Abstract
Background:
Bariatric surgery is underutilized in the United States.
Objectives:
This study examined whether utilization of bariatric surgery is associated with payer and insurance plan type, after removing potential socio-demographic confounders.
Setting:
The study used Pennsylvania Health Care Cost Containment Council’s data in five counties of Pennsylvania from 2014–2016.
Methods:
Bariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n=5,114). A logistic regression was performed to investigate the association of payer type and insurance plan within payer type with odds of undergoing bariatric surgery.
Results:
The odds of undergoing bariatric surgery were not statistically different based on payer type. Medicare preferred provider organization (PPO) plan was associated with greater odds of undergoing surgery, OR = 2.49, 95% CI [1.23; 5.04], p = 0.01, compared to Medicare health maintenance organization (HMO). Medicaid fee for service (FFS) plan was associated with smaller odds of undergoing surgery, OR = 0.04, 95% CI [0.005; 0.27], p = 0.001, compared to Medicaid HMO. Individuals with Blue Cross PPO, OR = 2.43, 95% CI [1.83; 3.24], p < 0.001, Blue Cross FFS, OR = 1.79, 95% CI [1.32; 2.43], p < 0.001, and Blue Cross HMO, OR = 1.85, 95% CI [1.39; 2.46], p < 0.001, had greater odds of undergoing surgery compared to those with other commercial HMO plans.
Conclusions:
Specific aspects of insurance plan design, rather than more general payer type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.
Keywords: Bariatric surgery, health insurance, insurance design
INTRODUCTION
Despite its effectiveness with respect to weight loss1–3 and improvements in obesity-related co-morbidities,2–5 bariatric surgery remains underutilized in the United States. Estimates suggest that approximately 1% of individuals who meet the weight criteria undergo bariatric surgery annually.6 The reasons for this are not well understood, but likely are influenced by several factors. Major barriers include patient and physician knowledge and views, patient-provider communication, as well as cost and insurance design related factors.7
Data available within the last decade suggest that approximately two thirds of bariatric surgery patients are white.8 Four out of five patients are women with an average age of 44.6 ±11.8 years.9 Most patients who undergo bariatric surgery have private insurance and higher median incomes.6,10–12
Studies that have investigated the link between health insurance and bariatric surgery utilization broadly categorized insurance status as “private insurance,” “government insurance,” “no insurance”10,12 or offered some detail about the insurer, but with little to no detail about the specific insurance plan type.6 For example, Martin and colleagues reported that 82% of bariatric surgery patients had private insurance, while only 65% of eligible patients had private insurance, based on data from 2006 Nationwide Inpatient Sample and 2005–2006 National Health and Nutrition Examination Survey.10 Mainous and colleagues found that among bariatric surgery recipients, private insurance status ranged from 71.1% (black women) to 75.9% (white men).12 Among bariatric surgery eligible patients, only 49.9% of black women had private insurance as opposed to 69.8% in white women; the corresponding value for black men was 52.4% and for white men was 71.4% (data based on National Hospital Discharge Survey and the National Health and Nutrition Examination Survey for 1999–2010).12 Among eligible patients who attended a bariatric surgery informational session in 2015 (n= 274), those with Medicare and private insurance other than Blue Cross Blue Shield/Blue Complete Network were more likely not to proceed to surgery.6 Despite these observations, there is a lack of understanding with respect to the role of specific payer type or insurance plan (e.g., health maintenance organization (HMO), preferred provider organization (PPO), point of service (POS), fee for service (FFS)) in determining the likelihood of bariatric surgery utilization.
The present study was undertaken to examine whether utilization of bariatric surgery is associated with a combination of both payer and insurance plan variables, after removing potential socio-demographic confounders, such as age, sex, race, and residence area.
METHODS
Data source and study population
This study used Pennsylvania Health Care Cost Containment Council’s (PHC4) inpatient and outpatient care databases for the years 2014–2016. The databases contain inpatient discharge data from all hospitals (except for Veterans Administration Hospitals) as well as outpatient and freestanding ambulatory surgery center clinical data in the Philadelphia, Bucks, Montgomery, Chester and Delaware counties in Southeastern Pennsylvania.
First, patients who received the two most common types of bariatric surgery, laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass, were identified using international classification of disease, ninth and tenth revisions (ICD-9 and ICD-10), and clinical modification procedure codes. We identified inpatient records with procedure codes 43.82 (laparoscopic vertical (sleeve) gastrectomy) or 44.38 (laparoscopic gastroenterostomy) and primary diagnosis code 278.01 (morbid obesity) for records coded using ICD-9 and procedure codes 0DB64Z3 (excision of stomach, percutaneous endoscopic approach, vertical) or 0D164ZA (bypass stomach to jejunum, percutaneous endoscopic approach) and primary diagnosis code E66.01 (morbid (severe) obesity) for those records coded using ICD-10.
