surgery in order tosecure adequate reimbursement. However, due to the fact that less than onepercent of eligible patients have undergone bariatric surgery, the marketshould continue to grow rapidly in the next five years. This brief provides anoverview of the market for bariatric surgery in the United States.

I. Snapshot of the Bariatric Surgery MarketII. Current and Historical Factors Affecting the

Market

III. Costs and Reimbursement Associated withBariatric Surgery

IV. Program Components

MAJOR SECTIONS

Advisory.com

ASSOCIATEJeffrey Kittel

MANAGERJohanna Willer


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REVIEW OF TRENDS IN THE MARKET FOR BARIATRIC SURGERY PAGE 5

I.SNAPSHOT OF THE BARIATRIC SURGERY MARKET

The market for bariatric surgerydefined as any surgery performed for the purpose of producing weightlossis undergoing explosive growth in the United States.1 Since 1992, the number of bariatric surgeriesperformed annually has increased exponentially from 16,000 to 144,000, as shown in the followingdiagram:

However, despite such drastic increases in bariatric surgery volumes, the potential for future growth isundiminished; as of 2002, only 0.6 percent of 11.5 million eligible patients had undergone the procedure.2

Morbid obesity constitutes 90 percent of total diagnoses for bariatric surgery

Bariatric surgery is almost exclusively used to treat morbid obesity as the vast majority of patients withsevere obesity fail to achieve and maintain a healthy weight without surgery.3 The tables listed on thefollowing page indicate the top five diagnoses and procedures that fall under diagnosis-related group(DRG) 288, obesity-related surgery. The tables are listed in descending order of percentages of totaldischarges.

1 Association of Perioperative Registered Nurses (AORN). AORN Bariatric Surgery Guideline. (2005). 2005 Standards,Recommended Practices, Guidelines. www.aorn.org/about/positions/default.htm#guidance (Accessed April 17, 2006).

2 Financial Leadership Council. Hospitals Can Overcome Payment, Cost Hurdles to Capitalize on Bariatric SurgerysPotential. Finance Watch. Washington, DC: The Advisory Board Company. (September 2, 2005).

3 American College of Surgeons (ACS). Bariatric Surgery Center Network: Accreditation Program Manual. (2005).www.facs.org/viewing/cqi/bscn/index.html (Accessed April 17, 2006).

Number of bariatric surgery procedures, 1992 to 2004

Source: American Society for Bariatric Surgeons (ASBS), 2006.

Demand for bariatric surgery grows exponentially across the past 12 years

0

1992 1993 1994 1996 1997 1998 1998 2000 200320022001 200419991995

16,800

140, 600

18,10025,800

36,700

47,200

63,100

103,200

7.7 percent 42.2 percent 28.6 percent

33.7 percent

63.5 percent

36.2 percent

42.5 percent


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Diagnosis Number of discharges Percentage of total discharges

Morbid obesity 72,808 92.4 percent

Localized adiposity 4,462 5.7 percentLipodystrophy 660 0.8 percent

Obesity (unspecified) 379 0.5 percent

Dysmetabolic Syndrome X 84 0.1 percent

The following table describes the five most common surgeries associated with obesity.

Majority of bariatric surgery patients are adult femalesThe average bariatric surgery patient is a female between the ages of 18 and 44. Across all age groups,women account for approximately 80 percent of bariatric surgeries, as shown in the chart on the followingpage:4

4 HCUPnet. Agency for Healthcare Research and Quality (AHRQ): Healthcare Cost and Utilization Project (HCUP).Rockville, MD. www.ahrq.gov/HCUPnet (Accessed April 24, 2006).

Procedure Number of procedures Percentage of total procedures

High gastric bypass 50,592 64.2 percentOther gastroenterostomy 13,843 17.6 percentGastric repair 6,838 8.7 percentSize reduction plastic operation 5,473 6.9 percentOther gastric operation 541 0.7 percent

Nearly 75,000 morbid obesity discharges occurred in 2002

Source: Solucient, LLC, The DRG Handbook: ComparativeClinical and Financial Benchmarks, (2004).

All payer data, 2002

Majority of total procedures are high gastric bypass

Source: Solucient, LLC, The DRG Handbook: ComparativeClinical and Financial Benchmarks, (2004).

