|I personally replace the whole grain portion with yet more veggies.|
by Melissa Healy, Los Angeles Times, February 20, 2013
In the span of 15 years, the number of bariatric surgeries performed in the United States has grown more than 16-fold to roughly 220,000 per year, gaining cachet as a near-panacea for obesity.
Despite the daunting price tag, mounting research has boosted hopes that the stomach-stapling operations could reduce the nation's healthcare bill by weaning patients off the costly drugs and frequent doctor visits that come with chronic obesity-related diseases like diabetes and arthritis.
But a new study has found that the surgery does not reduce patients' medical costs over the six years after they are wheeled out of the operating room.
The study, published Wednesday in the journal JAMA Surgery, tracked the expenses of nearly 30,000 Americans who got one of two forms of bariatric surgery, and compared their long-term health costs with those of similar patients who were obese but did not go under the knife to lose weight. Even when the initial $20,000-$25,000 cost of the procedure was taken out of the equation, the ongoing expenses for the patients who had surgery were roughly the same as for those who did not.
In an editorial accompanying the study, Dr. Edward H. Livingston wrote that "bariatric surgery does not provide an overall societal benefit." Though acknowledging that such surgery has "dramatic short-term results," he added that its longer-term effects — including on longevity — have been disappointing.
"In this era of tight finances and inevitable rationing of healthcare resources, bariatric surgery should be viewed as an expensive resource" that should only be offered to patients "if there is an overwhelming probability of long-term success," he wrote.
Obesity, which affects 1 in 3 American adults, is proving a tough and expensive challenge for the nation's healthcare system. The annual cost of treating obesity-related diseases — including stroke, heart disease and certain cancers — is now $190 billion. With no decline in U.S. obesity rates, that surcharge is projected to reach $550 billion by 2030.
The finding that bariatric surgery does not save money is sure to be disappointing to public health officials seeking to "bend the cost curve" downward. Despite high upfront costs that range from $10,000 to $43,000, broadening access to bariatric procedures might help drive down healthcare costs in the longer run, the thinking went.
"We were so hopeful," said Dr. David Goodman of Dartmouth College medical school, who was not involved with the new study.
Bariatric procedures foster rapid weight loss by surgically reshaping the intestinal tract. To varying degrees, they aim to reduce the stomach's capacity, decrease the calories and nutrients absorbed from food, and change the chemical signals of fullness that are passed between the brain, the gut and the endocrine system.
The new study considered two such procedures: Roux-en-Y gastric bypass, in which the path of food is rerouted around a large portion of the stomach and the upper intestine; and gastric banding, which constricts the stomach to create a smaller pouch for food.
Several studies have suggested that bariatric surgery might indeed be cost-saving. At a minimum, it could be seen as paying for itself when improvements in patients' quality of life were given a monetary value.
But the new analysis, which compared nearly 60,000 patients covered by Blue Cross Blue Shield health plans, showed that those who had bariatric surgery incurred an average of $29,517 in costs in the first 30 days after their procedures. The average costs for the control patients were $1,004 during the equivalent period.
That huge surgical bill was not recouped during the course of the study, since costs for patients in both groups were roughly the same. In the sixth and last year examined, the average medical expenses for a surgery patient were $9,259; for a patient in the control group, they were $8,714.
"We need to know better not just what works, but what gets us the best bang for the buck," said John Cawley, a Cornell University health economist who praised the study's design and ambition.
Dr. Philip Schauer, a bariatric surgeon at the Cleveland Clinic, said the benefits of surgery might have looked better if the study tracked patients for longer than six years and included indirect cost savings to employers and insurers, such as reduced absenteeism and fewer disability claims. For many patients, the cardiovascular benefits of bariatric surgery — and resulting savings in hospital care — may not be realized for at least 10 years, he said.
Among a dozen or so studies on the topic in the last decade or so, "theirs is kind of an outlier," Schauer said.
Study leader Jonathan P. Weiner of the Johns Hopkins Bloomberg School of Public Health said his team did not try to figure out whether some of the costs incurred by patients in the surgery group reflected underlying improvements in their health. For instance, patients who lost weight might have an easier time getting pregnant and could wind up in the hospital to give birth. Others might attempt knee or hip replacements that would have been too risky when they were obese.
If it turns out that bariatric surgery doesn't save money, public health officials will have to hope they can find cost savings with medications and lifestyle interventions, neither of which has shown consistent evidence of long-term success in helping patients maintain weight loss or head off obesity-related disease.
Kenneth Thorpe, chairman of health policy and management at Emory University's School of Public Health, said there's reason to believe that drug and behavioral therapies are a better investment than surgeries.
For patients considered pre-diabetic, studies have shown that a 16-week course called the Diabetes Prevention Program staves off the disease in 58% of those under 60 and 71% of patients over 60. And the Food and Drug Administration last year approved two new weight-loss medications, Qsymia and Belviq, that could bring similar health benefits.
The cost of these treatments are "a pittance compared with what we're doing with bariatric surgery," Thorpe said.