Bariatric surgery facing upheaval amid growing GLP-1 use

At Roxborough Memorial Hospital in Philadelphia, surgeon Piotr Krecioch has his hands full launching a program offering surgical interventions to treat obesity. One in three Philadelphians are living with obesity, putting them at higher risk of chronic conditions like diabetes and heart disease, but these days fewer are seeking the bariatric surgical procedures long considered a leading medical treatment for the condition.

"I'm trying to start a bariatric program at probably the worst possible time you can ever imagine because everybody's losing patients, and I don't even have a patient to begin with," Krecioch said.

Tower Health's Reading Hospital recently closed its bariatric surgery program, and other local health systems have seen declines in weight-loss operations approach 50%. Independence Blue Cross, the Philadelphia region's largest insurer, said the number of bariatric surgeries it paid for dropped by half in the five years ended June 30.

Those shifts in the bariatric surgery landscape have followed the meteoric national rise in the use of GLP-1s and related drugs for weight loss.

So far, the drugs have benefited patients by allowing them to avoid invasive surgery.  For hospitals, the upheaval in treatment options cuts into a profitable business line and adds to the financial pressure health systems have been experiencing since the pandemic.

Despite the ever-increasing popularity of GLP-1s for weight loss, like Novo Nordisk's Ozempic and Wegovy and Eli Lilly's Mounjaro and Zepbound, it's too soon to write off bariatric surgery as an option. Insurers are imposing limits on coverage because of the long-term cost of the drugs compared to surgery, and doctors are watching for side effects that may emerge as more people take the drugs for longer periods of time.

It's not the first time a new technology has reduced surgical volumes. Whenever a less-invasive treatment has come along, "surgical volumes have always taken a beating," said Dr Prashanth Ramachandra, a bariatric and general surgeon at Trinity Health Mid-Atlantic's Mercy Fitzgerald Hospital. Declines in peptic ulcer and open heart surgeries as past examples of the phenomenon, he said.

Such industry-wide moves away from profitable procedures can create financial challenges for individual clinics or independent hospitals, said Daniel Steingart, who leads the nonprofit health care practice at Moody's, a major credit ratings agency.

"But I also see it as an opportunity, because there are other patients out there, there are other services that can be provided. This is a matter of the management team being nimble," he said.

National data show a 38% decline in bariatric surgeries from the beginning of 2024 through September, according to data firm Strata Decision Technology.

A substantial portion of the drop is from patients who previously had bariatric surgery, but regained weight. In the past, they would have undergone a revision. Now, those patients are more likely to start taking GLP-1s.

Only two Philadelphia-area health systems provided details on changes in bariatric surgery volumes in recent years as GLP-1s for weight loss took off.

At the University of Pennsylvania Health System's three Philadelphia hospitals, the annual number of bariatric surgeries has fallen by more than half, from a peak of 850 three or four years ago to around 400 in the year that ended June 30, said Noel Williams, a physician who leads Penn's bariatric surgery program. At Mercy Fitzgerald in Darby, the number fell from an annual peak in the 220–230 range to about 125 last year, Ramachandra said. The volume at Mercy Fitzgerald was likely buoyed by the closure of the bariatric surgery program at nearby Crozer-Chester Medical Center in Upland.

Tower did not provide details on the Reading closure, which was part of cutbacks Tower announced in early November. The program closed last month after a 60-day notice to the state health department.

Main Line Health, which only offers bariatric surgery at Bryn Mawr Hospital, said surgeries have declined, but provided no details.

Virtua Health did not provide comparable data, but said that its Virtua Complete Weight Management Program, which opened in spring 2024 to expand into medication treatments, experienced a 35% increase in visits last year.

Jefferson Health and Temple University Health System did not respond to requests for information about their bariatric surgery programs. While full-scale closures like Reading's are unusual, cutbacks are occurring broadly.

When the bariatric surgeon at Penn Presbyterian Medical Center retired amid declining numbers of surgeries across the entire system, Penn did not replace him, Williams said.

Penn does the procedures locally at the Hospital of the University of Pennsylvania and at Pennsylvania Hospital.

"If the numbers were to continue the way they are now," Williams said, "we may want to consolidate into one of our hospitals in the city."

Outside of Philadelphia, Penn has bariatrics programs at Lancaster General Hospital and Penn Princeton Medical Center. After Jefferson Health acquired Einstein Health Care Network in late 2021, it consolidated bariatric procedures at Jefferson Abington Hospital, according to an Inquirer analysis of inpatient data through 2024 from the Pennsylvania Health Cost Containment Council. Jefferson did not respond to a request for information about the changes.

GLP-1s don't mean the end of bariatric surgery, even though the procedures are not likely to return to previous peaks, physicians said.

Some patients don't respond to GLP-1s and others can't tolerate them, which means they remain candidates for surgery, Williams said. Surgery is still recommended for patients who are considered severely obese, with body-mass indexes over 50, he added.

Outcomes cannot yet be compared over the long-term. Ramachandra and other doctors are keeping their eye on the ratio of fat loss and muscle loss in patients taking GLP-1s compared to those who have bariatric surgery. Losing muscle can lead to falls and fractures.

A study published in the Journal of the American Medical Association found that bariatric surgery is associated with a favourable ratio of fat loss.

At Roxborough Memorial Hospital, Krecioch, who also works as a general surgeon, sounds optimistic as he works on his new program. He became a Roxborough employee in April 2024 after eight years at Mercy Fitzgerald, where he worked with Ramachandra.

Krecioch's strategy for years has been to offer weight management services in addition to surgery. Patients come for a GLP-1, giving him a chance to build a long-term relationship.

"I have a feeling that these people are going to come back to my office," he said. "I'm gonna keep seeing them, and that they will actually convert to bariatric surgery at some point."

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