All payer data, 2002


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Sex

Male Female

Age

range

Total

discharges

Percentage

of totalDischarges

Percentage

of male

patients

Percentage

of patients

in age

range

Discharges

Percentage

of female

patients

Percentag

of patient

in age

range

1 to 17 259 0.22 126 0.62 48.47 134 0.14 51.53

18 to 44 67,208 56.27 9,997 49.13 14.87 57,012 58.06 84.83

45 to 64 50,013 41.87 9,844 48.38 19.68 39,887 40.62 79.75

65 to 84 1,520 1.27 377 1.85 24.80 1,138 1.16 74.85

Total 119,443 100 20,348 100 17.04 98,119 100 82.21

Patients predominantly covered by private insurance

Due to only recent coverage by Medicare and Medicaid, as well as the typical age of bariatric surgerypatients as demonstrated in the above chart, the majority of bariatric surgery patients are covered byprivate insurance. The national payer mix for bariatric surgery is illustrated in the chart on the following

page.5

5 Innovations Center. Future of General Surgery: Strategic Forecast and Investment Blueprint. Washington, DC: The AdvisoryBoard Company. (2005).

Approximately 80 percent of bariatric surgery patients are female

Bariatric surgery patient distribution, 2003

Source: HCUPnet, Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality(AHRQ), Rockville, MD, www.ahrq.gov/HCUPnet (Accessed April 24, 2006).


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Growth in the number of bariatric programs keeping pace with procedural growth

To accommodate growing demand, an increasing number of hospitals are offering bariatric surgeryprocedures. Between 2001 and 2002, the number of hospital-based bariatric surgery programs in the U.S.

increased by 62 percent, as shown in the chart on the following page.6


Nearly 80 percent of bariatric patients are covered by commercial payers

Payer mix, bariatric surgery, 2002

Source: Innovations Center, Future of General Surgery: Strategic Forecast andInvestment Blueprint, Washington, DC: The Advisory Board Company, (2005).

Other

3 percent

Self-pay

5 percent

Medicare/

Medicaid13 percent

Privateinsurance

79 percent


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While there is a national trend towards growth, there is variation across geographic regions.For example, although the number of bariatric programs in the South increased by 307 percent between2001 and 2002, during this same time period the number of programs in the West shrank by 23 percent.7In addition, evidence suggests that some markets are becoming more competitive. Although the totalnumber of bariatric procedures performed in the Midwest increased 129 percent during this time period,this growth was outstripped by a 155 percent increase in the number of bariatric programs in the region,causing a 10 percent decrease in the average number of bariatric procedures performed per institution.8


8 ibid.

273

459

2001 2002

62 percent increase

Number of bariatric programs quickly increasing

Number of U.S. bariatric programs, 2001-2002

Source: Innovations Center, Future of General Surgery: Strategic Forecast and Investment Blueprint,Washington, DC: The Advisory Board Company, (2005).


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II.CURRENT AND HISTORICAL FACTORS AFFECTING THE MARKET

Although the overall trend in the bariatric surgery market is towards growth, many factors have affectedits progression. The following factors have restricted the development of the bariatric surgery market.

Restrictive Factor #1Quality concerns

Early lack of adoption due to poor outcomes

Although bariatric surgery began in the 1950s with procedures such as the jejunoilcal bypass procedure,patients of many early bariatric surgery procedures experienced significant side effects caused byinadequate absorption of minerals, vitamins, and fatty acids and were at high risk of mortality due to thecomplicated nature of the procedures.9 It was only with the development of modern bariatric proceduressuch as the Roux-en-Y gastric bypasscurrently the most commonly-performed bariatric surgeryprocedurewhich reduce the risk of mortality and have a more acceptable profile of side effects thatbariatric surgery has achieved acceptance by the medical community. 10,11

Lingering concerns and relatively high mortality rates continue to curtail growth

However, despite improved outcomes and the endorsement of bariatric surgery by national medicalgroups such as the American Medical Association (AMA), lingering concern over the relatively highmortality risk faced by bariatric surgery patients has continued to restrict the growth of the market.Laparoscopic gastric bypass procedures are among the most difficult laparoscopic surgeries for surgeonsto learn, and inexperienced bariatric surgeons can have significantly higher mortality and complicationrates than more experienced surgeons.12 Because of this, many payers have remained unwilling toreimburse for bariatric surgery due to the high costs associated with complications and mortality.13

Restrictive Factor #2Unfavorable reimbursement

The vast majority of bariatric surgery patients are commercially insured; however, many private insurershave either eliminated reimbursement for bariatric surgery or instituted strong controls.14 Although a fewprivate insurers began covering bariatric surgery in the 1990s in an effort to reduce health care costs

associated with obesity, early financial returns were poor and high-profile incidents of patient deathscaused many to reconsider their decision.15 As of 2003, only 23 percent of employee-sponsored healthinsurance plans fully covered bariatric surgery.16 Policies of several national insurance carriers aredetailed in the chart on the following page.17

9 AORN. AORN Bariatric Surgery Guideline. (2005). 2005 Standards, Recommended Practices, Guidelines.www.aorn.org/about/positions/default.htm#guidance (Accessed April 17, 2006).

