News and Trends—December 2015

| December 1, 2015

AMERICAN SOCIETY FOR METABOLIC AND BARIATRIC SURGERY, OBESITY GROUPS TAKE AIM AT STATES THAT DENY COVERAGE OF OBESITY TREATMENT UNDER AFFORDABLE CARE ACT
Five Groups File Complaint with U.S. Health and Human Services Citing Non-Compliance and Discrimination in 27 States
GAINESVILLE, Florida—The American Society for Metabolic and Bariatric Surgery (ASMBS) and groups including The Obesity Society (TOS) and Academy for Nutrition and Dietetics (AND), filed a complaint this month with U.S. Health and Human Services (HHS) claiming the 27 states that deny coverage for bariatric surgery are in non-compliance with the Affordable Care Act (ACA) and that their failure to comply is discriminatory against women and people with disabilities, and violates the ban against denying coverage based on health status or a pre-existing condition.
The ASMBS, TOS, and AND are joined in the complaint by the Obesity Medicine Association (OMA) and the Obesity Action Coalition (OAC), a patient advocacy group with more than 50,000 members. All five groups belong to the Obesity Care Continuum.

“Qualified health plans should not be able to discriminate against people with the disease of obesity and unfortunately this is happening in most states,” said John M. Morton, MD, MPH, Past President of the ASMBS and Chief, Bariatric and Minimally Invasive Surgery, Stanford University School of Medicine. “The time has come for equitable treatment for the millions of patients affected by obesity. There needs to be one America where treatment for obesity is an option for everyone.”

Dr. Morton noted that treatment for chronic diseases other than obesity are routinely covered. Obesity was classified as a disease by the American Medical Association in 2013.
“There’s a double standard when it comes to obesity,” Dr. Morton added. “Most insurers are covering the treatments for the complications and consequences of obesity, but are not covering the treatment of obesity itself.”
In the complaint, the groups say there is a significant disparity between the 27 ACA benchmark plans that deny or exclude coverage for bariatric surgery, and the major private and government health insurance plans that provide coverage. Medicare, 49 state Medicaid plans, the Federal Employees Health Plan, the majority of state health plans, and the majority of employer-based plans with 500 employees or more cover bariatric surgery.

The groups cite that a qualified health plan under ACA may “not employ marketing practices or benefit designs that have the effect of discouraging the enrollment of such plan by individuals with significant health needs.” They say this is being done to individuals who have obesity. In addition, the ACA prohibits the denial of health care benefits on the basis of disability. The groups say severe obesity falls under the American Disabilities Act, as currently defined. Finally, the groups argue that “empirical research consistently demonstrates that obesity has a proportionally disparate adverse impact on women” in comparison to men, when it comes to hiring and earnings, and those with severe obesity who joined ACA qualified health plans within the last two years did so with obesity as a pre-existing condition.

“We believe there should be a single, consistent obesity health benefit for the entire country, and as part of that benefit proven obesity treatments such as bariatric surgery would be covered for those who need it,” said Dr. Morton.

SLEEVE GASTRECTOMY SURGES TO NEARLY HALF OF ALL WEIGHT-LOSS SURGERIES IN AMERICA, NEW STUDY FINDS
LOS ANGELES, California—Sleeve gastrectomy, a procedure where surgeons remove about 80 percent of the stomach, has become the most popular method of weight-loss surgery in America, surpassing laparoscopic gastric bypass, which had been the most common procedure for decades, according to researchers from Cleveland Clinic.

The findings were presented at ObesityWeek 2015, the largest international event focused on the basic science, clinical application and prevention and treatment of obesity. The weeklong conference is hosted by the American Society for Metabolic and Bariatric Surgery (ASMBS) and The Obesity Society (TOS).

Researchers studied nearly 72,000 patients who had bariatric surgery between the years 2010 and 2013. In 2010, sleeve gastrectomy accounted for just 9.3 percent of procedures, while 58.4 percent were laparoscopic gastric bypass and 28.8 percent were gastric band procedures. By 2013, nearly half (49%) the procedures were sleeve gastrectomy, 43.8 percent were gastric bypass, and the number of gastric band procedures had plummeted to just 6 percent.
“We’ve seen a real shift in the world of bariatric surgery with the emergence of the sleeve gastrectomy,” said Philip Schauer, MD, a study co-author and director of the Cleveland Clinic Bariatric and Metabolic Institute in Ohio. “In just four years, there’s been a five-fold increase in the number of these operations. This is likely due to a combination of factors including better insurance coverage and more data demonstrating its safety and effectiveness in treating obesity and related diseases.”

For the study, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database was analyzed to identify adult patients with a body mass index (BMI) of 35 or more who had some form of bariatric surgery. Patients were predominantly female (78.1%) and about 45-years-old.

During the four years covered in the study, there were no significant changes in age or gender in terms of overall operations, but the proportion of women undergoing sleeve gastrectomy increased to 79.2 percent from 73.2 percent, and the average BMI dropped from 47.8 percent to 45.9 percent. The number of patients with a BMI of 50 or more decreased (23.6% to 32%), as did the number of patients with hypertension (56.2% to 48.4%).

Gastric bypass appears to be the most popular operation among those with type 2 diabetes, rising to 33.3 percent from 30.4 percent. At the same time, patients with diabetes having sleeve gastrectomy dropped from 26.6 percent to 22.5 percent.

