Affordable Care Act and Bariatric Surgery. John Morton, MD, MPH, FASMBS, FACS Chief, Bariatric and Minimally Invasive Surgery Stanford University
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1 Affordable Care Act and Bariatric Surgery John Morton, MD, MPH, FASMBS, FACS Chief, Bariatric and Minimally Invasive Surgery Stanford University
2 Tertiary Prevention Prevention of disease progression and attendant suffering after it is clinically obvious and a diagnosis established.
3 Heart Disease and Obesity HD is leading cause of death: >300,000 annually Primary modifiable risk factors: Obesity & Smoking (Lavie et al, J Am Coll Cardiol, 2005) Smoking rates declining, obesity increasing (JAMA, 2003)
4 Cardiac Risk Factor Improvement Total Cholesterol Morton SOARD mos 6 mos 12 mos 41 HDL mos 6 mos 12 mos TC Linear (TC) HDL Linear (HDL) mos 6 mos 12 mos LDL TG mos 6 mos 12 mos LDL Linear (LDL) TG Linear (TG)
5 The Affordable Care Act and Bariatric Surgery The Essential Health Benefit (EHB) is an important centerpiece of the ACA with each state required to provide a sample plan and benefit package to be approved by HHS. The EHB is designed for those citizens who do not have current coverage. Adverse selection may occur when a single plan exclusively offers a benefit.
6 Adverse Selection Wherein an individual's demand for insurance (the propensity to buy insurance and/or the quantity purchased) is positively correlated with the individual's risk of loss (like higher risks buy more insurance), and the insurer is unable to allow for this correlation in the price of insurance AVOID INSURANCE FOR THE OBESE
7 Bariatric Surgery Coverage, All employers Mercer National Survey of Employer-Sponsored Health Plans 60% 50% 40% 30% % 10% 0% All Employers Small Employers (<500 employees) Large Employers (>500 employees)
8 AK Employer Coverage for Bariatric Surgery 2010 ALL EMPLOYERS WA MT ND ME OR CA NV ID UT AZ WY CO NM SD NE KS OK MN WI IA IL MO AR MS MI IN KY TN AL OH GA NY PA WV VA NC SC MD VT NH NJ DE RI CT MA TX LA HI FL % Employer Coverage: No Data 0 to 25% 51 to 75% > 75% 26 to 50% Source: Mercer s National Survey of Employer-Sponsored Health Plans 2010 All Employers
9 The Affordable Care Act and Bariatric Surgery The plan offering bariatric surgery benefit may take an high proportion of utilization The Essential Health Benefit avoids this issue of adverse selection by having a single benefit plan that over time all carriers will emulate. It has been established that there is only partial access to the only effective and enduring treatment for morbid obesity.
10
11 Who is Running the State Exchange? Business Unit or Department I
12 Is Bariatric Surgery Included in the State s Qualified Health Plan? Health Insurance Exchange (HIE) Coverage of Weight-Related Services AK Affordable Care Act Beginning January 2014 WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI IN KY TN AL OH GA NY PA WV VA NC SC NJ DE MD RI CT ME DC NH VT MA TX LA HI Does not cover bariatric surgery nor weight loss programs Covers weight loss programs but does not cover bariatric surgery Covers bariatric surgery but does not cover weight loss programs Covers bariatric surgery and weight loss programs Source: Center for Consumer Information and Insurance Oversight summary of EHB benchmark plans based on 2012 benefits STOP Obesity Alliance, Weight and the States Policy Research Bulletin, December Obesity Action Coalition Spreadsheet, May (States that have not selected an EHB benchmark plan defaulting to the largest small-group employer plan in the state.) FL Current as of ; Coverage may have changed since this printing
13 Cost-Effectiveness
14 Qualified Health Plans - Bariatric Surgery To Date Covidien March 3, 2014 Confidential Bariatric Surgery an EHB Plans w/o BS Benefits 14 Plans w/o SBC Information QIP's Plans w/ BS State EIX Type ID'd Benefits Arkansas State No California State Yes Colorado State No Connecticut State No 3 3 Florida FFE No Georgia FFE No Illinois State Yes Indiana FFE No Kentucky State No Massachusetts State Yes Maryland State Yes Michigan FFE Yes Once per lifetime Minnesota State No 5 5 Missouri FFE No North Carolina FFE Yes New Jersey FFE Yes New Mexico State Yes 2 2 Nevada State No 4 4 New York State Yes BS Access Restriction Noted One new surgery per lifetime (Hayes Tech Criteria) Ohio FFE-MPM No Pennsylvania FFE No 8 8 Rhode Island State Yes 1 1 Texas FFE No Virginia FFE-MPM No plans offer BS option as rider ($$$) Vermont State Yes 2 2 Washington State No 7 7 Wisconsin FFE No Totals
15 A Tale of Two States
16 ACA may not discriminate on basis of health condition
17 UHC data: In-Hospital Mortality 4.5 Bariatric Surgery In-hospital Mortality by Year (N = 105,287) Deaths per 1, Year Nguyen et al. SOARD 2012
18 NATIONAL COMPARISIONS OF BARIATRIC SURGERY SAFETY AND EFFICACY: FINDINGS FROM THE BOLD DATABASE John M. Morton, MD, MPH 1 ; Ninh Nguyen, MD 2 ; Bintu Sherif, MS 3 ; Deborah Winegar, PhD 3 ; Jaime Ponce, MD 4 ; Robin Blackstone,MD 5 Stanford University School of Medicine 1 ; University of California, Irvine 2 ; American Society of Metabolic and Bariatric Surgery 3 ; Dalton Surgical Group 4 ; Scottsdale Bariatric Center 5
19 Results: Change in BMI p<0.001
20 Results: Postoperative Safety Outcomes N (%) LAGB LRYGB LSG P-value 30-Day Mortality 31 (0.03) 187 (0.14) 13 (0.08) < Day Serious Complications 288 (0.25) 1729 (1.25) 155 (0.96) < Day Readmission 1609 (1.37) 6409 (4.64) 581 (3.60) < Day Reoperation 754 (0.64) 3801 (2.75) 274 (1.70) < Day Mortality 41 (0.03) 241 (0.17) 17 (0.11) < Day Serious Complications 330 (0.28) 1908 (1.38) 171 (1.06) < Day Readmission 2098 (1.79) 8727 (6.31) 693 (4.29) < Day Reoperation 1291 (1.10) 6356 (4.60) 355 (2.20) <.0001
21 AK Sleeve Gastrectomy Coverage by Medicare Administrative Contractors (MACs) (as of Feb 1, 2013) WA MT ND MN ME OR CA NV ID UT AZ WY CO NM SD NE KS OK WI IA IL MO AR MS MI IN KY TN AL OH GA NY PA WV VA NC SC NJ DE MD RI CT NH VT MA DC TX LA HI FL States with CONFIRMED Sleeve Coverage from their MACs States with DRAFT Local Coverage Decision (LCD) - MAC to decide within next days States with < 60 Age Restriction (Noridian: WA, OR, ID, AK, ND, SD, MT, WY, UT, AZ, MN (MAC A only)) States with < 64 Age Restriction (Palmetto GBA: SC, NC, VA, WV, CA, NV, HI) Coverage current as of 2/1/13; coverage may have changed since this printing
22 John Morton, MD
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Criminal History Reference Listings The following contacts may assist in obtaining criminal history checks from various state agencies. While the information is believed to be reliable, the links reflect