10 Advisory Board interviews. (2006).11 Marketing and Planning Leadership Council. Bariatric Surgery Programs: Clinical Innovation Profile. Washington, DC:

The Advisory Board Company. (2002).12 Innovations Center. Future of General Surgery: Strategic Forecast and Investment Blueprint. Washington, DC:

The Advisory Board Company. (2005).13 Financial Leadership Council. Hospitals Can Overcome Payment, Cost Hurdles to Capitalize on Bariatric Surgerys

Potential. Finance Watch. Washington, DC: The Advisory Board Company. (September 2, 2005).14 Innovations Center. Future of General Surgery: Strategic Forecast and Investment Blueprint. Washington, DC:

The Advisory Board Company. (2005).15 Advisory Board interviews. (2006).16 Innovations Center. Future of General Surgery: Strategic Forecast and Investment Blueprint. Washington, DC:

The Advisory Board Company. (2005).17 Trends in Bariatric Surgery Programs. (January 2005).


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Carrier Coverage policy

AetnaHartford, Connecticut

Covers gastric bypass surgery and vertical banding; no otherprocedures covered.

Blue Cross, Blue Shield

(BCBS) Association

Chicago, Illinois

Issued assessment statement for nationwide plans in June 2003;defined laparoscopic gastric bypass surgery, laparoscopic gastricbanding, and biliopancreatic diversion as experimental andinvestigational, which grants each BCBS plan leeway to denycoverage on these grounds.

Blue Cross, Blue Shield of

California

San Francisco, California

In 2001, eliminated coverage for duodenal switch, jejunoilealbypass, biliopancreatic diversion, gastric banding, and long limbgastric bypass.

Blue Cross, Blue Shield of

Michigan

Detroit, Michigan

Capped lifetime coverage for any and all obesity treatment at$10,000which will not cover the full cost of any bariatric

procedure.Cigna

Philadelphia, Pennsylvania

Changed position as of October 2003; will only cover gastricbypass surgery but not gastric banding.

United HealthCareMinnetonka, Minnesota

Excludes coverage for bariatric surgery from its corporateinsurance policies in an attempt to unify its approach to thesurgery. Also excludes all medical and surgical treatments forobesity as well as drug treatments.

Restrictive Factor #3Center of Excellence restrictions

The combination of quality concerns and the desire to lower costs associated with poor outcomes has ledmany private payers to designate centers of excellence (COEs) based on factors such as comprehensivesupport services and annual volume thresholds.18 The Centers for Medicare and Medicaid Services(CMS) has reinforced this trend through its recent decision to reimburse for bariatric surgery only atinstitutions accredited as COEs by the American Society for Bariatric Surgery (ASBS) or as Level 1Bariatric Surgery Centers by the American College of Surgeons (ACS).19 Many private insurers willlikely follow suit, which will profoundly impact the ability of smaller programs to remain viable.20


19 Financial Leadership Council. CMSs National Coverage Decision Rewards Some Bariatric Surgery Programs, ThrowsOthers into Turmoil. Finance Watch. Washington, DC: The Advisory Board Company. (March 17, 2006).

20ibid.

National insurance carriers curtail bariatric coverage

Coverage policies of national private insurers

Note: Policies may have recently changed.

Source: Alt, S, Market Memo: Bariatric Surgery May Become aSelf-Pay Service,Health Care Strategic Management,21(12), (December 1, 2003); BC of California CutsCoverage for Duoedenal Switches, Health Care Strategic

Management, 19(9), (September 1, 2001).


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Despite the restrictive effect of the above factors, bariatric surgery volumes have increased exponentiallyin recent years. The following factors have had a stimulating effect on the market for bariatric surgery:

Stimulating Factor #1Continued obesity epidemic

The explosive growth of bariatric surgery in recent years parallels the rise of obesity in the United States.

