Challenges of a Continually Changing Field of Medicine

An interview with John Baker, MD, President of the American Society for Metabolic and Bariatric Surgery

Dr. John Baker runs a private practice in Little Rock, Arkansas. He is Medical Director, Baptist Health Weight Loss Center, Little Rock, Arkansas, and co-director of the Baptist Medical Center’s bariatric surgery program, Little Rock, Arkansas.

Financial Disclosures:
Dr. Baker reports the following financial disclosures: President, ASMBS; Board of Directors, Secretary Treasurer for NOVUS insurance Company; Medial Director, Baptist Health Medical Weight Loss Program; Co-director Baptist Health Bariatric Surgery Program. Dr. Baker has also done cosulting for and has received honoraria from Ethicon Endosurgery, Cincinnati, Ohio and Covidien, Norwalk, Connecticut.

Bariatric Times. 2010;7(4):20–22

The staff and Editorial Advisory Board of Bariatric Times interviewed Dr. John Baker, president of the American Society for Metabolic and Bariatric Surgery (ASMBS). Here is what he has to say about his current challenges as ASMBS president.

The simplicity and effectiveness of sleeve gastrectomy speaks to the need for more insurance companies to cover this procedure. What can you tell us about the plans of the society to push for that?
ASMBS has updated the clinical position statement recently to reflect additional review of both short-term and midterm follow-up data. Long-term data are lacking, especially in regard to nutritional complications. Standardized surgical technique is in development.
I, along with several members of ASMBS, have presented to several national carriers regarding coverage policy for the sleeve gastrectomy. The medical directors have voiced concerns related to complications, reoperations, and revisions to other procedures. Review of the literature reveals leak rates and bleeding rates similar to gastric bypass and duodenal switch. Reoperation rates are lower, though this is with a limited interval for follow up.

Last fall, United Health made this part of their coverage policy. Dr. Mitch Roslin, state chapter president for the New York chapter of ASMBS, has worked with their medical director for coverage policy for several years. These types of professional contacts are important for dissemination of current scientific literature. We will need to work at all levels to improve access.

What is ASMBS doing (or what can they do) to facilitate insurance approval without the onerous six-month waiting period for weight loss surgery.

We have addressed this with several carriers. The California Health plans have dropped this requirement. Health Care Service Corporation (HCSC), a parent company of Blue Cross in Texas, Illinois, New Mexico, and Oklahoma, has reduced this to a three-month period. Other companies, such as Horizon Blue Cross, continue to require a waiting period. The insurance carriers should pay for this medically supervised weight loss program if it is mandated as part of the approval process. Failure to provide this coverage is discriminatory and will discourage patients from completing the process.

What do you see as future horizons in bariatric surgery?
Future therapies will be directed at reducing both the economic- and health-related burden of diabetes. The diabetes epidemic requires earlier intervention to reduce the morbidity. We should also work to tailor the surgical procedure to each patient. Earlier intervention may involve a hybrid therapy: endolumenal treatment combined with medical therapy. We should evaluate therapy for its impact on future interventions. Will your future patient remember the specific type of endoluminal procedure or implant he or she received? Would this lead to a complication?

We need to be cognizant of surgical history when changing the nature of the approach used to complete a surgical procedure. Patient safety should be paramount with the addition of newer procedures or approaches, i.e., single-incision approaches.

I think the same applies to outpatient surgery. Appropriate multidisciplinary evaluation of the patient should be carried out. Risk stratification is needed to identify those patients who are low risk to consider for an outpatient procedure.  We should resist the push by insurance carriers to perform ambulatory surgery in patients who need monitoring overnight after general anesthesia.

