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

Abstract

Background: Insurance companies often require a mandated medical program (MMP)
before bariatric surgery. It is unknown whether MMPs improve weight loss before and after surgery.

Objective: The purpose of our study was to determine if MMPs improve pre- and
postoperative weight loss.

Setting: Tertiary care, U.S. academic teaching hospital

Methods: After IRB approval, data were collected prospectively on consecutive patients
undergoing non-revisional laparoscopic gastric bypass (LRYGB) or adjustable gastric
banding (LAGB) between August 2006 and 2010 by a single surgeon (TSK). Patients
were divided into two groups: 1) MMP and 2) non-MMP. MMP patients underwent a
standardized program of at least 6 months duration under the direction of our medical
bariatricians and nutritionists. LRYGB and LAGB patients were analyzed separately.
Primary outcome data included time to surgery and %EWL before surgery and at 6 and
12 months after surgery.

Results: There were 440 patients (327 LRYGB and 113 LAGB) in the study. When
comparing MMP and non-MMP patients, there was no significant difference in
preoperative %EWL or %EWL at 6 and 12 months after surgery. MMP patients had a
significantly longer wait time to surgery.

Conclusion: Patients who undergo a standardized MMP have a significant delay in time
to surgery and do not experience significant benefit in preoperative or postoperative
weight loss. Insurance companies should abandon the policy of mandating preoperative medical weight loss programs.
Key words: Gastric bypass, adjustable gastric band, health care insurance, weight loss

Introduction

Obesity is a major health issue in the Unites States.  According to the National Health
and Nutrition Examination Survey (NHENES), in 2007 the prevalence of morbid obesity
in the U.S. was 20%,
1
which exceeds the prevalence of congestive heart failure (CHF),
coronary heart disease (CHD), and diabetes mellitus (DM) combined.
morbid obesity has a wide range of deleterious effects and has been directly linked to
serious health conditions such as  type 2 diabetes mellitus, hypertension, and sleep
apnea.

3, 4

Bariatric surgery is the most effective treatment for obesity, with many patients losing
more than 50% of their excess weight.
5, 6
2
In addition,
Furthermore, studies have also shown that
bariatric surgery can improve or resolve many obesity-related comorbidities.
surgery not only is highly effective but also is relatively safe when compared with other
commonly performed elective procedures. A prospective analysis of patients undergoing
bariatric surgery performed at 10 hospitals in the United States showed a 30-day
mortality of only 0.3% and morbidity of 4.3%.
8
5-7

Bariatric

In contrast, 30-day mortality rates for
laparoscopic cholecystectomy, colorectal surgery, total hip arthroplasty, and coronary
artery bypass grafting were 0.5%, 3.9%, 1.2%, and 4.7%, respectively.

9-12
In 1991, a National Institute of Health (NIH) consensus conference on obesity developed
criteria for bariatric surgery.
13
To qualify for surgery, a patient needed to be morbidly obese, “motivated”, and an
acceptable operative risk. In 2005, the American Society for
Metabolic and Bariatric Surgery (ASMBS) revised the NIH recommendations and stated
that patients should “…have attempted to lose weight by nonoperative means…”
However, they specifically stated that patients “should not be required to have completed
formal nonoperative obesity therapy as a precondition for the operation”.

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

Despite the proven benefits and safety of bariatric surgery, most states do not require
“core benefit” designation of bariatric surgery thus limiting patient access to surgery.
Policies that cover surgery often require a mandated medical program (MMP) before
approving weight loss surgery. The rationale and efficacy of MMPs are questionable with
several authors suggesting that MMPs have no beneficial effect on weight loss after
bariatric surgery.
15, 16
14
Furthermore, there is evidence that MMPs may increase patient
attrition before surgery without improving preoperative weight loss.
15

This study was designed to examine the effect of MMPs on pre- and postoperative weight loss surgery in
patients undergoing either LRYGB or LAGB and to determine the degree to which
MMPs delay surgery.

Methods

After Institutional Review Board (IRB) approval, we analyzed prospectively collected
data of consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass
(LRYGB) or laparoscopic adjustable gastric banding (LAGB) between 2006 and 2010 by
a single surgeon (TSK). Patients were separated by procedure and then divided into two
groups for each procedure. The MMP group consisted of patients whose insurance carrier
required a mandated medical program. The second group (non-MMP) included patients
who underwent a bariatric procedure without a formal MMP.

All patients underwent preoperative assessment and counseling at our multidisciplinary
weight loss center (Carolinas Weight Management and Wellness Center).  This included
a comprehensive, standardized nutritional evaluation with our Registered Dietician and a
psychological assessment with our psychologist. There were a small percentage of
patients whose insurance plan did not cover psychological care with our provider and
these patients were referred to an outside psychologist. Furthermore, all patients attended
a nutritional class 2 weeks prior to surgery and were given detailed instructions on
intiation of standardized 1300 kcal/day liquid diet  in an attempt to reduce liver mass.  In
addition to the above, MMP patients underwent a preoperative, multidisciplinary medical
weight loss program at our center with one of our board certified medical bariatricians
and a team of registered dieticians and exercise physiologists. Patients who underwent a
MMP for fewer than 6 months were excluded from this study.

The primary outcome variables were weight loss and time to surgery (days from the
initial consultation to the date of surgery). Preoperative weight loss, which was reported
in Kg and percent excess weight loss (%EWL), was divided into three time frames: 1)
time from the initial consultation to the 2-week preoperative appointment; 2) time from
the 2-week preoperative appointment to the day of surgery (liquid diet) and 3) time from
the initial consultation to the day of surgery (total preoperative weight loss).  Patients
who did not have weight loss data for all three preoperative intervals were excluded from the study.
Postoperative weight loss (%EWL) was analyzed at 6 and 12 months after surgery.