Approximately 65 percent of Americans are overweight and 30 percent are obese, and annual medicalspending due to these conditions may comprise as much as 9.1 percent of total medical spending.21As long-term medical and behavioral weight-management interventions have not been proven successfulin treating morbid obesity, increasing numbers of these patients are turning to bariatric surgery.22

Stimulating Factor #2Rise in consumer awareness of bariatric surgery

Despite critical articles highlighting patient deaths due to complications from bariatric surgery, in recentyears the successful procedures undergone by celebrities such as singer Carney Wilson, celebrity SharonOsbourne, comedian Roseanne Barr, NBC Today show weatherman Al Roker, and New YorkCongressman Jerry Nadlercombined with increasing public consciousness of the negative health effectsof obesityhave raised awareness of the potential benefits of bariatric surgery.23

Stimulating Factor #3Growing numbers of trained bariatric surgeons

In response to the large demand for bariatric surgery, the number of surgeons with significant experienceperforming bariatric surgeries has been increasing rapidly, contributing to the growth of the market.24For example, between 1998 and 2002, the number of bariatric surgeons with membership in the ASBSincreased 144 percent.25 A growing number of bariatric surgeons performing more surgeries will likelylead to improved outcomes and even more interest in the procedure, both from patients and vendorspromising less-invasive and more cost-effective technologies.26

Rate of growth expected to decrease as market matures

Advisory Board analysis suggests that two phases of expansion lie ahead for bariatric surgery volumes;first, a rapid increase driven by 20 percent growth in demographics and 113 percent growth in utilization,

followed by a second phase of more moderate expansion tempered by market maturation and replacementtherapies, as shown in the chart on the following page.

21 AORN. AORN Bariatric Surgery Guideline. (2005). 2005 Standards, Recommended Practices, Guidelines.www.aorn.org/about/positions/default.htm#guidance (Accessed April 17, 2006).

22ibid.23 The Facts About Obesity Surgery. (May 2004). The Johns Hopkins Medical Letter: Health After 50.

www.hopkinsafter50.com/html/silos/nutrition/nwLIB_HA50_ObesitySurgery.php (Accessed April 17, 2006).24 Innovations Center. Future of General Surgery: Strategic Forecast and Investment Blueprint. Washington, DC: The Advisory

Board Company. (2005).25 Nguyen, N., et al. Accelerated Growth of Bariatric Surgery With the Introduction of Minimally Invasive Surgery.Archives

of Surgery. 140. (2005). http://archsurg.ama-assn.org/cgi/content/abstract/140/12/1198 (Accessed April 17, 2006).26 Financial Leadership Council. Hospitals Can Overcome Payment, Cost Hurdles to Capitalize on Bariatric Surgerys

Potential. Finance Watch. Washington, DC: The Advisory Board Company. (September 2, 2005).


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III.COSTS AND REIMBURSEMENT ASSOCIATED WITH BARIATRIC SURGERY

Overall procedure costs may reach $100,000

Obesity surgeries cost, on average, at $20,000 to $25,000 each to the consumer. Should complications inthe surgery occur, costs to the hospital may rise to between $100,000 and $200,000.27 Total spending onbariatric procedures in the United States is approaching $3 billion per year as of 2003.28 In addition to theinitial surgery costs, life-long follow-up careincluding check-ups and counselingis strongly

recommended. Including one to two years of follow-up costs, the overall procedure cost for hospitalswithout complications can skyrocket to $50,000 to $100,000.29

The graph on the following page depicts average total hospital charges for obesity-related surgeries,DRG 288. However, the costs listed in the diagram do not include follow-up costs.

27 Alt, S. Market Memo: Bariatric Surgery May Become a Self-Pay Service.Health Care Strategic Management. 21(12).(December 1, 2003).

28 Freudenheim, M. Hospitals Pressured By Soaring Demand for Obesity Surgery.New York Times. (August 29, 2003).http://query.nytimes.com/gst/fullpage.html?sec=health&res=9F02E5DA1F39F93AA1575BC0A9659C8B63(Accessed April 24, 2006).

29 Alt, S. Market Memo: Bariatric Surgery May Become a Self-Pay Service.Health Care Strategic Management. 21(12).(December 1, 2003).

Volume growth will slow by 2010 as market matures

Drivers of growth for bariatric surgery, 2005

Source: Innovations Center, Future of General Surgery: Strategic Forecast and Investment Blueprint,Washington, DC: The Advisory Board Company, (2005).


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Average total cost for bariatric surgery $29,717

Operating room

(OR), $6,606

Special care unit,

$2,018

General care unit,$3,020

Radiology, $602

Laboratory,

$1,749

Anesthesiology,$1,281

Reimbursement rates for surgical treatments falter

Third-party payer reimbursement for bariatric procedures varies widely. While some insurance carriershave refused to cover surgical treatments for obesity, other carriers will reimburse providers with someexceptions. The table below notes average charges, costs, and reimbursement for obesity surgeries in

2000 and 2001.

