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Surgery for Obesity and Related Diseases ] (2014) 00–00

Review article

Affordable care act and bariatric surgery John Morton, M.D., M.P.H.* Bariatric and Minimally Invasive Surgery, Stanford University, Stanford, California Received February 27, 2014; accepted February 27, 2014

The Affordable Care Act (ACA) represents the largest change in healthcare delivery since the passage of Medicare in 1965 [1]. In addition to the ACA, the United States federal government plays an out-sized role in healthcare with 56% of all health costs being paid for by federal agencies including Medicare, Medicaid, Children’s Health Insurance Program, Tricare, Veterans’ Affairs, Indian Health, Federal/State Employees Health Plans, and National Institutes of Health clinical care. The Obama Administration enacted the ACA in 2010, to provide coverage to the 15% of the U.S. population that are uninsured and to limit the 17% of gross domestic production devoted to healthcare. With this significant change in healthcare delivery, it is critical for all surgeons to be aware of the implications of the ACA. Specifically, there are critical elements of the ACA that directly address obesity and bariatric surgery. Key elements of the ACA are described below.

patients toward treatment. An ACA landmark is to provide coverage for preventive services like obesity screening. Dietary counseling and obesity screening is a Level B recommended service by the United States Preventive Services Task Force and consequently mandated under the ACA. As a consequence of more patients being screened for obesity and counseled regarding diet, it may be anticipated that bariatric surgery will gain further prominence given its high safety and effectiveness for obesity. While the ACA places emphasis upon primary prevention, bariatric surgery should also be seen as a preventive service as it provides tertiary prevention or prevention of further progression of disease. Heart disease remains the leading cause of death in this country with obesity as a key contributor. Bariatric surgery has been proven to prevent future progression of many diseases like hyperlipidemia [2].

Access Removal of benefit restrictions As part of the ACA, patient protection regulations were enacted including removing annual and lifetime restrictions on amount of insurance coverage. This is important for bariatric surgery as obesity is a chronic disease and there will be more potential need for revisional surgery and adjunctive obesity management. Prevention The Affordable Care Act stipulates that restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drivethrough menus, and vending machines. This provision will raise awareness regarding obesity and potentially drive *

Correspondence: Dr. John Morton, Stanford University, 300 Pasteur Drive, H3680, Stanford, CA 94305. E-mail: [email protected]

A significant advance for coverage is the ACA provision allowing young adults to remain under their parents’ plan until the age of 26. With obesity increasing rapidly, particularly in the youngest sector of the population, provision of coverage is critical for obesity treatment. The largest piece of the ACA devoted to access is the individual mandate requiring all U.S. citizens who do not have employer-based health coverage to obtain coverage. A forum for individual insurance coverage is the state-level health exchanges that provide a market place for health plans. Each state-exchange health plan must provide a statelevel Essential Health Benefit (EHB) [3]. In October 2013, enrollment began for the EHB state plans, which are generally based on the largest small business plan. Bariatric surgery coverage with small employers is poor, due in part to adverse selection. Many small employee health plans do not provide bariatric surgery coverage because with a small risk pool they are unable to spread the risk of payment for bariatric

http://dx.doi.org/10.1016/j.soard.2014.02.029 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

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surgery coverage. However, with the state-level EHB, all insurance plans can have the same level of risk with a uniform health benefit. Unfortunately, only 22 states have bariatric surgery coverage and a mere 5 states have medical obesity coverage. Even more alarming than lack of obesity treatment coverage is the presence of exclusionary language for bariatric surgery in some state-level EHBs. The ACA has language that states that no health plan can discriminate based on a health condition. Given that the ACA excludes discrimination against health conditions, how can state EHBs allow for exclusion of a safe and proven therapy (bariatric surgery) for an American Medical Association recognized disease (obesity)? The White House Office for Healthcare Reform can remedy this discriminatory practice, as it must approve each individual EHB. The federal government’s decision to devolve the responsibility of determining the essential health benefit to states has also resulted in a crazy quilt of obesity treatment coverage. For example, in the 2 states adjoining Washington, D.C., we see bariatric surgery covered in Maryland but not Virginia [4]. The states are comparable in obesity disease burden, and the Maryland Healthcare Commission determined that adding bariatric surgery coverage would increase individual costs by a modest .4%. For a variety of reasons, 37 states have deferred administration of their state exchanges to the federal government. The Office for Healthcare Reform can and should close this obesity treatment gap by assuring obesity treatment coverage for all 50 states.

