Centers of Excellence: The Bariatric Surgery Story

Insurers, regulators and statisticians have long contended that where patients undergo weight loss surgery can be as important as who performs it. A skilled, experienced bariatric surgeon will only perform optimally and patients will only receive ideal post-op care if the center in which he or she works is well-equipped. This was the premise behind the Centers for Medicare & Medicaid Services’s (CMS) requirement that bariatric surgery be performed only in hospitals designated as a Center of Excellence (COE). This rule, promulgated by the National Coverage Determination manual, took effect in February, 2006. CMS lifted this requirement in September, 2013. Did that requirement limit access to bariatric surgery? That is the question surgeons attempted to answer in a study published ahead of print in JAMA Surgery.

These researchers used retrospective data from the National Inpatient Sample to identify 134,227 patients who underwent bariatric surgery in calendar years 2006 through 2011.

They identified a shift in procedures by patient age, with older patients undergoing more than twice the number of procedures at the study’s end than at its beginning. In 2006, approximately 3% of patients were 64 or older; in 2013 7% were 64 or older. Similarly, the proportion of patients who were 49 years and younger declined.

Over the years, the percentage of male patients increased from less than 20% to about 22%. Surgeries on Black, Hispanic, or Asian or Pacific Islander patients increased by about 25%.

Patients using Medicare coverage increased from 8.5% in 2006 to 16.3% in 2013, as did Medicaid coverage (up from 6.6% in 2006 to 11.8% in 2013). Procedures covered by private insurers declined from 72.4% to 63.3%.

Income-based disparity was also lower. Patients with incomes in the lowest income quartile were significantly more likely to have bariatric surgery in 2013 than in 2006; a similar decrease was seen in patients having incomes in the highest income quartile.

Previous studies have suggested that inpatient mortality, 90-day reoperations, complications, and readmissions decreased from 2003 through 2009 in COE facilities, but costs remained the same. Others have argued that COE and non-COE facilities are similar. This study’s findings suggest that CMS’s COE certification requirement did not limit access to bariatric surgery, and actually reduced some barriers.