Let’s Get Real: Return on Investment?

with Walter J. Pories, MD, FACS

Dr. Pories is Professor of Surgery, Biochemistry and Kinesiology, East Carolina University, Greenville, North Carolina

FUNDING: No funding was provided in the preparation of this manuscript.

FINANCIAL DISCLOSURES: Dr. Pories reports no conflicts of interest relevant to the content of this column..

Bariatric Times. 2013;10(7):9.

“We have submitted over 200 applications for bariatric surgery but only five have been approved. What do you suggest?” This question was directed to Dr. Aldona Wos, the new Secretary for Health and Human Services for North Carolina, who was in Greenville on Thursday, May 16, to discuss the impact of the state’s opting out of the Affordable Care Act’s Medicaid expansion. She turned to her companion, Ms. Carol Steckel, the new Director for Medicaid, who replied that the issue was under review because of concerns about the “return on investment (ROI).”

The response was met with a stunned silence. Return on investment? The ROI is certainly a useful metric in business, but its application to healthcare for the poor was breathtaking. Was the state announcing that care would be denied unless there were profits in relation to capital invested?
Denial of bariatric surgery is not new. For decades, some carriers denied metabolic surgery on the basis that the efficacy of the approaches was not proven. Today, virtually all private carriers, Medicare and the VA recognize that it is the only effective therapy for severe obesity.

The evidence is strong. There are multiple long-term studies[1] as well as prospective, randomized trials,[2,3] that document that metabolic surgery produces full and durable remission of type 2 diabetes (T2D), hypertension, hyperlipidemias, and even polycystic ovary disease. It reduces mortality from diabetes by 83 percent[4] and the prevalence of cancers by 70 percent within five years.[5] It is as safe a routine as cholecystectomy with a mortality rate of 0.3 percent.
It is certainly appropriate for the Director of the North Carolina Medicaid program to be concerned about cost. The state’s program is badly underfunded and the decision to opt out of the Affordable Care Act raises even more hurdles. However, even in the most stringent fiscal analyses (and there have been several) bariatric surgery is not only the most effective but also the most cost effective treatment for T2D and severe obesity.

The costs of the surgeries are readily offset by the benefits.[6] Although there is some disagreement about expenditures and savings, most economists concur that the cost of surgery is amortized over 2 to 3 years, mostly due to the sharp reduction in medications. The savings in medications for diabetes alone exceed $10,000 per year. Not considered in these analyses are the additional social benefits due to reduction in disabilities and the ability to return to work and be productive at those jobs.

Eric Finkelstein, one of our most respected healthcare economists, summarized the situation best:
“Bariatric procedures should not be held to a different standard than other medical or surgical interventions, regardless of what the return on investment might be…no one asks to see a positive return on investment of treatment of cancer, heart disease, or diabetes. Treatments for these conditions are covered in almost every health plan. The coverage decision should be based on whether or not the intervention can improve the condition in a cost-effective manner compared with other potential treatments.”

In North Carolina, we hope that Secretary Wos, a physician, will have a chance to review the basic principles of our profession and conclude that the most effective and lifesaving therapy, available to some of our population, should not be denied to our poor and minority citizens.

References
1.    Sjöström LJ. Review of the key results from the Swedish Obese Subjects (SOS) trial—a prospective controlled intervention study of bariatric surgery. Intern Med. 2013;273(3):219–234.
2.    Schauer PR, Kashyap 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.
3.    Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577–1585
4.    MacDonald KG Jr, Long SD, Swanson MS, et al.The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg. 1997;1(3):213–220
5.    Ashrafian H, Ahmed K, Rowland SP, et al. Metabolic surgery and cancer: protective effects of bariatric procedures. Cancer. 2011;117(9):1788–1799.
6.    Wang BC, Wong ES, Alfonso-Cristancho R, et al. Cost-effectiveness of bariatric surgical procedures for the treatment of severe obesity. Eur J Health Econ. 2013 Mar 24. [Epub ahead of print]
7.    Finkelstein EA, Brown DS Return on investment for bariatric surgery. Am J Manag Care. 2008;14(9):561–562.

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