Weighed Down by Paperwork: Identifying Barriers to Metabolic and Bariatric Surgery Evaluation in the United States

Abstract

Background

Obesity affects over 42% of U.S. adults, yet access to metabolic and bariatric surgery (MBS) remains limited despite its proven efficacy. While use of GLP-1 receptor agonists has risen in the past three years, MBS volume has declined over 25% during the same period. Reported barriers to MBS include long wait times, societal sigma, fear of surgery, and insurance restrictions. This study investigated appointment accessibility and program requirements for patients seeking MBS.

Methods

We conducted a secret shopper study of bariatric surgery centers in North Carolina (n=18) and South Carolina (n=17) June - August 2025. Trained callers contacted each program twice, once posing as a patient with Medicaid and once as a patient with private insurance, to request an initial consultation appointment. Data collected included appointment wait times, required documentation, pre-surgical prerequisites, and administrative barriers.

Results

Of the 24 centers successfully contacted, all accepted private insurance and 94.3% accepted Medicaid. Median wait time to appointment was 20 days, with no difference by insurance type. On average, programs required 1.7 calls before reaching a scheduler. Most centers (77.1%,n=27) required pre-appointment steps such as an online application, seminar, or PCP referral. Eleven centers could not be reached due to incorrect contact information, and two offered only online intake forms.

Conclusions

Rather than insurance-related disparities, we found that administrative barriers such as repeated call attempts, inaccurate contact information, and variable prerequisites were the main obstacles to MBS access. The lack of standardization across programs highlights the need to streamline the evaluation process.

Introduction

Obesity is a significant public health crisis because of its high prevalence, associated morbidity and mortality, and substantial economic burden [1]. Despite this, metabolic and bariatric surgery (MBS), the most effective treatment for achieving sustained weight loss, is utilized by only 1–2% of eligible patients [2]. Research has previously shown that attendance to the initial MBS appointment results in higher rates to completion of surgery [3]. Studies are lacking in appointment accessibility, and potential barriers to attendance. This study investigated appointment accessibility and program requirements for patients seeking MBS in two states of the USA.  

Methods

We conducted a secret shopper study of metabolic and bariatric surgery centers in North Carolina (n = 18) and South Carolina (n = 17) June - August 2025 locations shown in Fig. 1. Metabolic and bariatric programs were obtained from publicly available sources. A random-sequence generator (Random.org, Dublin, Ireland) [4] was used to randomize the order in which centers were called within each set. Trained callers contacted each program twice, once posing as a patient with Medicaid and once as a patient with private insurance. The order in which the insurance scenario each practice received was also randomized. The callers explicitly confirmed insurance acceptance during the calls. If during the call, a practice accepted the insurance type but required insurance number or government information for an appointment date, the callers did not provide any falsified information. Calls were conducted between 9 − 3 pm EST, to request an initial consultation appointment. Repeat calls to each practice were separated by at least 2 weeks. Callers were provided scripted responses, including demographics and clinical details, as needed for the appointment screening process. Calls that did not obtain an appointment were excluded from the analysis for appointment wait time. Data collected included appointment wait times, required documentation, pre-surgical prerequisites, and administrative barriers. If programs had incorrect or nonfunctional contact information or could not be reached after three attempts on different days, this was documented as access barrier.

Fig. 1.

Map of MBS programs in North Carolina and South Carolina

Results

Between South Carolina and North Carolina, 24 of 35 (68.6%) centers were successfully contacted by telephone. Of centers with successful telephone encounters, all accepted private insurance and 94.3% accepted Medicaid. Median wait time to appointment was 20 days [3–62], with no difference by insurance type. On average, programs required 1.7 [1–4] calls before reaching a scheduler. Most centers (77.1%, n = 27) required pre-appointment steps: online application (45.8%, n = 16), seminar attendance (29.2%, n = 10), PCP referral (25%, n = 9) and screening questionnaires (20.8%, n = 7) (Fig. 2). Of the 24 centers, 8 (22.9%) required completed two or more steps before appointment could be scheduled. Eleven centers (31.4%) could not be reached despite multiple contact attempts. Nine centers had incorrect contact information and two only offered online intake forms.

Fig. 2.

Pre-appointment requirements for metabolic and bariatric surgery programs in North Carolina and South Carolina

Conclusion

This study found that rather than insurance-related disparities, administrative barriers such as repeated call attempts, inaccurate contact information, and variable prerequisites were the identified obstacles to MBS appointment access in North and South Carolina. Despite multiple contact attempts, 31.4% of centers could not be reached, representing a significant and potentially modifiable barrier to access for MBS. In the setting of an obesity epidemic, these readily correctable barriers to care must be mitigated for patients’ health. On average, 1.7 calls were required to reach a scheduler, which may pose a barrier for patients with limited time. Most centers required pre-appointment steps (77.1%), and nearly one quarter (22.9%) required multiple steps before an appointment could be scheduled, which may disproportionately burden patients with limited time, lower health literacy, or reduced social support. The median wait time for an initial appointment was 20 days, which prolongs the time to metabolic and bariatric surgery and delays the benefits of MBS. Longer wait times in other fields are also associated with higher no-show rates [5]. Pitzul et al. found in their cohort of patients that when patients were assessed by a health-care professional only 13.2% did not continue to MBS treatment [3]. This is an extremely low rate and may be more site specific; however, it does instill the importance of streamlining the process of patients obtaining their initial appointment. Obesity is a significant health crisis that can be effectively reversed with MBS; however, this study found that simple administrative tasks stand between many patients and this procedure. Metabolic and bariatric surgery centers should work to streamline the process of getting patients into their clinics, and analyze how their practice may be creating barriers to care for these patients. Patients face enough barriers without their own healthcare providers creating more.

Author Contributions

SM, MKB, RP and KS contributed significantly to data collection via telephone calls and internet searches. RP, SM, KS, MKB, and RB all contributed to the data interpretation and editing. RB and MKB were responsible for writing. All authors were responsible for reviewing the manuscript.

Funding

Open access funding provided by the Carolinas Consortium.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.