A sample of individuals eligible for bariatric surgery who did not receive a bariatric procedure was identified. For the analyses this study applied the following criteria to determine eligibility: 1) Included outpatient records with a diagnosis code for morbid obesity; 2) Excluded patients who had a record for bariatric procedures during 2014–2016. Prior bariatric surgery procedures were identified using ICD-9 and ICD-10 codes in the corresponding inpatient records, as well as Healthcare Common procedure Coding System (HCPCS) Level I Current Procedural Terminology (CPT-4) codes to exclude patients who received a bariatric procedure in an outpatient setting (presented in Appendix 1); 3) excluded records with diagnoses codes that could make the receipt of the bariatric surgery less likely, particularly congestive heart failure, coronary artery disease, common cancers (lung, breast, colorectal, prostate), portal hypertension, Crohn’s disease and impaired intellectual capacity. Duplicate records (for the same patient) in the inpatient and outpatient databases were identified and removed using pseudo patient identifier variable. The latter is a unique patient code assigned by PHC4, intended to be used as a patient identifier to match patient readmissions or transfers.
When determining the payer type, Medicare and Medicaid plans administered via commercial insurers were listed under Medicare or Medicaid respective categories (e.g. Medicare PPO). Within the commercial payer category, Blue Cross plans were listed separately from other insurers’ plans. This was done due to the large share of Blue Cross within the category and a small share of other commercial insurers, individually.
Study design and statistical analysis
In order to assess the distribution of payer and insurance plan mix without potential confounding effects of age, sex, race, and place of residence, records of surgery patients were 1:1 matched by age, sex, race, and zip code with those of eligible patients who didn’t receive surgery. Match tolerance was set to a value of zero (exact match) for matching variables; sampling was done without replacement.
Patients within this study who received bariatric surgery are referred as surgery group and those who were eligible but did not receive the surgery as eligible group. Population proportion tests were used to perform univariate comparisons. Logistic regression analyses were performed to examine the association between payer type and the likelihood of undergoing bariatric surgery, as well as insurance plan and the likelihood of undergoing the surgery, within each payer type. Significance level was determined using an alpha of 0.05. The analyses were performed with IBM SPSS Statistics for Windows, Version 25.0., Armonk, NY: IBM Corp. and R (R statistics), version 3.5.1.
RESULTS
The study population included 2,557 patients who underwent bariatric surgery and 2,557 individuals who were eligible but did not undergo surgery. The mean age of the study population was 46.7 ± 11.4 years. The large majority (86.3%) were female. White patients comprised 49.4% of both the surgery and eligible groups, followed by 47.2% of black patients, 3.2% of other races, and 0.2% of individuals for whom race was not available. The demographic characteristics in the surgery and eligible groups did not differ, as the records were matched on these variables.
The matching was done to eliminate any potential confounding effects of those socio-demographic factors on the insurance status or the likelihood of undergoing bariatric surgery. As a result, no significant differences were observed in the distribution of Medicare, Medicaid and commercial payer categories among the surgery vs. eligible groups (Table 1). Commercial insurance was the most common payer type (54.2%), followed by Medicaid (26.7%), and Medicare (16.4%). The analysis revealed differences in the distribution of specific insurance plans (Table 2). For example, among individuals with commercial HMO plans (other than Blue Cross HMO) (n = 271), 60.5% were in the eligible group, compared to only 39.5% in the surgery group. Among Blue Cross PPO plan holders (n = 719) 38.7% were in the eligible group, compared to 61.3% in the surgery group. In both instances, the difference was statistically significant, p < 0.001.
Table 1:
Payer profile for bariatric surgery vs. eligible patients who did not receive the surgery 1:1 matched by age, gender, race, and zip code
| Payer type, total (% within column) |
Surgery group n=2,557 |
Eligible group n=2,557 |
p value (2 sided) |
|---|---|---|---|
|
Mean age = 46.7, SD = 11.4* Female=86.3%, Male =13.7%* White=49.4%, Black=47.2%, Other=3.2%, Unknown=0.2%* |
|||
| n (% within row) | |||
|
Uninsured** 53 (1.0%) |
27 (50.9%) | 26 (49.1%) | p = 0.90 |
|
Medicare 838 (16.4%) |
413 (49.3%) | 425 (50.7%) | p = 0.69 |
|
Medicaid 1,366 (26.7%) |
656 (48.0%) | 710 (52.0%) | p = 0.14 |
|
Commercial 2,770 (54.2%) |
1,428 (51.6%) | 1,342 (48.4%) | p = 0.09 |
|
Other/not listed*** 87 (1.7%) |
33 (37.9%) | 54 (62.1%) | p = 0.02 |
Notes: Medicare and Medicaid plans administered via commercial insurers are listed under Medicare or Medicaid;
applicable to both groups;
includes total for self-pay and charity / indigent care,
includes total for government payers other than Medicare or Medicaid and other/not listed.