2000 2001Percent increase

from 2000 to 2001

Charges $27,395 $29,717 8 percent

Costs $10,700 $11,246 5 percent

Reimbursement $10,677 $11,027 3 percent

As indicated in the above table, from 2000 to 2001, charges, costs, and reimbursements for obesitysurgery increased. However, despite the fact that costs increased five percent, average reimbursementonly increased three percent.30

30 Solucient, LLC. The DRG Handbook: Comparative Clinical and Financial Benchmarks . (2003).

Source: Solucient, LLC, The DRG Handbook: ComparativeClinical and Financial Benchmarks, (2003.)

Average costs of surgery charges, 2001

Costs on the rise, while reimbursements dwindle

Average financial statistics per discharge in U.S. dollars, 2001*

Source: Solucient, LLC, The DRG Handbook: ComparativeClinical and Financial Benchmarks, (2003).*DRG 288


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Disparities in public and private insurance reimbursements

In addition, public and private payers differ substantially in their level of reimbursement, as shown in thetable below.

Payer Surgeon Hospital P-value

Private (n=59) $2,356 (+/- 822) $4,435 (+/- 316)*


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IV.PROGRAM COMPONENTS

Future programs will be shaped by COE requirements

As a result of CMS February 2006 decision to limit reimbursement to only those hospitals that have beenaccredited as COEs, many smaller programs will likely have difficulty remaining competitive. Although

only a small percentage of bariatric surgery patients are covered by Medicare, this final decision hasimportant repercussions for private payers, who now may reassess their coverage policies. Moreover,the decision has critical financial implications for programs that are unable to meet the new volumethreshold necessary to qualify for Medicare reimbursement.33 Consequently, the landscape of remainingprograms will be strongly influenced by the requirements of the ASBS and the ACS for gaining COEaccreditation. In order to remain successful, hospitals will be forced to offer the kinds of comprehensivesupport services required of COEs. The diagram on the following page describes the criteria that must bemet to attain Provisional COE statuswhich focuses on the resources of the applicant hospitalcreatedby the Raleigh, North Carolina-based Surgical Review Corporation (SRC), a not-for-profit entity createdby the ASBS for the accreditation of COEs.



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Source: Surgical Review Corporation, Requirements Provisional Status, (2005),www.surgicalreview.org/r_provisional.html (Accessed April 17, 2006).

1. The hospital displays an institutional commitment at the highest levels of the medical staff and theinstitutions administration to excellence in the care of bariatric surgical patients as documented with an

ongoing regularly scheduled in-service education program and credentialing guidelines for bariatricsurgery.

2. The hospital will perform at least 125 bariatric surgical cases per year. Each applicant surgeon will haveperformed at least 125 total bariatric cases with at least 50 cases performed in the preceding 12 monthperiod.

3. The hospital maintains a designated physician medical director for bariatric surgery who participates inthe relevant decision-making administrative meetings of the institution.

4. The hospital maintains, within 30 minutes of request, a full complement of the various consultativeservicesrequired for the care of bariatric surgical patients including the immediate availability of anAdvanced Cardiac Life Support (ACLS)-certified physician on-site who can perform patient

resuscitations.

5. The hospital maintains a full line of equipment and instruments for the care of bariatric surgicalpatients including furniture, wheelchairs, operating room tables, beds, radiologic facilities, surgicalinstruments, and other facilities suitable for morbidly obese patients.

6. The hospital has a bariatric surgeon who spends a significant portion of his or her efforts in the fieldof bariatric surgery and who has qualified coverage and support for patient care.

7. The hospital utilizes clinical pathwaysand orders that facilitate the standardization of peri-operative carefor the relevant procedure. In addition, all bariatric surgicalprocedures are standardized for eachsurgeon.

8. The hospital utilizes designated nurse or physician extenders who are dedicated to serving bariatricsurgical patients and who are involved in continuing education in the care of bariatric patients.

9. The hospital makes available organized and supervised support groups for all patients who haveundergone bariatric surgery at the institution.

10. The hospital provides documentation of a program dedicated to a goal oflong-term patient follow-up ofat least 75 percent for bariatric procedures at five years with a monitoring and tracking system foroutcomes, and agreement to provide annual outcome summaries to the SRC in a manner consistent withHealth Insurance Portability and Accountability Act (HIPAA) regulations.

