Disease Mangement

More Health Plans Use Bariatric Centers of Excellence to Manage Obesity

Reprinted from the Feb. 17, 2006, issue of INSIDE DISEASE MANAGEMENT.

Health plans increasingly are making bariatric centers of excellence a component of their disease management strategy for managing obesity, but are not requiring members to enroll in and complete formal DM weight-management programs prior to bariatric surgery.

Still, plan quality experts say that such surgery centers of excellence educate their patients thoroughly and often require them to diet before agreeing to the surgery — in effect performing most or all the functions of a strong morbid obesity DM program, right down to data collection.

"When you go to a good bariatric program, they will — on their own — want to make sure you've attempted to control your weight," says Don Bradley, M.D., executive medical director for Blue Cross and Blue Shield of North Carolina (BCBSNC), which instituted a bariatric surgery centers-of-excellence program in October 2004 as part of its overall weight-management DM strategy.

While the North Carolina Blues plan doesn't force patients considering bariatric surgery to enroll first in its DM program, the patients who don't enroll almost always receive education about nutrition, activity and health risks comparable to that received by those in the DM program — and of course about the surgery — from the surgery practices themselves.

"Say someone's been morbidly obese for the past five years," says Bradley. "The surgeons are going to spend a lot of time educating people about what the surgery will and won't do. They'll tell them, 'If you try to eat McDonald's hamburgers in the volume you did before the surgery, you'll just throw it up.'"

Blue Cross and Blue Shield of Massachusetts (BCBSMA) is in the process of implementing a bariatric surgery facility privileging program, which it expects to have in place by Jan. 1, 2007. Massachusetts Blues spokesperson Susan Leahy says that 24 hospitals now perform bariatric surgery in the state, and there's no way to know yet how many will receive privileges.

BCBSMA paid for 756 bariatric surgeries in 2002, 1,169 in 2003, 1,337 in 2004 and 1,325 in 2005, Leahy says.

Members will not be required to go through BCBSMA's weight-management DM program before becoming eligible for bariatric surgery, but the plan intends to provide support for surgery candidates, which will include information about patient safety guidelines and about different hospitals' bariatric surgery programs, Leahy says.

This is "so that members can make informed choices when selecting a bariatric surgery program," she says. "Participation in this [weight-management DM] program will be voluntary, and members can opt out at any time — there is no impact to member benefits if they choose not to participate."

N.C. Blues' Initial Results Are Good

In October 2004, BCBSNC launched its Centers of Excellence for Morbid Obesity Surgery program as part of its overall weight-management DM program. The North Carolina Blues plan conducted a rigorous request-for-proposals process, working with the American Society of Bariatric Surgery to develop quality guidelines, Bradley says.

As part of the bariatric surgery effort, the plan created "a truly comprehensive program" that includes mental health evaluations, nutritional and activity assessments, and thorough vetting of those who might be candidates for the surgery, he says. Bradley adds, "We wanted to make sure these surgeons weren't just cutting these people and running."

In addition, the surgery itself creates a malabsorption syndrome, which means patients need to be followed closely afterwards, he explains.

Out of the 20 that originally applied, the plan now credentials seven bariatric surgery sites that include a total of 12 physicians, "nicely distributed across the state," says Bradley. These surgeons perform a minimum of 50 bariatric surgeries per year, he says.

BCBSNC doesn't require preauthorization from these physicians, and in fact pays them 30% to 50% more than what it paid before the program began.

Surgeons who aren't in the program aren't barred from performing the procedure on plan members, but must go through preauthorization, he says.

Results from the program have been striking, Bradley says — the number of members undergoing bariatric surgery actually has dropped, after rising dramatically in the first year or two of the decade. Since the overall obesity DM program is so new, it's still not clear how much it is saving overall, says Bradley. But he notes costs to the plan are very low.

In the first quarter of 2001, surgeries were performed at a rate of 1.5 per 10,000 members. By the second quarter of 2004, the rate was 10 per 10,000 members. Now, preliminary data indicate that the rate dropped in the first and second quarters of 2005 to about six or seven per 10,000 members, Bradley says, adding "that's still higher than it was back in 2001, but it has tapered off some. By shining the light on what is good criteria [for the surgery], folks make better decisions."

Also, since BCBSNC launched the centers-of-excellence program, plan-wide readmission rates for bariatric surgery have fallen from close to 17% to about 8%. Readmission rates for patients of surgeons in the program run about 4% to 4.5%, according to the plan.

Future plans for the program include talking to physicians not now credentialed to see if they want to apply, and also collecting clinical data on patients to determine "what happens to their diabetes and their hypertension — to see how well these problems are resolving" after the surgery, says Bradley. "We now have a year's worth of data to see how well these folks are doing."

Horizon Prepares Bariatric Program

Horizon Blue Cross Blue Shield of New Jersey also is vetting facilities in preparation for a new bariatric surgery centers-of-excellence program designed to complement and connect to the plan's DM programs, says Sue Binder, director, health and wellness education program, quality management and clinical innovations. The program, slated to start later this year, will include three facilities.

"A lot of these people going for bariatric surgery approach the surgery with chronic conditions already," says Binder. "They have the surgery and really need to be connected to the DM program."

Horizon's weight-management DM program likely will help with follow-up on these patients once the bariatric surgery program is in place, notes Premila Kumar, senior clinical manager, health and wellness education program, quality management and clinical innovations.

The weight-management DM program, which targets members ages 12 and up with a body mass index of more than 30, initially rolled out in May 2004 just to the plan's HMO population, but since has been expanded to Horizon's fully insured lines and is offered as an add-on to self-insureds, says Kumar. Program payment terms for self-insureds vary per contract, she says.

In the plan's "hierarchy" of DM programs, obese patients with a comorbid condition such as diabetes enter the DM program for that comorbid condition, rather than the obesity DM program, Kumar says. That means patients in the obesity program have only a diagnosis of obesity. Horizon — a plan with around 1 million members — now has enrolled 9,188 patients into the obesity program.

Potential enrollees are identified through medical claims with obesity as a primary diagnosis, and through pharmacy claims, which Kumar says is the way most patients are targeted.

"We initially did think that identifying them would be a big problem, but as you can see from the numbers, it is a huge number," she says.

Once in the program, they're stratified to five risk levels; patients in the top two risk levels receive telephonic counseling, while the rest receive quarterly mailings and access to counselors on a nurse phone line, Kumar says.

High-risk patients in the Horizon weight-management DM program are followed much more frequently than are those in the plan's other DM programs, she says.

Kumar adds that "we talk to them every week, and we keep the physician in the loop."

Although the program is too young to have outcomes figures, "we do track utilization rates, and we have seen a positive trend," Kumar says.

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