Table 2:
Insurance plan profile for bariatric surgery vs. eligible patients who did not receive the surgery 1:1 matched by age, gender, race, and zip code
| Payer type | Insurance plan | Surgery group | Eligible group | p value (2 sided) |
|---|---|---|---|---|
| n=2,557 | n=2,557 | |||
| n (% within row) | ||||
| Uninsured | Self-pay or Charity / Indigent Care | 27 (50.9%) | 26 (49.1%) | p = 0.90 |
| PPO | 32 (72.7%) | 12 (27.3%) | p = 0.003 | |
| POS | 0 (0.0%) | 1 (100.0%) | p = 0.32 | |
| Medicare | Part A or B / FFS | 248 (46.3%) | 288 (53.7%) | p = 0.09 |
| HMO | 133 (51.8%) | 124 (48.2%) | p = 0.56 | |
| Medicaid | FFS | 1 (3.4%) | 28 (96.6%) | p < 0.001 |
| HMO | 655 (49.0%) | 682 (51.0%) | p = 0.46 | |
| Blue Cross PPO | 441 (61.3%) | 278 (38.7%) | p < 0.001 | |
| Blue Cross POS | 40 (47.1%) | 45 (52.9%) | p = 0.59 | |
| Blue Cross FFS | 251 (53.9%) | 215 (46.1%) | p = 0.09 | |
| Blue Cross HMO | 377 (54.6%) | 313 (45.4%) | p = 0.02 | |
| Blue Cross / Not | 6 (35.3%) | 11 (64.7%) | p = 0.22 | |
| Commercial | Listed | |||
| Other commercial PPO | 119 (40.9%) | 172 (59.1%) | p = 0.002 | |
| Other commercial POS | 19 (55.9%) | 15 (44.1%) | p = 0.49 | |
| Other commercial FFS | 19 (34.5%) | 36 (65.5%) | p = 0.02 | |
| Other commercial HMO | 107 (39.5%) | 164 (60.5%) | p < 0.001 | |
| Other commercial/other plan | 49 (34.5%) | 93 (65.5%) | p < 0.001 | |
| Other/ not listed* | 33 (37.9%) | 54 (62.1%) | p = 0.02 | |
Notes: Medicare and Medicaid plans administered via commercial insurers are listed under Medicare or Medicaid;
includes total for government/PPO, government/FFS, government/HMO, government/unknown, and other/not listed.
As presented in Table 3, the odds of undergoing bariatric surgery were not statistically different based on payer type. However, the regression model assessing the association between insurance plan and the likelihood of undergoing surgery within each payer category identified statistically significant differences. Among those with Medicare, only the PPO plan was a statistically significant predictor for undergoing bariatric surgery, OR = 2.49, 95% Confidence Interval (CI) [1.23; 5.04], p = 0.01 (reference category was the Medicare HMO plan). Among those with Medicaid, the FFS plan was associated with less likelihood of undergoing bariatric surgery, OR = 0.04, 95% CI [0.005; 0.27], p = 0.001, compared to the Medicaid HMO plan. Among individuals with commercial insurance and known insurance plan, those with Blue Cross PPO, OR = 2.43, 95% CI [1.83; 3.24], p < 0.001, Blue Cross FFS, OR = 1.79, 95% CI [1.32; 2.43], p < 0.001, and Blue Cross HMO OR = 1.85, 95% CI [1.39; 2.46], p < 0.001, had greater odds of undergoing bariatric surgery, compared to other commercial insurers’ HMO plan. Other insurance plans were not significant predictors of surgery.