COE designation will require significant investment

SRC Provisional COE status requirements, 2005


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Reimbursement eligibility additionally requires demonstration of acceptable outcomes

To attain full accreditation as a COEand therefore be eligible for Medicare reimbursementhospitalsmust further demonstrate the achievement of acceptable outcomes and host a site inspection by SRCpersonnel.34 Over 120 bariatric programs are currently accredited as COEs.35

The following sections examine bariatric program components in the following areas:

Patient selection Pre-operative care Care coordination and support services Post-operative care

Patient selection

Patient selection often a multi-step process

With the understanding that near-term bariatric surgery volumes will continue to rise, expandingprograms must institute measures to care for the growing number of patients who will seek and receive

the treatment. These programs must have substantial capability to filter for appropriate candidates,offer pre- and post-operative education, and cultivate a comprehensive suite of patient support services.Past research has identified certain strategies as among some of the most effective currently beingundertaken by leading bariatric programs to ensure accurate patient selection and pre-operative care.36,37

For example, administrators at Indianapolis, Indiana-based Saint Vincent Hospitals and Health Serviceshave tried to improve effectiveness and throughput in the hospitals bariatric surgery program by ensuringthat surgical consultations are granted only to qualified candidates and that disqualifying patientconditions (such as psychological problems or severe co-morbidities) trigger immediate removal from thesurgery schedule.38 The process for patient selection is detailed in the graphic on the following page.

34 Surgical Review Corporation, Requirements Full Approval. (2005). www.surgicalreview.org/r_provisional.html(Accessed April 17, 2006).


36 Comprehensive Weight Loss Programs. (February 2004).37 Quality Measurements for Bariatric Surgery Programs. (January 2004).38 Marketing and Planning Leadership Council.Bariatric Surgery Programs: Clinical Innovation Profile.

Washington, DC: The Advisory Board Company. (2002).


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Of particular interest in the St. Vincent Hospitals and Health Services screening process is that of thepatients passing all four stages of pre-selection evaluation, an additional 20 percent may further bedisqualified and are directed towards other treatment options. Additionally, conscious of the fact thatmany disqualifying factors can be eliminated over time, administrators at programs such as St. VincentHospitals and Health Services assist patients in gaining surgical eligibility by offering non-surgicalmedical support. Ultimately, many formerly ineligible patients become qualified candidates andeventually receive surgery.39

39 Marketing and Planning Leadership Council.Bariatric Surgery Programs: Clinical Innovation Profile.Washington, DC: The Advisory Board Company. (2002).

Source: Advisory Board interview; Marketing and Planning Leadership Council, Bariatric SurgeryPrograms: Clinical Innovation Profile, Washington, DC: The Advisory Board Company, (2002).

Case Study A: Stringent selection process targets most appropriate treatment option

Patient selection process at Indianapolis, Indiana-based St. Vincent Hospitals and HealthServices, 2002


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Pre-operative care

Pre-operative care plays important role in effective programs

In addition to a stringent patient selection process, clinically solid bariatric surgery programs have alsoinstitutionalized rigorous pre-operative care tactics, including those discussed below:

Tactic #1Dedicated pre-surgery consultation instrumental in educating and selectingcandidates.

Pre-operative education is essential to ensuring positive surgical outcomes due to the significant role thatpatients play in achieving long-term success through changes in lifestyle and diet. Notably, groupsessions prove much more effective than individual counseling, as patients are more comfortable raisingconcerns and participating in discussions in a group environment. Additionally, a number of potentialpatients may elect not to have the surgery following these discussions, as they do not believe they wouldbe able to adapt to the necessary lifestyle changes.40

Tactic #2Psychological counseling essential for behavioral modification andmonitoring for depression.

Administrators believe that support services must incorporate significant psychological counseling,both during pre-screening for the procedure and to address the lifestyle choices that have brought aboutthe surgerys necessity. Patients are forced to recognize previous eating disorders and must demonstratean adequate support system to ensure the treatments long-term success. Additionally, due to theextreme nature of the procedure and its positioning as a last resort treatment, patients may beespecially susceptible to depression, which psychological counselors can anticipate and treat.41

Tactic #3Leading programs have full range of support services available to patients.

A multidisciplinary panel of physicians and support staff should evaluate and care for patients in thepre- and post-operative stages of care. This panel may include the individuals listed below.42

o Anesthesiologistso Cardiologistso Internistso Nutrition staffo Pre-operative education staff: surgeon,

registered nurse (RN), and a prior patient

o Psychiatristso Psychologistso Pulmonologistso RN program coordinator

Testing and surgery appointment is final confirmation of surgery eligibility

Although the exact ordering of pre-surgery testing and physician meetings varies between programs,many contain the components listed below and on the following page.

