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CMS Lap-Band change reduced costs, increased safety

Restricting who could perform bariatric procedures cut the incidence of death. Photo: istockphoto
Cohort study shows restricting reimbursement to accredited centres reduced costs and increased safety
Decision more than halved deaths within 90 days of procedure

According to a study featured in the Annals of Surgery, the February 2006 decision by the Centers for Medicare and Medicaid Services (CMS) to restrict reimbursement for bariatric surgery to accredited centres and include coverage for laparoscopic adjustable gastric band (LAGB) reduced the cost of procedures and increased safety measures.

Prior to the 2006 changes, the CMS only reimbursed gastric bypass surgeries. As a result, Dr David Flum, the study's lead author and a Professor at the University of Washington, and colleagues decided to investigated the impact of the CMS’ bariatric surgery national coverage decision on the use, safety and cost of care for CMS beneficiaries.

Study design

The researchers established a cohort study using nationwide Medicare data (2004–2008) evaluating rates of bariatric procedures/100,000 enrolees, 90-day mortality, readmission rate and payments.

A total of 47,030 patients underwent procedures at 928 sites pre-NCD and 662 post NCD. The procedure rate/100,000 patients dropped after the NCD to 17.8 (from 21.9 in 2005) increasing to 23.8 and 29.1 in 2007 and 2008, respectively. Pre and post NCD data are seen in Tables 1, 2 and 3.

  ORYGB* LRYGB** LAGB***
Pre-NCD 56.0% 35.5% n/a
Post-NCD 12.8% 48.7% 36.7%

Table 1: Procedure rates pre- and post-NCD

* Open Roux-en-Y gastric bypass ** Laparoscopic Roux-en-Y gastric bypass *** Laparoscopic adjustable gastric band

  ORYGB LRYGB LAGB Total p value
Pre-NCD 1.8% 1.1% n/a 1.5%  
Post-NCD 1.7% 0.8% 0.3% 0.7% <0.001

Table 2: 90-day mortality rate pre- and post-NCD

  Re-admission Re-operation Payments p value
Pre-NCD 19.9% 3.2% US$24,363 <0.001
Post-NCD 15.4% 2.1% US$19,746 <0.001

 Table 3: 90-day re-admission, re-operation and payments pre- and post-NCD

Conclusions

The NCD was associated with a temporary reduction in procedure rate and a shift in types of procedures and patients undergoing bariatric surgery. It was associated with a significant decrease in the risk of death, complications, readmissions, and per patient payments.

The research revealed that 15 out of every 1,000 people who had weight loss surgery before the CMS decision died within 90 days of the procedure. After the rules change, seven out of every 1,000 people died after the surgery. Furthermore, re-admission and reoperations also dropped, as did the cost of the procedure.

The NCD limited reimbursements to hospitals that receive a particular accreditation through the American College of Surgeons or the American Society for Bariatric Surgery by performing a certain number of procedures each year and by having staff and facilities that meet certain standards.

Before Medicare's new requirement for accreditation in 2006, patients received surgery at 928 sites. Afterward, patients went to 662 facilities for surgery. This resulted in a decrease in access in places that were not accredited; however, the authors support the notion of accreditation standards around safety or volume, as this has been proven to improve outcomes.

The CMS’ current coverage for weight loss surgery excludes sleeve gastrectomy and officials are seeking input on whether there are enough data on its effects and safety to include the procedure.

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