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Medical Director, Bariatric Surgery

Mountainview Regional Medical Center

!  None

!  Discuss the ongoing epidemic of obesity !  Discuss current treatment options !  Discuss the role of bariatric surgery !  Review the qualifications for bariatric surgery !  Review basic insurance process !  Consider long term strategies for managing our

obese patients !  Improving our long term success in managing our

obesity epidemic

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!  Who needs it? !  How do they get it?

BMI ≥ 30, or ~ 30 lbs. overweight for 5’4” person

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

1985 1990 1995 2000 2005 2010 2011

2011

2001

“Doing the same thing over and over again and expecting different results.“

Albert Einstein

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!  Mainstay of therapy:

◦  Diet(s) and exercise

◦  Pharmacology

◦  Assorted fads

!  1) recognize obesity and overweight as a chronic medical condition (de facto disease state) and urgent public health problem;

!  (2) recommend that providers receive appropriate financial support and payment from third-party payers, thus ensuring that providers have an incentive to manage the complex diseases associated with obesity;

!  (3) work with third-party payers and governmental agencies to recognize obesity intervention as an essential medical service; and

!  (4) establish a comprehensive ICD code for medical services to manage and treat obese and overweight patients.

!  Will hopefully shift insurers to consider obesity as a chronic medical illness (i.e. hypertension, arthritis) ◦  NOT a self inflicted medical condition for which the patient is

the sole responsible agent ◦  This does NOT relieve the patient of their responsibility to their

lifestyle/diet decisions contributing to ongoing obesity

But… Will it shift the mindset of healthcare providers to reconsider their approach to the treatment of the Chronic Medical Disease called Obesity?

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!  The complexity and poor understanding of the disease entity and etiologic properties ◦  Genetics ◦  Gut hormones ◦  Systemic hormones ◦  Gut bacterial flora ◦  Social factors ◦  Environmental factors ◦  Insulin resistance ◦  Effect of food type consumption over the past 50 years ◦  And more, and more…

!  Just like we treat all other complex medical diseases: ◦  We evaluate our patients and individualize their

treatment regimen ◦  Recognize traditional therapies do not appear to be

making a significant impact ◦  If we want different outcomes, we need different inputs ◦  Surgery should no longer be considered a highly risky,

last resort treatment for only the very super obese ◦  Multiple medical groups and insurers are recognizing

surgery as a vital therapy component

!  Probably more patients than we are considering or recommending…

◦  Lancet, Feb. 2014…argues that, given its benefits for

weight loss, metabolic status, and quality of life, as well as its safety and effectiveness, bariatric surgery should be "an option to use when appropriate, and not only when all other options have been eliminated."

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!  American Association of Clinical Endocrinologists (AACE) includes consideration of weight loss surgery in their algorithm for treating DM II on patients with BMI>35

!  International Diabetes Federation (IDF) position statement in 2011 that Bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes presented by leading experts at the 2nd World Congress on Interventional Therapies for Type 2 Diabetes in New York

!  5 year history of ◦  BMI over 40, or ◦  BMI over 35 with associated obesity related

comorbidities !  Diabetes Type II, Sleep Apnea, Hypertension, Dyslipidemia,

Heart Disease Failed attempts at nonsurgical weight loss Willingness to make appropriate long term dietary and lifestyle changes Willingness to participate in long term followup

!  Preoperative supervised weight loss visits. 3,6,12 months

!  Preoperative Psychology evaluation !  Preoperative Nutritional evaluation !  Surgery to be performed at a recognized Center of

Excellence (COE) !  Some have restrictions on which surgeries are

approved

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!  Blue Cross Blue Shield New Mexico !  Blue Cross Blue Shield Federal !  Blue Cross Blue Shield Tennessee !  Lovelace (Transitioning to BCBS NM) !  Presbyterian !  Medicare !  Medicaid/Saludes

!  Talk to your patients about weight and weight loss options, including surgery. Studies show most patients do not find this offensive and want to have discussions with their health care providers about meaningful weight loss.

!  Patients are very slow to call a bariatric surgeon and seek a consultation by verbal suggestion alone. Help establish appointment. ◦  They often need your support and ‘approval’ to consider

surgery as an option.

!  Preconsultation educational seminar !  Consult with surgeon !  Preoperative evaluation/education ◦  Labs: CBC, CMP, Lipids, A1C, Thyroid Function !  Consider inflammatory/cardiac markers, PT/INR Nutritional evaluation Psychological evaluation Consider Sleep Study Consider EKG, Cardiac Evaluation/Stress Test Consider EGD, Upper GI, Venous Doppler/IVC Filter Surgical education – EMMI, Office based programs

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!  Supervised weight loss visits, if required !  Preoperative very high protein, very low calorie

diet (Reduce fatty liver size, friability) !  Final preop visit to review all data, review surgical

procedure and risks, obtain informed consent

!  This is a minimum of 6 weeks for most patients, and can be 6 months if weight loss visits are required

!  Must be a dedicated visit to address weight loss activity

!  Very specific assessment/discussion must be documented to be accepted by insurance

!  Must be completed in a timely fashion without missed or delayed visits

!  This documentation must be provided with preapproval request to insurance company

!  Once all criteria and steps required by insurance have been completed, the package of information is submitted to the insurance company for preauthorization/approval.

!  Insurance companies usually have between 14 and 28 days to respond

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!  We are all aware of the obesity epidemic ◦  Estimated 78 million Americans meet surgery criteria ◦  Approximately 180,000 had surgery in 2013

!  Current treatment approaches and mindsets are ineffective ◦  Must consider surgery an ‘early’ treatment option,

especially for BMI group over 40, and Type II Diabetics ◦  Patients need to feel that primary care providers support

bariatric surgery as a treatment option

!  Bariatric Surgery IS NOT solution to our obesity epidemic! ◦  It is the most effective long term option we have to offer

at this time !  The real fix is a cultural change in food and eating

habits that will take generations to bring about ◦  In the meantime, what do we do for current generations

of severe and morbidly obese individuals?

The Surgical Procedure

Proper Nutrition & Exercise

Psychology of Eating

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!  It has been my privilege to speak with you today

!  I thank you for your attention

!  I look forward to answering any questions