Laboratory testing: All patients are required to receive standard pre-surgery blood work.Stool samples are tested for the presence of the bacteria H-pylori, a potential cause of stomachulcers and cancer. Because the bacteria cannot be treated once the stomach is closed, patients withthe bacteriaabout 30 percent of the general populationare put on a regimen of strong antibioticsprior to surgery.

40 Quality Measurements for Bariatric Surgery Programs. (January 2004).41ibid.42ibid.


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Detailed medical history and bariatric physical: Detailed medical histories are either taken by thesurgeon or a nurse clinician. The bariatric physician always conducts the pre-operative physical andpatient consultation. At this point, the physician gives final approval for the procedure and asurgery date is set. In some cases, the patient is required to meet several additional standards priorto receiving physician approval. For example, all patients may be required to weigh less than350 pounds so that the hospitals radiology equipment can be employed to diagnose postoperative

complications. Physicians will set additional appointments with bariatric dieticians to help patientsreach this goal.

Preoperative anesthesiology: As with most surgeries, the anesthesiologist meets with patients toanticipate any complications that could arise under general anesthesia.

An example of the educational and pre-operative components of a bariatric surgery program at onehospital is provided in the following case study:43

43 Components of a Bariatric Surgery Program. (April 2003).

The bariatric program at AMC Ba 300-bed, not-for-profit AMCserves patients from across theregion, many of whom travel multiple hours to reach the physicians office. In order to improve theconvenience of care, much of the preliminary verification of program eligibility and education can beconducted via the telephone, internet, and e-mail. A patient may make one pre-surgical visit to thephysicians office. Then, the patient arrives for surgery two days before the actual surgery date.The three day program operates as follows:

Day 1: Patients arrive at the surgeons office and immediately have blood drawn forlaboratory (lab) tests and have a gall bladder ultrasound, pulmonary function test,electrocardiogram (EKG), chest X-ray, and H-pylori test. The patient spends theafternoon with the educator, reviewing the procedure, postoperative recovery, and dietinformation.

Day 2: The surgeon performs an outpatient esophagogastroduodenoscopy(EGD)procedure ensuring that the patients stomach is healthy and ulcer free. The patient alsomeets with the anesthesiologist. In the afternoon, the patient again meets with thephysician for a pre-surgery consultation, undergoing a final review of the patientscomprehensive medical history, laboratory and test results, and postoperativeprocedures.

Day 3: Surgery is performed.

Case Study B: AMC B condenses education, testing, pre-operative appointment,and surgery into three days

Source: Components of a Bariatric Surgery Program, (April 2003).


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Care coordination and support services

Comprehensive support services necessary for optimal outcomes

Due to the complicated nature of the procedure and the potentially life-altering changes associated with it,many programs have found it necessary to provide patients with a wide variety of support services.According to the medical director for bariatric surgery at the 257-bed, for-profit University of Southern

California (USC) University Hospital in Los Angeles, California:

There must be an organized team of doctors, surgeons and staff or else[the program]

will fail. No other specialty takes the kind of effort and time as this particular specialty.

You are married to the patient for life.44

To a greater extent than most surgical patients, individuals undergoing bariatric surgery have sufferedfrom lifestyle, dietary, and emotional proclivities that result in a need for surgery. While the surgicalprocedure physically alters the patient, accounting for these other factors forces a bariatric surgeryprogram to include far more than the actual surgical procedure, such as thorough candidate screening and

dedicated follow-up to ensure dietary compliance.

Program coordinator essential component of comprehensive service line

In order to effectively provide the wide variety of services necessary for a successful program,many hospitals maintain a bariatric surgery program coordinator.45 The coordinator is essential formanaging patient flow between first contact and surgery. When combined with the five- to six-monthconsultative process, the reliance of bariatric surgery programs on disparate hospital servicesincludinganesthesiology, surgery, psychiatry, nutrition, and nursingrequires centralized management for efficientand effective care delivery. However, in addition to this strictly administratorial role, programcoordinators are often called upon to provide the guidance and emotional support required by bariatricsurgery candidates throughout the process. Bariatric surgery program coordinators may fulfill the roleslisted on the following page.46

44 Alt, S. Market Memo: Bariatric Surgery Programs Growing Quickly Nationwide.Health Care Strategic Management.(September 2001).

45 Components of a Bariatric Surgery Program. (April 2003).46ibid.


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Informational resource: Throughout the pre-operative and post-operative processes,the program coordinator serves as an invaluable informational resource for both patients andprogram staff members. In general, program coordinators are available to answer all questionsabout bariatric surgery, the program, and other related issues.

