Bariatric Surgery Does Not Reduce Long-Term Health Costs

Bariatric surgery does not reduce overall long-term health costs for obese individuals, a 6-year analysis of private health insurance data has found.

The study, published online February 20 in JAMA Surgery, also found no evidence that any one type of bariatric surgery is more likely than another to reduce costs.

"To assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings," write Jonathan P. Weiner, DrPH, professor of health policy and management from Johns Hopkins University, Baltimore, Maryland, and colleagues.

In an accompanying editorial, JAMA deputy editor Edward H. Livingston, MD, says that the findings call into question whether bariatric surgery is worth the cost. "Accumulating evidence suggests there is no economic benefit for weight-loss surgery... Bariatric surgery has dramatic short-term results, but on a population level its outcomes are far less impressive," he writes.

On the other hand, Robin Blackstone, MD, medical director of the Scottsdale Healthcare Bariatric Center, Arizona, and immediate past president of the American Society for Metabolic and Bariatric Surgery, told Medscape Medical News, "Obese patients routinely experience remission of their major medical problems, get off medications that have serious side effects, and increase their productivity at work… One can argue about the validity of this particular paper, but the essential value of the human experience of life after bariatric surgery cannot perhaps be measured by claims data."

Comparable Costs

The study group comprised 29,820 adult members of 7 Blue Cross/Blue Shield plans who underwent bariatric surgery during 2002 – 2008. Each of those patients was matched with 1 control patient who did not undergo bariatric surgery but who had been diagnosed with obesity-related conditions, including hypertension, type 2 diabetes, sleep apnea, metabolic syndrome, and/or gallbladder disease.

One can argue about the validity of this particular paper, but the essential value of the human experience of life after bariatric surgery cannot perhaps be measured by claims data. Dr. Robin Blackstone

Controls were also matched to the surgery patients for age, sex, and other factors, including obesity propensity score, a measure developed by the authors for identifying obese patients from claims data.

Total costs — including surgery and inpatient, professional office, pharmacy, and other non-inpatient services — were similar between the surgery and nonsurgery groups in the year prior to the index surgery, at $8850 and $9590, respectively. The cost of the surgery itself plus the 30-day postoperative care totaled $29,517.

Following the index surgery, annual total costs peaked at year 2 and then leveled off but remained above that of the presurgery period for the entire 6-year follow-up. After adjustment, total expenditures for the surgery patients were 16% higher than for those of the nonsurgery patients in year 2 postsurgery and 7% higher in year 3, but costs for the 2 groups were roughly comparable in the subsequent postsurgical time periods.

However, there were notable differences in the types of costs incurred. After adjustment, inpatient costs were significantly higher for the surgery patients, while pharmacy and physician office costs were significantly lower compared with the nonsurgery patients.

An analysis of just the surgery patients by type of bariatric procedure showed that total costs for laparoscopic gastric bypass and for laparoscopic banding were significantly lower than for open gastric bypass during years 1 and 2 — primarily due to lower inpatient costs — but not thereafter. However, there was less follow-up time for laparoscopic procedures because they are newer, the authors note.

Is Bariatric Surgery Worth It?

Dr. Livingston — a gastrointestinal/endocrine surgeon himself — says bariatric surgery should not be done for the sole indication of high body mass index (BMI) but rather should be restricted to individuals with obesity complications known to improve with bariatric surgery, such as diabetes and osteoarthritis.

"Current data suggest that weight-loss operations should be offered to highly selected patients," Dr. Livingston writes.

He adds, "In this era of tight finances and inevitable rationing of healthcare resources, bariatric surgery should be viewed as an expensive resource that can help some patients. Those patients should be carefully vetted and the operations offered only if there is an overwhelming probability of long-term success."

But Dr. Blackstone questioned the study's lumping together of the older open procedures with more recent laparoscopic procedures. During the course of the study, surgery trends had shifted so that while 70% of those in 2002 were open gastric bypass, laparoscopic procedures had become far more common by 2005.

"The cost differential between open and laparoscopic cases has been shown to be substantial in other studies… I am wondering, if they [had] just concentrated on laparoscopic [gastric bypass] and matched them more closely with the nonoperated cohort, whether the outcomes would have been quite different," she told Medscape Medical News.

And, she noted, a previously published analysis found bariatric surgery to be cost-effective among all obese people with BMI of 35 and above, with or without obesity-related comorbidities.

Dr. Weiner told Medscape Medical News that it is important to remember that his study was not a cost-benefit analysis. "This simply looked at cost. We did not look at benefit. This would only be one half of the value equation... If I were an insurer, I would never use just this study. I would look at longevity, improved health, and of course satisfaction."

Dr. Weiner, who served on the 2004 Medicare Coverage Advisory Committee that addressed coverage for bariatric surgery for morbid obesity, said future policy decisions regarding who should be candidates for bariatric surgery will need to take into account both short-term and long-term benefit as well as cost and that this study contributes to the knowledge base.

"Well-done, empirical long-term studies are a very important source of input into the process, and this is a well-done [and the] longest-term, biggest study done to date. It's not the only source of information, however."

The study was supported in part by unrestricted research grants from Ethicon Endo-Surgery (a division of Johnson & Johnson), Pfizer, and GlaxoSmithKline. In-kind support was provided by Blue Cross BlueShield. No other disclosures were reported. Dr. Livingston's only disclosure is his position as JAMA deputy editor. Dr. Blackstone is a consultant for Johnson & Johnson and a principal investigator for Enteromedics on a Food and Drug Administration trial of a medical device.

JAMA Surg . Published online February 20, 2013. Abstract