Collaborative Advocacy against the Rising Tide of Obesity: A Winning Strategy Pays Off in South Carolina

| May 1, 2017

by John D. Scott, MD, and Natalie Heidrich

John D. Scott, MD, is Associate Professor of Surgery with the University of South Carolina School of Medicine Greenville, Greenville, South Carolina; Metabolic and Bariatric Surgery Director for the Bariatric Surgical Program of Greenville Health System; Assistant Program Director for Greenville Health System General Surgery Residency Program and Minimally Invasive Surgery Fellowship Program; and Director of Research for Greenville Health System’s Department of Surgery. Dr. Scott also serves as Co-chair of the Access to Care Committee for the American Society for Bariatric and Metabolic Surgery. Natalie Heidrich is Director of Health Economics and Market Access for Ethicon, Cincinnati, Ohio.

Bariatric Times. 2017;14(5):12–14.


ABSTRACT
In mid-2012, the Centers for Medicare & Medicaid Services issued a decision stating that Medicare Administrative Contractors may determine coverage of stand-alone laparoscopic sleeve gastrectomy for the treatment of comorbid conditions related to obesity in Medicare beneficiaries who met listed criteria. Until July 2016, Medicaid patients in South Carolina received coverage for Roux-en-Y gastric bypass but not sleeve gastrectomy. Here, the authors, who were involved in concentrated lobbying and advocacy efforts, describe the process that led the South Carolina Department of Health and Human Services to expand program coverage for bariatric surgery to include sleeve gastrectomy for South Carolinians with fee-for-service Medicaid benefits.

Background
After a year and a half of concentrated lobbying on multiple fronts, the South Carolina Department of Health and Human Services (SCDHHS) has expanded program coverage for bariatric surgery to include sleeve gastrectomy for approximately 890,000 South Carolinians with fee-for-service Medicaid benefits. This decision, which took effect July 1, 2016, marked a significant turning point in obesity treatment access for Medicaid patients in South Carolina, who previously only had coverage for Roux-en-Y gastric bypass (RYGB).

This story is one of victory in which advocates fought against the rising tide of obesity, where economic and clinical barriers are still slow to fall and allow access for patients to the proven treatment of bariatric surgery.

Collaborative Advocacy and Staying Power
We have been separately active in the long history of advocacy for bariatric surgery coverage in South Carolina. By 2010, when laparoscopic sleeve gastrectomy had been added to bariatric procedure options, we broadened our advocacy targets and joined forces.

We put our combined efforts to work to play a key role in the Centers for Medicare & Medicaid Services (CMS) approving Medicare members’ access to bariatric surgery. However, the question of expanding that coverage to include laparoscopic sleeve gastrectomy brought new hurdles to clear. In mid-2012, CMS delegated that decision to each regional Medicare Administrative Contractor. In response, our advocacy movement launched a multi-year, grassroots lobbying campaign to approach each separate regional Medicare administrative contractor (MAC) and complete their lengthy processes to change the rules.

With that successful campaign behind us in 2014, we realized that South Carolina—our shared home state—denied its Medicaid patients the same bariatric surgery benefits that were available to every Medicare patient in the country and to most commercially insured members. Every day we were seeing residents living with the burden of obesity and type 2 diabetes mellitus (T2DM). To us, this was an issue of fairness as well as economics. As taxpayers, we understand the state’s challenges in offering universal access, but we believe that if we cannot begin to prevent obesity and treat those already dealing with it, the health impact to our residents and financial impact to our state will be devastating.

Three Essential Strategies for Winning
We began discussions with SCDHHS in earnest in 2014 to pursue Medicaid coverage for the sleeve procedure. Our efforts prompted some high-profile resistance. Politicians wrote editorials in the state’s newspapers, arguing against spending taxpayer money on what they termed elective weight-loss surgery. Other opponents feared a rush to surgery that would drain Medicaid funds.

It is critical in advocating for obesity treatment to turn those perceptions about bariatric surgery from weight loss to health gain. We pursued three proven strategies to change hearts and minds. Successful advocacy needs lobbyists for access to decision makers. It needs doctors willing to present the devastating process of obesity and the science to support the benefits of treatment, including surgery. It also needs patients willing to make the emotional case.

