When I began my healthcare career at Michigan Blue Cross many years ago, the hospital relations division where I worked made the discovery that appendectomies, hysterectomies and cholecystectomies in one modest-sized community in that state were unusually common.  Staff investigators visited the community and discovered that its hospital’s only surgeon claimed to perform them prophylactically, to prevent problems, rather than wait to cure them.

The investigation concluded that the real reason for most of these procedures seemed to be related more to the surgeon’s need to pay off the mortgage on his expensive new home and boat, rather than to benefit his patients.  With no other surgeons in on the hospital’s medical staff, there was no effective tissue or other peer review to hold him in check, but the investigation and resulting warnings to the hospital had the desired effect of significantly dampening the rate of surgery subsequently.

In a CBS Evening News story on April 21, the subject of bariatric surgery for obese patients was covered in some depth.  One champion for this method of severe obesity reduction noted how much safer the surgery has become as its techniques have changed, and how much added benefit has been found in patients who have it.  One surprise was the bypass of the stomach and attachment of the duodenum directly to the small intestine seems to “cure” diabetes virtually overnight.

A panel of eight patients had been assembled for this story, with all eight of them reporting that prior to their surgery, they were diabetes sufferers.  But in some cases only days after surgery, and in all cases at some time afterwards, all eight no longer had the disease, and were no longer taking medications to control it.  While the mechanism for this effect was not described, and may not be known as yet, even before they experienced any weight loss, which in most cases only took off about a third of the excess weight, they had gained a “reversal” of their diabetes.

It was also noted in the story that the success of stomach bypass surgery has a “success rate” in terms of significant reduction in obesity, and most particularly in keeping the weight off, of roughly 85%.  This is roughly seventeen times the success rate for other methods of weight loss, where initial losses are common, but commonly associated with gaining most or all the weight lost within a year.

The combination of reducing patients from morbid or extreme obesity to mere “normal” obesity or even mere overweight status, i.e. of at least one BMI (body mass index) category, and keeping it off indefinitely, can be a big money saver for insurers and employers.  Health care use and expenditures have been found to be roughly $382 lower for every BMI point of reduction.  Since a BMI category equals five points, this would suggest annual savings, in medical, pharmaceutical, and disability claims alone, of five times as much, or $1910 per year for employers, and since the vast majority of these savings are paid by health insurance, they would be almost that much for insurers, as well.

The BMI connection with lower claims costs were amazingly uniform at all BMI levels, i.e. there was no “law of diminishing returns” in the levels of expenditure increase as BMI got larger.  Moreover, the reported cost differences by BMI levels were reported seven years ago, using data that was even older.  Given health care cost inflation since then, the savings could be twice that amount or more by now.  [“The Impact of a Worksite Health Promotion Program on STD Usage” JOEM (Journal of Occupational and Environmental Health) 43:1, Jan 2001 25-29]

Since bariatric surgery costs roughly $25,000 (though insurers may pay significantly less if they cover it), the upfront costs of achieving such savings will be considerable.  It is no wonder that insurers, in particular, are hesitant to pay for it, and commonly impose strict requirements as to how much overweight patients must be to qualify, and how long they must try to lose weight through other methods first. [K. Dunn “Bariatric Surgery at Tufts Health Plan” WorldHealthCareBlog.org, Apr 23, 2008]

Moreover, since insurers normally retain their members for only a few years, even savings of $5000 a year would not deliver a positive ROI in most cases for them.  But employers might consider covering such surgery, given its higher success rate and far greater savings to them.  They stand to gain not merely reductions in medical, drugs and disability expenditures, but savings in absenteeism and presenteeism as well, which are typically two to five times greater, altogether.

If even 50% of bariatric surgery patients gain a reduction of one BMI category and maintain that loss indefinitely, employers could save enough in just a few years to cover the costs of the surgery.  Only predictive analysis based on their own workforce health and performance costs, and the contribution value of their employee assets, will enable them to make a reasonable forecast of their potential ROI and how long it would take to gain it, but employers, at least, might consider it a worthwhile investment.

As a long-term investment, it might even be justified by commercial and government insurers, as well.  Commercial insurers might be willing to cover it based on how many of their members come to them from other insurers’ plans, and are already at lower costs due to obesity “cures” thanks to surgery.  Medicare might consider the risk vs. reward potential of subsidizing or at least promoting bariatric surgery among populations soon to be their responsibility, rather than waiting until they actually are beneficiaries.

It is even possible that the combined savings potential in preventing both obesity and diabetes, to say nothing of other conditions, including cancer and arthritis, for example, that are far more likely among obese populations, could justify bariatric surgery as a preventive, i.e. prophylactic measure.  Whether consumers would be willing to undergo such surgery merely to dramatically reduce their risks of obesity, diabetes, and their co-morbidities is open to question, though consumers have demonstrated a common preference for the “quick fix” compared to the rigorous lifetime self-discipline necessary to prevent weight gain or cure it after the fact.

I mention this possibility at least partially with tongue firmly planted in cheek.  But insofar as employers and insurers recognize the constantly rising costs of obesity and the co-morbidities associated with it, together with their negative impact on workforce productivity and overall performance, there may be some justification for at least giving its reactive use some thought, if not its proactive potential, as well.