The White House, through the efforts of First Lady Michele Obama, has helped to promote better prevention and wellness regarding childhood obesity. We also need to direct attention to the treatment arm that is necessary. Arkansas was the first state in the nation to recommend body mass index (BMI) measurement of all public schoolchildren. The results were striking and revealed a rate higher than the sampling provided through the National Health and Nutrition Examination Survey (NHANES). The ASMBS is working with pediatric surgeons, National Association of Children’s Hospitals and Related Institutions (NACHRI), and American Academy of Pediatrics (AAP) for treatment guidelines for adolescent surgery. I envision the developments of multidisciplinary programs that will utilize pediatric or adult surgeons and the teams for, example with a children’s hospital, to provide the care needed for adolescents. The pending results from the ongoing trials with adjustable banding in adolescents in addition to the randomized trial from O’Brien et al[1] provide the additional scientific basis for coverage. Removal of off-label indication for use of adjustable banding in adolescents would reduce the threat for medico-legal action for surgery in adolescents.
We will continue to work with other societies in promoting treatment of obesity and related diseases. Obesity Week is being planned for 2013. This annual meeting with The Obesity Society is designed to be the meeting regarding obesity treatment. I envision it to include other specialties related to the treatment of metabolic diseases

What are your thoughts on nonplastic surgeons performing skin reduction surgery—might it be too controversial?
Not all our patients can pay cash for body contouring after weight loss surgery. My own patients, who have Medicare and Medicaid, have been denied access to a plastic surgeon. We can work within our own society or others, such as ASPS, to promote best practices.

What is ASMBS doing to advance patient safety?
The vision of the ASMBS is to improve public health and well being by lessening the burden of the disease of obesity and related diseases throughout the world.

The purpose of the society is to advance the art and science of bariatric surgery by continued encouragement of its members to carry out the following mission:
•    To improve the care and treatment of people with obesity and related diseases
•    To advance the science and understanding of metabolic surgery
•    To foster communication between health professionals on obesity and related conditions
•    To be the recognized authority and resource on metabolic and bariatric surgery
•    To advocate for healthcare policy that ensures patient access to high-quality prevention and treatment of obesity
•    To be a highly valued specialty society that serves the educational and professional needs of our diverse membership.

We will have a patient safety course this year at the annual meeting to address a number of topics. We will have speakers discuss data collection from each of the certification organizations. We should evaluate these outcomes and continually work to improve them. For example, identifying the prophylactic measures in a patient care pathway that reduces venous thromboembolism (VTE). Surgeons should know their outcomes.

What are the hurdles to patient access to care? How can surgeons help?
Society must address the bias and stigma our patients face on a daily basis. Obesity is a disease and should be treated. It meets the criteria to be designated a disease. Treatment of obesity should be an essential benefit of any healthcare plan, public or private. The economic burden due to obesity and related disease will overwhelm Medicare and Medicaid. We cannot afford to take care of a young disabled population for 30 to 40 years. In 2008, 17 percent of the Medicare covered population was under the age of 65. The incidence of obesity in the Medicare eligible population is increasing as well. Can we afford the Medicare Part D costs due to treatment of obesity and related diseases.

The ASMBS has met with members of Congress and their healthcare policy liaisons on several occasions. For example we met with the key members of the Senate Finance committee and suggested model language to be included in the Senate Finance Health care bill. We will continue to work with the Obesity Action Coalition (OAC) to advocate for our patients. We need to encourage our patients to speak up as well. Their voice is important. Surgeons should encourage their patients to contact their congressional delegation regarding overall treatment of obesity. We should speak out to the support groups and at our educational seminars. Even when I represent ASMBS in these meetings, I am still viewed as a surgeon wanting to operate.

We have the most rehabilitative treatment in medicine today.

Is there a role for simulators and simulation to advance surgeon training?
Simulation can be helpful in learning to identify the steps needed for example to complete a procedure. The haptics may be limited in the transfer of information to the trainee. Advances in the simulation modules will help. The drills utilized can help with eye/hand coordination and depth perception. These, however, cannot completely replace hands-on experience. This may become more apparent in revision surgery when working with a distorted anatomy.

While no one is sure, what impact do you expect healthcare reform to have on Medicare changes (reimbursement) for bariatric surgery over the next five years?
The number of bariatric surgery cases may increase with insurance reform. What would happen to a practice today if the barriers to access were gone? Do we have the infrastructure to accomplish this? The elimination of pre-existing clauses, lookbacks, and other insurance reforms may improve access to care. We may need to work with the panels or insurance exchanges that are developed in response to current legislation. Access to surgery for Medicare may diminish if the payments continually are decreased. The Sustainable Growth Rate (SGR) needs to be addressed by Congress. The current system utilizing Relative Value Units (RVUs) does not take into account the work expense and practice work expense for data collection required for outcomes reporting. Surgeons at some point will buckle due to the demands placed under the current payment system. They can opt for Medicare and contract privately with patients to provide services. This should be carefully discussed with an attorney experienced in healthcare and contracting with Medicare.