Ideal body weight was defined as the mean weight for a given height in the medium
frame column in the Metropolitan Life height-weight table.
17
All patients were weighed in the preoperative holding area on the day of surgery, and this weight was used to define
the preoperative weight. A Student’s t-test and chi-square test were used for statistical analysis.

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

Results

Four hundred forty patients met inclusion criteria for the study; 327 patients underwent
LRYGB and 113 underwent LAGB with no patient deaths in either group.  There was no
significant difference in age or initial body mass index (BMI) between MMP and non-
MMP patients in the LRYGB and LAGB groups (Tables 1). The LRYGB non-MMP
group had significantly more women than the LRYGB MMP group (90% vs 83%,
p=0.044). There was no significant difference in gender in the LAGB group.

Laparoscopic Gastric Bypass
 
In the LRYGB group, 28% of patients required a MMP.  There was no significant
difference in weight loss (kg or %EWL) between the MMP and non-MMP groups at any
of the three preoperative time intervals (Table 2).

There was no significant difference in %EWL 6 months (p=0.69) and 12 months (p=0.75)
following LRYGB between the MMP and non-MMP groups Furthermore, there was no
significant difference in % follow up at 6 months and 12 months between the 2 groups,
p=0.44 and 0.86 respectively (Table 1).

Laparoscopic Adjustable Gastric Band

In the LAGB group, 23% of patients required a MMP.  There was no significant
difference in weight loss between the MMP and non-MMP groups at any of the three
preoperative time intervals.

There was no significant difference in %EWL at the 6 month (p=0.81) and 12 month
postoperative visits (p=0.22) following LAGB between the MMP and non-MMP groups.
Furthermore, there was no significant difference in % follow up at 6 months and 12
months between the 2 groups, p=0.42 and 0.78 respectively (Table 1).

Discussion
 
The goal of this study was to determine if MMPs significantly improve weight loss
before and after bariatric surgery (LRYGB and LAGB). We also wanted to quantify the
degree to which MMPs delay surgery. According to our data, there was no significant
difference in weight loss at any preoperative weight loss interval or at 6 and 12 months
after surgery between the MMP and non-MMP groups; this held true for both procedures.
Our study also confirmed that MMPs are a relatively common prerequisite for bariatric
surgery, with 26% of insurance carriers imposing this requirement. As expected, MMPs

significantly prolonged the time to surgery.  For LRYGB, the average MMP patient spent
105 days (p<0.001) longer waiting for surgery, while the average LAGB MMP patient
waited 111 days (p<0.001) longer than their non-MMP counterpart.

Morbid obesity is a recognized disease with an accompanying ICD-9 code. Bariatric
surgery has been shown to be an effective treatment for morbid obesity and its associated
comorbidities.
4, 5
However, unlike almost any other disease, insurance coverage for the
treatment of morbid obesity is highly variable and patients who have coverage often face
a myriad of obstacles in obtaining insurance approval for bariatric surgery.  Despite the
fact there is no proven benefit of MMPs, many insurance companies continue to
arbitrarily impose this requirement on their policy holders.

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

There are several reasons why an insurance carrier may require an MMP.  First,
additional weight loss achieved during an MMP may reduce perioperative risks.
Although preoperative weight loss has been shown to improve perioperative parameters
(estimated blood loss, hospital stay, and complications), it is unclear whether MMPs
actually improve preoperative weight loss. To our knowledge, other than this current
study, Ochner et al is the only other study that specifically compared MMP and non-
MMP preoperative weight loss.
16
They concluded that MMP patients did not experience significant weight loss benefit in
the preoperative period. In fact, MMP patients in their study actually gained weight before surgery.
16
In an attempt to fully understand the factors that may influence weight change during the preoperative
phase, we examined weight changes during three different preoperative time intervals. There was no
statistically significant difference in weight loss between the MMP and non-MMP groups
for both LRYGB and LAGB at any of these three time intervals.  Regardless of procedure
or insurance requirement, all groups lost the vast majority of their preoperative weight during the 2 week liquid diet interval.

Insurers also argue that counseling and education during a MMP may increase
compliance, thus enhancing postoperative weight loss. Of the few studies that have
examined the effect of MMPs on postoperative weight loss, none have demonstrated a
clear benefit of MMPs. A study by Jamal et al showed that patients who undergo a
mandatory 6-month MMP loose less weight at 1 year compared with a non-MMP group
(60% vs 67% EWL; p<0.05).
15
Ochner et al also compared postoperative weight loss between 94 MMP patients and
59 non-MMP and concluded that MMPs did not enhance postoperative weight loss, however
their follow up was relatively short ( 3 months). Our data are consistent with papers from Jamal and Ochner.
15, 16

When we compared

postoperative weight loss at 6 and 12 months for LRYGB and LAGB patients, the MMP
groups’ weight loss was not significantly different than the non-MMP group.

Finally, insurance companies may have financial motivations for requiring MMPs.  Our
study and several others have demonstrated that MMPs prolong the time to surgery.  This
delay may lead to higher attrition rates, act as a deterrent to surgery and reduce claims for
bariatric surgery.
15, 16, 18
A study by Jamal et al showed that MMP patients have a
significantly higher dropout rate compared with their counterparts without a similar
requirement (28% vs 19% P<0.05).
15
Although our study did not evaluate attrition rates,
16

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