Use and Costs of Bariatric Surgery and Prescription Weight-Loss Medications

William E. Encinosa; Didem M. Bernard; Claudia A. Steiner; Chi-Chang Chen


Health Affairs. 2005;24(4):1039-1046. 

In This Article

Discussion and Policy Implications

As bariatric surgeons perform more surgeries and outcomes continue to improve, it is likely that more people will opt for the surgery. This potential demand may be quite large since the number of bariatric surgeries has grown 400 percent in just five years. This growth will likely continue, given that only 0.6 percent of the 11.5 million eligible people underwent the surgery in 2002.[21]

Use of weight-loss medications declined in 1997 with the removal of fenfluramine and dexfenfluramine from the market (because of heartvalue abnormalities), but it picked up again in 1999, when orlistat entered the market.[22] The industry reports that total U.S. sales for weight-loss medications in 2002 were $362 million.[23] In 2002 an estimated 63.3 million

U.S. adults were clinically eligible for weight-loss medications but these drugs were used by less than 2.4 percent of those eligible. Thus, usage could greatly increase, given that many new, more effective prescription weight-loss medications are being developed.[24] Some of the new drugs in the pipeline, such as rimonabant (Acomplia), will block a pathway in the brain that produces the craving for food. In recent trials of rimonabant, 44 percent of subjects lost more than 10 percent of body weight at one year compared with 10 percent of subjects taking placebo.[25] Other new drugs will block the hormone ghrelin, which is sent from the stomach to the brain to create an appetite.[26] Some drugs will instead stimulate beta 3 receptors to increase fat burning within the body.[27] These new medications will likely increase the demand for weight-loss drug therapy.

For the elderly, the Medicare program covers bariatric surgery only for those patients with coexisting conditions such as diabetes.[28] Therateofincreasein bariatric surgery between 1998 and 2002 was highest among the near-elderly (ages 55-64), at 900 percent. An estimated 395,000 elderly people (ages 65-69) will be clinically eligible for bariatric surgery in 2005.[29] By 2010 this number could grow to 475,000. Thus, if Medicare decides to expand coverage for bariatric surgery in the near future, the potential demand by the elderly may be quite large.

Bariatric drugs are not included in the final version of U.S. Pharmacopeial Convention (USP) Model Guidelines created under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. The act excludes agents used for weight loss. However, according to the final rules recently released by the Centers for Medicare and Medicaid Services (CMS), bariatric drugs can be covered by Medicare Part D if they are prescribed for a "medically accepted indication" such as morbid obesity. Thus, it is not yet clear to what extent the 500 potential drug plans in Medicare Part D will choose to include bariatric medications on their formularies. We estimate that about 3.3 million Medicare beneficiaries ages 65-69 will be clinically eligible for bariatric drugs in 2005.[30]

Our results show a clear difference between the sexes in the use of bariatric treatments. We estimated that 43 percent of the adults clinically eligible for drug therapy in 2002 were men; however, only 22 percent of adults taking bariatric prescription drugs were men. In contrast, while 57 percent of those clinically eligible were women, women accounted for 78 percent of drug users. Also, 31 percent of adults eligible for bariatric surgery in 2002 were men, but only 16 percent of procedures among adults were performed on men.[31] In contrast, while 69 percent of those eligible for surgery were women, women accounted for 84 percent of the surgeries. Moreover, men had worse in-hospital mortality rates than the women in their same age group. The higher inpatient mortality for men is consistent with higher coexisting illnesses or higher BMI at the time of surgery.[32]


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