outcomes particularly a 10-fold reduction in mortality [5]. The Center for Medicare and Medicaid Innovation was implemented, and this center is looking for ways to increase quality of care for Medicare recipients including linking payment to quality outcomes like 30-day readmissions and hospital-acquired conditions like surgical site infection. The first MBSAQIP quality improvement program beginning in 2014 will be directly relevant to this center by creating a nation-wide collaborative to decrease readmissions, Decreasing Readmissions through Opportunities Provided. Another platform for increasing medical efficiency is the Accountable Care Organizations (ACOs). ACOs are legal entities consisting of physicians and other providers working together to coordinate care for Medicare beneficiaries. These groups must meet defined quality-performance standards. Through shared savings programs, ACOs can receive a portion of the savings if they sufficiently reduce costs and improve quality. Obviously, the ACOs who can manage and integrate bariatric surgery will have a fundamental advantage in meeting population goals for diabetes. Conclusion The ACA represents challenges and opportunities for the bariatric surgeon. Knowledge regarding the ACA is paramount given its widespread influence upon healthcare delivery. Given that the ACA is a governmental enterprise, advocacy for the obese patient will be important. Bariatric surgeons can provide influence and advocacy by having data, unity, collaboration, patience, and persistence.

Investigation A critical element to the ACA is the establishment of the Patient-Centered Outcomes Research Institute (PCORI). With declining support for National Institutes of Health funding, PCORI provides a new source of research funding that has specific application for bariatric surgery. For example, 1 of the charges for PCORI is to examine the relative health outcomes, clinical effectiveness, and appropriateness of different medical treatments by evaluating existing studies and conducting new studies. Clearly, this comparative effectiveness approach would have application for surgery versus medical therapy for obesity. The implication of this research can be far-reaching given that the Centers for Medicare and Medicaid Services may consider PCORI’s research when deciding what procedures it will cover. Quality and efficiency The ACA calls for both quality improvement and cost reduction. Bariatric surgery has demonstrated clear return on investment and has shown striking improvement in

Disclosures ’’’ References [1] Healthcare.gov [homepage on the Internet]. Baltimore: U.S. Centers for Medicare & Medicaid Services. Available from: https://www.health care.gov/. [2] Williams B, Hagedorn J, Lawson E, et al. Gastric bypass reduces biochemical cardiac risk factors. Surg Obes Relat Dis 2007;3:8–13. [3] The Wall Street Journal [homepage on the Internet]. Find your state’s health-care exchange. Available from: http://online.wsj.com/news/ articles/SB10001424052702304526204579099422440044100?mg=re no64-wsj&url=http%3A%2F%2Fonline.wsj.com%2 Farticle%2FSB10 001424052702304526204579099422440044100.html. [4] The Washington Post [homepage on the Internet]. Available from: http://www.washingtonpost.com/business/economy/obesity-surgery-co verage-balloons-the-cost-of-some-health-care-plans-in-virginia/2013/ 10/11/bea01b32-328c-11e3-9c68-1 cf643210300_story.html. [5] Nguyen NT, Nguyen B, Shih A, Smith B, Hohmann S. Use of laparoscopy in general surgical operations at academic centers. Surg Obes Relat Dis 2013;9:15–20.

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Affordable Care Act and bariatric surgery.

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