Insurers are expanding access to bariatric surgery

Bariatric surgery refers to several different procedures, including gastric bypass or gastric sleeve, that reduce the size of a patient's stomach to change the way they eat. Although research has shown that bariatric surgery is one of the most effective weight-loss treatments, adoption remains relatively low.

According to a 2019 study published in Surgery for Obesity and Related Diseases, an estimated 228,000 patients undergo bariatric surgery in the United States each year, or only 1% of the eligible population. High costs, which can average between $17,000 and $26,000, and a lack of insurance coverage are common barriers to the procedure for many patients.

However, some insurers are now expanding access to bariatric surgery by eliminating prior authorization requirements and covering the procedure for more conditions.

For example, Blue Cross Blue Shield of Michigan removed prior authorization requirements for bariatric surgery in September. Blue Cross and Blue Shield carriers in Massachusetts and Vermont have also updated their requirements for bariatric surgery.

"We saw, at the end of the day, that we were making people go through unnecessary hoops for bariatric surgery," said Jim Grant, CMO of Blue Cross Blue Shield of Michigan. "Why make our physicians and our members go through unnecessary hassles?"

Similarly, Geisinger Health Plan expanded its coverage of bariatric surgery to cover more conditions. "If you have patients who benefit from GLP-1s, but can't tolerate them for whatever reason, they may be great candidates to have bariatric surgery," said Geisinger CMO John Bulger. "There are a lot of patients that don't tolerate them and, in the end, whether people will continue to take them or not remains to be seen. People start them and stop them."

At the same time, insurers are also implementing more stringent requirements for expensive new weight-loss medications, such as Novo Nordisk's Wegovy and Ozempic and Eli Lilly's Trulicity.

According to James Chambers, a professor at Tufts Medical Center, covering bariatric surgery for patients may be cheaper than covering weight-loss drugs for them, as the drugs can cost roughly $1,000 per month in perpetuity. "This is an example of how a new technology is forcing the healthcare system to reevaluate existing technologies, not just in terms of the cost, but also the value," he said.

For their part, insurers say that the changes in their coverage of bariatric surgery are simply the result of regular reviews and not in response to new weight-loss medications.

"Our policies don't prioritize bariatric surgery over GLP-1s [glucagon-like peptide 1 drugs]," Grant said. "The decision between a GLP-1 and bariatric surgery is not our decision. That's a decision made by the patient with the consultation of their physician."

Could bariatric surgery become more common?

According to medical device companies such as Johnson & Johnson (J&J), Medtronic, and Intuit Medical Products, new weight-loss treatments are expected to increase their bottom lines as more people learn about obesity as a medical condition and identify potential treatment options.

"When we talk to bariatric surgeons, many of them comment on the fact that they could see a tailwind for bariatric surgery down the road," said J&J CEO Joaquin Duato. "Many of the patients—about 30% of them—are not going to be tolerating these medications. There would be another funnel for our bariatric business."

More primary care doctors are also working with surgeons to develop integrated treatment plans that combine surgery with weight-loss medication, said Kristal Hartman, board chair of the Obesity Action Coalition, a patient advocacy group that is supported by drugmakers, device companies, and providers. Hartman herself has received bariatric surgery and uses GLP-1 drugs to manage her weight and other health conditions.

"We already have data that shows the surgery has shown to be successful," Hartman said. "Insurers may be thinking, 'We should start reducing some of the barriers to bariatric surgery while we work out everyone in the world thinking that suddenly 40% of America is going to be put on a $1,300 a month GLP-1 drug.'" (Tepper, Modern Healthcare, 1/4)

Hospital and health system leaders worry that Wegovy and similar weight management medications will erode their bariatric surgery volumes and revenue. However, when health systems and providers provide comprehensive obesity care, they can drive growth for surgical services by improving outcomes, increasing volume, and decreasing costs.