Information and introductory meetings: In addition to serving as a point of first contact,program coordinators generally organize and run introductory and informational sessions on theprocedure. Program coordinators and other staff often attempt to build personal relationships withbariatric candidates, winning confidence and trust in the programs medical sophistication andpatient support-oriented philosophy.

Patient screening: Program coordinators are often the first program representatives with whompotential patients interact. In addition to securing relevant patient information and determiningwhether patients are appropriate candidates for bariatric surgery, initial contact conversations canalso cover a wide range of obesity and bariatric surgery-related topics.

Process management: Once a candidate has been accepted into the bariatric program,the coordinator may assume responsibility for managing pre-operative and post-operative

throughput. The pre-operative process generally includes diagnostic laboratory work, patienteducation, surgeon consultation, psychological counseling, and support group participation.The post-operative process may include nutritional counseling, surgeon follow-ups, lab testing,and support group attendance.

Support group liaison: For maximum effectiveness, the support group is often partially managedby the program coordinator. Serving as a liaison between the group and the program,the coordinator ensures the support group continues to meet the informational and emotional needsof candidates and patients.

Post-operative careIn addition, a crucial component of ensuring high quality bariatric surgery is the implementation of aneffective follow-up care regimen. The following are selected effective strategies for follow up care:47

Support groups help patients walk the line, both mentally, physically

Long-term follow-up care is both essential to meaningful weight loss and the most difficult part of therecovery process. Bariatric surgery programs must therefore provide patients with extensive supportnetworks, including both individualized support from staff members and patient-based support groups.These groups can also engender essential friendships, as recovering patients can connect over treatmentand encourage each other to make significant lifestyle changes through group activities such as takingactive walks or preparing healthy meals. A support group profiled in recent Advisory Board research is

led by two nurse practitioners (NPs) and two psychologists with whom members meet monthly.

48

47 Assessing Bariatric Surgery Programs. (May 2004).48 Quality Measurements for Bariatric Surgery Programs. (January 2004).

Source: Components of a Bariatric Surgery Program, (April 2003).

Bariatric program coordinators fulfill clinical, administrative responsibilities


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Tracking data critical to maintaining high quality clinical outcomes

In order to benchmark and optimize clinical outcomes, administrators must track data;comprehensive programs invest often in bariatric information systems to accomplish this task.A sampling of data tracked by bariatric surgery programs is provided below.49

Average length of stay (ALOS) In 2001, the ALOS for open gastric bypass surgery was 3.5 to4.0 days and 2.5 to 4.0 days for laparoscopic procedures.

Surgeons incidence of leaks occurring post surgeryA one to two percent rate isconsidered acceptable for hospitals with high bariatric surgery volumes.

Wound infection ratesInfection rates should equal less than five percent.In combination with these post-surgery processes and metrics, consistently tracking comprehensivesurgical outcomes data is imperative for benchmarking and quality assurance purposes.

49 Comprehensive Weight Loss Programs. (February 2004).


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The Advisory Board has worked to ensure the accuracy of the information it provides to its members.

This project relies on data obtained from many sources, however, and the Advisory Board cannotguarantee the accuracy of the information or its analysis in all cases. Further, the Advisory Board is notengaged in rendering clinical, legal, accounting, or other professional services. Its projects should not beconstrued as professional advice on any particular set of facts or circumstances. Especially with respectto matters that involve clinical practice and direct patient treatment, members are advised to consult withtheir medical staffs and senior management, or other appropriate professionals, prior to implementingany changes based on this project. Neither the Advisory Board Company nor its programs areresponsible for any claims or losses that may arise from any errors or omissions in their projects,whether caused by the Advisory Board Company or its sources. 1-JV6MF

2006 by the Advisory Board Company, 2445 M Street, N.W., Washington, DC 20037.Any reproduction or retransmission, in whole or in part, is a violation of federal law and is strictlyprohibited without the consent of the Advisory Board Company. This prohibition extends to sharing this

publication with clients and/or affiliate companies. All rights reserved.

Professional Services Note

During the course of research, Original Inquiry staff searched the following resources toidentify pertinent information:

Advisory Boards internal and online (www.advisory.com) research libraries Factiva, a Dow Jones and Reuters company Internet, via search engines and multiple websites, including the following:

American College of Surgeons (ACS) at www.facs.org American Society for Bariatric Surgery (ASBS) at www.asbs.org PubMedTM at www.pubmed.com Surgical Review Corporation at www.surgicalreview.org/requirements.html Surgery for Obesity and Related Diseases at www.soard.org Weight Control Information Network (WIN) at

http://win.niddk.nih.gov/statistics/index.htm

Research Methodology

Documents

Bariatric Trends May 2006