What are your thoughts about the possibility of changing the BMI ranges to qualify for surgery? Can we move away from BMIs altogether?

We need some degree of measurement as a basis for discussion or establishment of guidelines. While BMI was chosen arbitrarily, it has been a measure for reporting outcomes. It may be that a lower BMI will be considered for patients with a metabolic disease or in certain ethnic groups. Moving to a measurement system our patients can understand easier may be important. For example, they can tell the difference in waist circumference.

In the era of increased scrutiny of outcomes from patients, insurance companies, and others, what is the role of reporting outcomes and the Center of Excellence (COE) Programs?
Outcomes reporting will be an integral part of healthcare in the future. Centers for Medicare and Medicaid Services (CMS) and others will eventually move from an administrative claims database to payment tied to outcomes reporting.  The data collection tools are needed.  Bariatric surgeons should establish the measures to be reported. ASMBS is working to help establish these with Surgical Quality Alliance, (SQA). This data reported should be risk adjusted. We will work with the Surgical Review Corporation (SRC) and the American College of Surgeons, Bariatric Surgery Network (ACS BSN) to establish these data points.

Public reporting of outcomes that is not risk adjusted should be avoided. Who will take care of the complicated cases in the future?

I understand that a questionnaire was sent to the ASMBS membership regarding the SRC and COE program. What is the future of the COE program regarding ASMBS/SRC and ACS?
The survey was sent out to the membership for feedback on the different COE programs.

The ASMBS entered into a contract with SRC in 2004. The environment for bariatric surgery was different in 2004 compared to 2010. Some background information reveals that the ACS was offered three seats on the Board of the SRC and declined due to the presence of stakeholders and a difference of opinion about the potential commercial use of the data by SRC. The most important point is about who controls the data and its use. A separate COE program was established by the ACS with many of the same data elements.

The development of the SRC and its control of the data was established under the guise that a COE program developed by the ASMBS and controlled by ASMBS would not be creditable to stakeholders. The insurers and other stakeholders continue to recognize the ACS bariatric program without qualification. The ASMBS has no control of the data submitted by its membership. The ASMBS is not a party to the contracts that are signed between the surgeon, hospital centers, and the SRC.

Surgeons have been involved with measuring outcomes and promoting patient safety. The ACS helped to establish Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now known as The Joint Commission.

The ASMBS has been involved in discussions with the SRC regarding a new contract. The existing contract, which is due to expire December 31, 2010, was the starting point for discussion regarding a new contract.  The SRC was contracted to be our certification program. The monies paid by our members and their participating facilties as provisional centers were used for the development of the Bariatric Outcomes Longitudinal Database (BOLD™) software and database. These funds were not designated for advocacy. The SRC was not contracted to develop international Centers of Excellence. The ASMBS was not informed of the change in its mission until the program was actually listed on the SRC website, for example. Was service under our existing contract not what it should have been due to funds being used outside the scope of the original contract? Site visits for renewal of ASMBS COE designation were rescheduled several times for different centers. One of which, already a National Surgical Quality Improvement Program (NSQIP) hospital and dual certified, dropped their ASMBS designation.

The burden of data entry for BOLD in its present configuration is daunting. Most surgeons have one or two employees to enter data. Larger practices have a larger burden. The current reimbursement system with Relative Value Units (RVUs) for bariatric surgery does not include the practice cost element or work element for data collection and entry. We need risk-adjusted data elements now. The data points needed for outcomes reporting should be consolidated. Any data collected for research should be voluntary not mandatory. Fewer data points required for reporting will increase the accuracy and completeness of the data set.

ASMBS has several options regarding the future course of its COE program. A number of members have expressed interest in having one designation.

References
1.    O’Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA. 2010;303(6):519–526.

Category: Interviews, Past Articles