As the volume of bariatric surgeries performed in the U.S. expands exponentially along with Americans' waistlines, the New York Health Plan Association issued a set of guidelines last week that could eventually determine which hospitals are able to fatten their profit margins by providing the lucrative service.
Designed as a tool for providers, consumers and health plans, the guidelines set standards for selecting the most appropriate patients, the most skilled surgeons and the best equipped and prepared facilities.
Establishing guidelines around certain diseases such as asthma and diabetes is nothing new, and health plans are increasingly working with specialty societies to establish criteria for certain high-volume procedures, said Mohit Ghose, a spokesman for America's Health Insurance Plans, a national trade group that represents insurers. The New York project, however, marks the first such effort around bariatric surgery, he said.
"This is definitely a trend that is going to continue as we focus more and more on evidence-based medicine," Ghose said.
The guidelines were designed only to "create a standard"-not as binding rules for hospitals, said Leslie Moran, a spokeswoman for the New York Health Plan Association, or NYHPA. Neither costs nor reimbursement levels factor into it. "The purpose was to help develop a best-practice pathway," she said.
Bariatric surgery, also known as stomach stapling, is considered a surgical last resort for the morbidly obese. It costs anywhere from $20,000 to $35,000 and usually entails two or three days in the hospital-assuming a re-admission is not required. But the surgery also carries considerable risk. A survey of several thousand patients conducted at the University of Washington determined that one in 50 patients died from the surgery, in part because of "inexperienced surgeons rushing to offer a lucrative but technically demanding `plumbing job,' " said Betsy Mulvey, project coordinator for the NYHPA. Patients of surgeons who had performed fewer than 20 operations were nearly five times more likely to die than others, she added.
Still, demand for this "surgical silver bullet" is skyrocketing, according to the NYHPA. The 144,000 bariatric procedures expected to be performed in the U.S. in 2004 represent more than twice the number performed in 2002 and more than five times the 25,800 surgeries performed in 1998, the association said (March 4, 2002, p. 20).
Funded by a state grant, the group that produced the guidelines was composed of nine health plan medical directors and 12 high-volume bariatric surgeons. For hospitals, the guidelines establish both minimum requirements and criteria for centers of excellence. For example, at the minimum, hospitals offering the procedure should have a specially equipped operating room and a surgery team led by a surgeon meeting the minimum requirements for doctors. On the other hand, a hospital where more than 200 cases are performed per year by a board-certified or board-eligible surgeon who spends at least 75% of the time on bariatric surgery would be considered a center of excellence under the guidelines.
Health plans will be using the guidelines to assess hospitals performing the surgery, Moran said. "We certainly hope the facilities will use them, and the plans will definitely use them," she said.
Oxford Health Plans, which participated in the development of the guidelines, will spend the next three or four months educating its provider network and 1.4 million subscribers in Connecticut, New Jersey, New York and Pennsylvania, said Alan Muney, Oxford's executive vice president and chief medical officer.
As is typical with other guidelines for treatments and procedures, Oxford will eventually publish the names of the hospitals that are recommended and ultimately may only approve the procedure at certain hospitals. "But we've got some work to do in terms of communicating," Muney said.
Noting that the guidelines were developed in collaboration among physicians, health plans and the state, officials at Beth Israel Medical Center in New York said they were very supportive of the results. One of the hospital's attending surgeons, Elliot Goodman, who has performed about 900 bariatric surgeries, was a member of the workgroup.
"Anything that helps improve quality of care and helps patients when they have to make a decision about choosing a healthcare provider, we're in favor of," said Jim Mandler, a Beth Israel spokesman.