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Insurance-mandated Medical Programs Prior To Bariatric Surgery: Do Good Things Come To Those Who Wait? Part 2

we did observe that the average MMP patient waited over 3 months longer for surgery
than the non-MMP patients. There were several unique aspects of our study that further
our understanding of MMPs. The current literature investigating the benefits of MMPs is
sparse and is hampered by confounding factors such as multiple surgeons, ill-defined
weight loss metrics, and heterogeneous, unstructured medical weight loss programs.
Our study was limited to a single surgeon, and our MMP patients underwent a standardized
medical program for at least 6 months at our bariatric center. In addition, regardless of
insurance criteria, all patients underwent nutritional counseling with a team of two “surgical”
dieticians at our center and were placed on a standardized low-calorie, 2-week preoperative
liquid diet. Furthermore, we clearly defined the time intervals before surgery and the method for
calculating %EWL.  Finally, our investigation is, to our knowledge, the only published
study that compares weight loss outcomes between MMP and non MMP groups during
the pre and postoperative phase for both LRYGB and LAGB.

Our study has some limitations. First, our follow-up did not go beyond 1 year. This may
be insufficient to fully examine weight loss in LAGB patients, as the weight nadir in this
group is thought to be 2 to 3 years after surgery. In addition, our follow-up period was
insufficient to formulate any conclusions about the effect of MMPs on prevention of
weight regain after LRYGB.  Furthermore, our study did not examine the effect of MMPs
on preoperative attrition, complications or resolution of comorbid conditions. Finally, although
larger than most published studies, our LAGB patient population size was
limited, especially in the 12-month follow up LAGB group.

Must Read:  Insurance-mandated Medical Programs Prior To Bariatric Surgery: Do Good Things Come To Those Who Wait?

Morbid obesity is a complex disease that can involve abnormalities in behavior,
metabolism and neural and endocrine pathways. While effective, surgery is not for
everyone and most surgeons support the concept of thorough psychological and
nutritional counseling before surgery.  The duration and type of preoperative therapy and
evaluations should be individualized, and there are clearly patients who benefit from a
prolonged period of intensive behavioral and psychological preoperative therapy.
However, we disagree with the practice of arbitrarily requiring all patients to undergo a
fixed time period, mandated medical program before surgery. Physicians, as opposed to
the insurance industry, should determine if and when a patient is ready for surgery.
Finally, because MMPs prolong the preoperative phase, it is likely that they increase
health care utilization and inflate the costs associated with bariatric surgery.

Conclusion

Many insurance companies require patients to participate in a medical weight loss
program before surgery.  According to our data, MMPs do not significantly improve
weight loss before or after LRYGB or LAGB; however, they significantly increase the
wait time for surgery.  Thus, we believe that the insurance industry should abandon the
practice of mandating preoperative medical weight loss programs. In addition, further
research is necessary to determine the effect of MMPs on the durability of bariatric
surgery and health care utilization and costs.

 

References

1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity
among US adults, 1999-2008. JAMA 2010;303:235-41.
2. American Heart Associatio. Heart Disease and Stroke Statistics – 2010 Update.
American Heart Association 2010; Dallas, Texas.
3. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term
mortality, morbidity, and health care use in morbidly obese patients. Ann Surg
2004;240:416-23; discussion 423-4.
4. Kushner RF, Noble CA. Long-term outcome of bariatric surgery: an interim
analysis. Mayo Clin Proc 2006;81:S46-51.
5. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review
and meta-analysis. JAMA 2004;292:1724-37.
6. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on
mortality in Swedish obese subjects. N Engl J Med 2007;357:741-52.
7. Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA
2002;288:2793-6.
8. Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal
assessment of bariatric surgery. N Engl J Med 2009;361:445-54.
9. Dolan JP, Diggs BS, Sheppard BC, Hunter JG. The national mortality burden and
significant factors associated with open and laparoscopic cholecystectomy: 1997-
2006. J Gastrointest Surg 2009;13:2292-301.

Must Read:  10 Things Your Doctor Won’t Tell You About Weight Loss Surgery

10. Cram P, Rosenthal GE, Vaughan-Sarrazin MS. Cardiac revascularization in
specialty and general hospitals. N Engl J Med 2005;352:1454-62.
11. Fehringer EV, Mikuls TR, Michaud KD, Henderson WG, O’Dell JR. Shoulder
arthroplasties have fewer complications than hip or knee arthroplasties in US
veterans. Clin Orthop Relat Res 2010;468:717-22.
12. Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an American
College of Surgeons National Surgery Quality Improvement Program: morbidity
and mortality risk calculator for colorectal surgery. J Am Coll Surg
2009;208:1009-16.
13. Gastrointestinal surgery for severe obesity: National Institutes of Health
Consensus Development Conference Statement. Am J Clin Nutr 1992;55:615S-
619S.
14. Buchwald H. Consensus conference statement bariatric surgery for morbid
obesity: health implications for patients, health professionals, and third-party
payers. Surg Obes Relat Dis 2005;1:371-81.
15. Jamal MK, DeMaria EJ, Johnson JM, et al. Insurance-mandated preoperative
dietary counseling does not improve outcome and increases dropout rates in
patients considering gastric bypass surgery for morbid obesity. Surg Obes Relat
Dis 2006;2:122-7.
16. Ochner CN, Puma LM, Raevuori A, Teixeira J, Geliebter A. Effectiveness of a
prebariatric surgery insurance-required weight loss regimen and relation to
postsurgical weight loss. Obesity (Silver Spring) 2010;18:287-92.
17. Harrison GG. Height-weight tables. Ann Intern Med 1985;103:989-94.

18. Madan AK. Insurance mandated preoperative dietary counseling does not
improve outcome and increases drop-out rates in patients considering gastric
bypass surgery for morbid obesity. Surg Obes Relat Dis 2006;2:417-8.

 

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