Covering Bariatric Surgery Is About More Than Weight Loss

Paired with lifestyle changes, evidence suggests the procedure can help reverse or substantially reduce the risk of several obesity-related diseases.

About two years ago, Roger Jones* got some hard news. He was in the intensive care unit with a bad bout of pancreatitis, on top of other issues like high blood pressure, sleep apnea and diabetes.

“The doctor sat on my bed and said, ‘I’ve gotta be honest, you’ve gotta get your numbers under control or you’re not going to have a very long life.’”

That spurred him to make some changes. He started dieting and got 10,000 steps in each day, tracked by his wearable fitness device. Unfortunately, the number on the scale wouldn’t budge.

“It was very frustrating that everything I tried to do didn’t work,” he says.

Obesity as a disease

Jones is far from alone in his struggle to lose weight. According to the latest data, nearly 40 percent of U.S. adults are obese. With that comes several related conditions, like Type 2 diabetes, high blood pressure, sleep apnea, heart disease, certain cancers, joint pain and more.

And obesity is costly. It adds $3,508 to an obese adult’s yearly medical costs, researchers determined in 2017, and costs the U.S. $315.8 billion each year.

But obesity wasn’t always thought of as a disease. It wasn’t until 1998 that the National Institutes of Health called it “a complex multifactorial chronic disease,” and the American Medical Association didn’t define it as such until 2013.

In the past, treatment options for people with obesity were slim. They were simply told to eat less and move more. But, like Jones experienced, that doesn’t always do the trick.

A surgical cure

Surgeons started developing bariatric surgery — a blanket term for several procedures that aid weight loss by making patients’ stomachs smaller or by promoting malabsorption — in the 1950s, even before people defined obesity as a disease.

In the 1970s, Dr. Bruce Wolfe — now a professor in the bariatric surgery program at OHSU in Portland, Ore. — was a surgeon at St. Louis University. He saw the high risks associated with early attempts at bariatric surgery.

“We knew (obesity) is a severe problem that we needed to take care of. But the mortality rate (of the first surgeries) wasn’t acceptable,” he says.

But techniques have gotten more sophisticated in the last seven decades. Mortality rates for the procedures have dropped dramatically to less than 2 per thousand.

And bariatric surgery doesn’t only treat obesity. It can also lead to remission or reduced risk of several obesity-related issues as well.

“The effects are really profound,” says Dr. Tim Wetherill, a bariatric surgeon and medical director with the Blue Cross and Blue Shield Plans of Illinois, Montana, New Mexico, Oklahoma and Texas.

For instance, bariatric surgery can help people with obesity and Type 2 diabetes either improve diabetes management or put it into remission entirely. Weight-loss surgery can also improve things like high blood pressure, sleep apnea and more.

“If weight loss is achieved, those are reversible, at least in many of the patients,” Wolfe says.

The big ‘if’

The problem is, sustained weight loss isn’t guaranteed after the procedure.

“The body figures it out, understands what was done to it, and wants to revert back to where it was,” says Wetherill. “A lot of people regain the weight.”

To be truly effective, he says, patients need to change what they eat, how they exercise and how they deal with stressors in their lives. Surgeons often counsel patients about this before agreeing to operate.

When Wetherill was practicing, he and his team of clinicians and social workers would help patients completely revamp their lives before operating.

He recalls one patient who may have suffered from hoarding. “We didn’t let her leave the office without dealing with it,” he says.

They helped improve the patient’s situation before operating. She lost the weight, “but her life changed dramatically” beyond that. “That’s what successful programs need to be and deal with,” Wetherill says.

Paying for it

Bariatric surgery isn’t cheap. Gastric bypass, on average, costs about $27,000, according to data from the Health Care Cost Institute. The surgery can cost a lot more depending on the patient’s location and choice of health care provider.

And in the past, most health plans didn’t cover the surgery, for several reasons. Chief among them were the stigma around obesity and poor outcomes of early surgeries.

But, Wolfe says, “over time, the evidence of improved health and safety has been more and more solid and accepted, and as a result it’s appropriate for insurance companies to cover.”

Now, many health plans do cover it. But success still hinges on patients also changing their behaviors, so most plans place limits on when it will be covered.

Following evidence-based practices and industry norms, the five Blue Cross and Blue Shield Plans put some requirements on members who seek the surgery. They must have a certain body mass index or certain obesity-related conditions, and go through surgical, dietary and psychological screens before the surgery will be approved.

The requirements are designed to help health plan members have the most successful surgery possible. If patients aren’t armed with valuable guidance, it’s likely the life-saving surgery may undo itself and they’ll gain the weight back.

That may be why the jury is still out on if paying for bariatric surgery reduces health care costs in the long run.

A 2013 study in JAMA Surgery looked at claims data and concluded bariatric surgery doesn’t reduce overall health care costs in the long term.

But more recent studies come to different conclusions. Research presented at ObesityWeek 2015 showed gastric bypass surgery could reduce a patient’s health care costs by 40 percent. If the patient also had Type 2 diabetes, their costs fell 80 percent after surgery. And a study published in 2018 in British Journal of Surgery shows weight-loss surgery is cost-effective over 10 years.

For Jones, bariatric surgery and the lifestyle changes that came with it were exactly the push he needed. He booked a procedure with a surgeon covered by his Blue Cross and Blue Shield of Texas plan and started forming new habits. He added three or four gym trips a week to his routine. He stopped drinking soda and went from three hamburgers a week to none.

In the first few months after surgery, Jones lost 48 pounds and 6 inches off his waist.

But almost more importantly, his blood sugar is below diabetic level. His sleep apnea vanished, his blood pressure is now “rock solid,” and he could stop taking many medications.

Even his state of mind has improved.

“Everything’s changed,” he says. “It really changed everything for me. I have a much brighter outlook on life now.”

*Name has been changed

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