We recruited Dawn Gabriele, Senior Manager Ethicon HEMA; J.J. Darby with Johnson & Johnson State Government Affairs; Joe Nadglowski, President & CEO of the Obesity Action Coalition, and Christopher Gallagher, Washington Representative for the American Society for Metabolic and Bariatric Surgery (ASMBS). They helped open doors and prepare physicians to present the clinical case. Lobbyists know the policymakers and decision makers. They provide the insights to tailor every presentation to the individual’s position in the decision process and where each stands on the issues. They “set the table” for clinicians to make their plea.

Across the state, physicians such as South Carolina bariatric surgeons Marc Antonetti, MD; Glen Strickland, MD; Edward Rapp, MD; and T. Karl Byrne, MD, stepped up to present the scientific evidence and educate policy- and decision makers on the health risks of obesity, the costs of untreated disease, and the well-documented benefits of sleeve gastrectomy.

Their platform drew from the large body of existing evidence linking obesity to an increased risk for T2DM, chronic heart disease, some cancers, stroke, hypertension, arthritis, and obstructive sleep apnea.[1] They presented results of studies showing that, in addition to weight loss after bariatric surgery, patients may also experience resolution or improvement of their obesity-related conditions.[2–7]

They also provided data specific to South Carolina patients documenting fewer heart attacks and strokes following bariatric surgery (e.g., a 65 percent reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM).[8]

They emphasized the disparity in excluding the Medicaid population from sleeve gastrectomy when SCDHHS was already offering the bypass option that carried higher costs and potentially higher risks and complication rates.

In a hearts and minds battle, however, evidence alone does not always win the day. The physicians then invited their patients to share their stories in a grassroots letter-writing campaign. At first, we observed that patients with obesity were still attempting to find their voice. They were reluctant to come forward and hard-pressed to advocate for themselves because of obesity’s lingering stigma. When completed, the heartfelt, personal letters from patients struggling with obesity gave a face and a voice to the issue. Those stories painted the very real picture of obesity’s toll on South Carolina lives and it was ultimately those letters that turned the key and won the vote.

As of July 1, 2016, we achieved victory when the SCDHHS expanded program coverage for bariatric surgery to include sleeve gastrectomy for approximately 890,000 South Carolinians with fee-for-service Medicaid benefits. Covered surgery is limited to members who demonstrate medical necessity based on InterQual® criteria and receive prior authorization. It is our hope that this decision helps turn the tide of obesity in South Carolina, which, as of September 2016, ranks 13th in the United States for obesity prevalence.[9]

Much Work Remaining
In 2015, the National Conference of Insurance Legislators called for all treatments of obesity to be covered, including surgery.

We are still far from that vision. Across the country, coverage and access to bariatric surgery vary wildly. South Carolina’s decision leaves Montana and Mississippi as the last holdouts to offer no bariatric surgery coverage for their Medicaid recipients. State employees are in the same position in nine states that exclude coverage for bariatric surgery or are conducting limited pilots. To test the economic feasibility of bariatric surgery, the state granted access to the procedure to just 100 of its more than 400,000 state employees. South Carolina has yet to extend that benefit to the rest of its workforce.

We are encouraged to see bariatric surgeons, medical device industry advocates, medical societies, national associations, and the Obesity Action Coalition, standing shoulder to shoulder with patients to seek ways to prevent obesity and change the outcomes for this rampant disease.

We call on every bariatric surgeon in America to advocate for these patients and for an end to treatment disparity.  We invite other clinical and industry stakeholders to collaborate with us to raise awareness and expand access at every point of entry—Medicaid, Medicare, employers, commercial insurers and government – so that more patients can receive the treatment they need to live healthier, more fulfilling lives.

References
1.    Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. Working paper 16467. National Bureau of Economic Research website. http://www.nber.org/papers/w16467. Published October 2010. Accessed April 8, 2016.
2.    Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121(10):885–893.
3.    Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5(4):469–475.
4.    Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-529.
5.    DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235(5):640–645; discussion 645–647.
6.    Schauer PR, Kashyup SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366(17):1567–1576.
7.    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–1737.
8.    Johnson B, Latham B, Cull D, et al. Bariatric surgery is associated with a reduction in major macrovascular and microvascular complications in moderately to severely obese patients with type 2 diabetes mellitus. J Am Coll Surg. 2013;216(4):545–558.
9.    Trust for America’s Health and the Robert Wood Johnson Foundation. The State of Obesity: Better Policies for a Healthier America. 2016. http://StateofObesity.org. Accessed September 9, 2016.)

FUNDING: No funding was provided.

DISCLOSURES: Natalie Heidrich is Director of Health Economics and Market Access for Ethicon, Cincinnati, Ohio.

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