According to the ASMBS, about 193,000 people had bariatric surgery in 2014, and by its own estimates, sleeve gastrectomy was also found to be the most common procedure, accounting for 51.7 percent of weight-loss operations, followed by gastric bypass (26.8%), gastric band (9.5%), and biliopancreatic diversion with duodenal switch (0.4%).

In addition to Dr. Schauer, study authors of the abstract entitled, “Recent National Trends in the Surgical Treatment of Obesity: Sleeve Gastrectomy Dominates,” include Zhamak Khorgami, MD; Amin Andalib; Ricard Corcelles MD, PhD; Ali Aminian, MD; and Stacy Brethauer, MD, all from Cleveland Clinic in Cleveland, Ohio.

OBESITY CARE ADVOCACY NETWORK (OCAN) LAUNCHED TO
HELP ADDRESS THE NATION’S GROWING OBESITY EPIDEMIC
LOS ANGELES, California—During the 2015 ObesityWeek, leading healthcare organizations announced the formation of a new advocacy network, the Obesity Care Advocacy Network (OCAN). The Founding members, the Academy of Nutrition and Dietetics, the American Association of Clinical Endocrinologists (AACE), the American Society for Metabolic and Bariatric Surgery (ASMBS), the Endocrine Society, Novo Nordisk, the Obesity Action Coalition (OAC), the Obesity Medicine Association (OMA), and The Obesity Society, aim to partner with other medical societies and organizations to change how the nation perceives and approaches the U.S. obesity epidemic by educating and advocating for public policies and increased funding for obesity education, research, treatment and care.

“Efforts to address the obesity epidemic have expanded dramatically over the past few years; however, we know that many individuals still struggle with obesity. OCAN will work to increase access to treatment and educate the public, especially the U.S. healthcare system, on the seriousness of this epidemic,” said Joe Nadglowski, OAC President and CEO.

OCAN hopes to prevent the progression of obesity and increase access to treatment through uniting key obesity stakeholders and the larger obesity community around key education, policy and legislative efforts.

“Obesity is a complex, multi-faceted disease with no easy remedies. Coalitions, such as OCAN, are crucial to enacting change in the national dialogue about obesity and helping patients get the care that they need,” said Dr. George Grunberger, President of AACE.

“Treating obesity seriously is a crucial first step in addressing this disease. With the help of each organization within the Network, OCAN will change the way obesity is viewed in this country and hopefully lay the groundwork for positive global change,” said Francesca Dea, Executive Director of The Obesity Society.

For more information on the Network or to learn how your organization and/or company can become more involved in this national effort, please visit www.ObesityCareAdvocacyNetwork.org.
About the OCAN. The Obesity Care Advocacy Network (OCAN) is a diverse group of organizations who have come together to change how the nation perceives and approaches our country’s obesity epidemic by educating and advocating for public policies and increased funding for obesity education, research, treatment, and care.

NEW STUDY SHOWS BARIATRIC SURGERY IS SAFE OPTION FOR MANAGING TYPE 2 DIABETES IN OVERWEIGHT OR MILDLY OBESE PATIENTS
LOS ANGELES, California—Weight-loss surgery, long considered a treatment largely reserved for people with severe obesity, may also be a good and safe option for the treatment of uncontrolled type 2 diabetes in those who are overweight or have mild to moderate obesity, according to researchers from Cleveland Clinic in Ohio.

The findings were presented at ObesityWeek 2015. Cleveland Clinic researchers say this study is the largest ever-published series of bariatric surgery in patients with type 2 diabetes and body mass index (BMI) of 35kg/m2 or less. They studied 1,003 patients from North America with a BMI of between 25 and 35, with the average BMI being 33.5kg/m2. Forty-six patients had a BMI of 30 or less. All had weight-loss surgery, or what is known as bariatric or metabolic surgery, between 2005 and 2013. Four-in-10 patients were taking insulin injections and 60 percent were on oral medications for their diabetes before surgery. Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
According to guidelines from the National Institutes of Health (NIH), a person is overweight if their BMI is between 25 and 30, and considered to have obesity, if their BMI is 30 or more. Severe obesity begins at a BMI of 35 kg/m2. The NIH guidelines, which have not been updated since 1991, consider surgery an option only for people with a BMI of 35 or more with one or more obesity-related conditions such as diabetes or a BMI of 40.

The study showed bariatric and metabolic surgery had a high degree of safety in lower BMI patients. The operations included gastric bypass (57%), gastric banding (23%), sleeve gastrectomy (19%) and duodenal switch (1%). The 30-day postoperative mortality rate was 0.2 percent and the cumulative rate of 16 postoperative adverse events was 4 percent. The procedures were generally two hours in length and patients were discharged from the hospital within two days.
Last year, Cleveland Clinic researchers presented a study that found the 30-day complication rate associated with metabolic surgery, specifically gastric bypass in patients with type 2 diabetes and BMIs of 35 or more, was 3.4 percent, about the same rate as laparoscopic cholecystectomy (gallbladder surgery) and hysterectomy. Hospital stays and readmission rates were similar to laparoscopic appendectomy. The month-long mortality rate for metabolic or diabetes surgery was 0.3 percent, about that of total knee replacement, and about one-tenth the risk of death after cardiovascular surgery (Published in the Diabetes, Obesity & Metabolism journal—2015;17(2):198–201).

Previous studies have shown that metabolic and bariatric surgery improves type 2 diabetes in nearly 90 percent of patients and diabetes goes into remission in up to 50 percent.

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