Table 3:
Association of payer type and insurance plan type within payer category with odds of bariatric surgery
| Payer type | Insurance plan | Odds Ratio | 95% CI | p value |
|---|---|---|---|---|
| Model 1: Payer type | ||||
| Medicare | - | 0.94 | [0.54; 1.63] | p = 0.94 |
| Medicaid | - | 0.89 | [0.51; 1.54] | p = 0.68 |
| Commercial | - | 1.03 | [0.60; 1.77] | p = 0.93 |
| Other* | - | 0.59 | [0.30; 1.18] | p = 0.13 |
| Uninsured** | Reference category | |||
| Models 2 – 4: Insurance plan within payer type | ||||
| Medicare | PPO | 2.49 | [1.23; 5.04] | p = 0.01 |
| Part A or B / FFS | 0.80 | [0.60; 1.08] | p = 0.15 | |
| HMO | Reference category | |||
| Medicaid | FFS | 0.04 | [0.005; 0.27] | p = 0.001 |
| HMO | Reference category | |||
| Commercial | Blue Cross PPO | 2.43 | [1.83; 3.24] | p < 0.001 |
| Blue Cross POS | 1.36 | [0.83; 2.23] | p = 0.20 | |
| Blue Cross FFS | 1.79 | [1.32; 2.43] | p < 0.001 | |
| Blue Cross HMO | 1.85 | [1.39; 2.46] | p < 0.001 | |
| Other commercial PPO | 1.06 | [0.76; 1.49] | p = 0.70 | |
| Other commercial POS | 1.94 | [0.95; 3.99] | p = 0.07 | |
| Other commercial FFS | 0.81 | [0.44; 1.48] | p = 0.49 | |
| Other commercial HMO | Reference category | |||
Notes: CI: Confidence Interval;
includes total for government payers other than Medicare or Medicaid and other/not listed;
includes total for self-pay and charity / indigent care.
DISCUSSION
To our knowledge, this is the first study to examine the association between combination of payer/insurance plan variables and bariatric surgery utilization. In this large sample of patients who underwent surgery and who were well matched to those eligible for, but did not undergo surgery, specific aspects of insurance plan design, rather than more general payer type, was more strongly associated with the utilization of bariatric surgery.
The average age and sex distribution among the surgery patients studied is comparable to most other reports in the literature.9 However, the proportion of surgery patients who were white was smaller (49.4%) compared to previous reports (60-65%).8 This may be a result of the racial composition of the 5 major counties in Southeastern Pennsylvania, where 67.2% of individuals are white, 23.2% black, and 9.6% are other races.13 Further, the age-adjusted prevalence of extreme obesity (body mass index (BMI) ≥ 40) is 7.6% among white individuals as opposed to 12.4% among black individuals.14
This study did not detect statistically different odds of undergoing bariatric surgery based on payer type. This is in contrast with previous work in this area.10,12 It may be that sociodemographic variables, such as age, gender, race, and geographic area, account for this difference. Nevertheless, the present study found statistically significantly different odds of undergoing bariatric surgery associated with insurance plan within each major payer category. The latter may be explained by the insurance plan design, particularly the list of covered procedures and services, preoperative medical weight management requirements, patient out-of-pocket costs, among other factors.
The coverage for bariatric surgery, out-of-pocket costs, and insurance-mandated requirements (e.g. preoperative medical weight management) vary not only among payers but also based on insurance plan.6,15 Individuals with PPO plans generally have freedom to choose doctors and hospitals in-network or out-of-network, with lower cost-sharing when staying in-network. HMO plans, on the other hand, require individuals to choose a primary care physician and obtain written referral for specialized care. POS plans are similar to HMOs but are less restrictive in terms of the out-of-network services use. Like HMOs, POS plans generally require a referral from primary care physician for all care.16 This could explain the more favorable access to bariatric surgery among individuals with PPO plans within Medicare and Blue Cross Commercial payer types, compared to HMO plans.
In traditional FFS plans, health plan pays the medical provider directly or reimburses the patient after filing a claim for each covered medical expense.16 Most Medicaid FFS beneficiaries transition into HMO plans in a period of few months, after their initial enrollment in the Pennsylvania Medical Assistance program.17 The limited time within Medicaid FFS plan would significantly decrease their chances of undergoing the surgery. This is captured in our data through lower odds of undergoing bariatric surgery among Medicaid FFS beneficiaries (compared to Medicaid HMO).
Prerequisites and insurance denials 15,18,19 as well as patient cost-sharing 20are often limiting factors for patients seeking bariatric surgery. For example, in terms of the preoperative management, Independence Blue Cross commercial plans require its members to participate in a multidisciplinary surgical preparatory regimen (commonly called preoperative medical weight management), provided by the bariatric surgery program or their physician. However, there is no specific minimum time requirement.21 Aetna HMO plan (included in other commercial HMO plans within our dataset) requires its members to undergo either physician-supervised nutrition and exercise program for a cumulative total of six months or multidisciplinary surgical preparatory regimen for at least three successive months; both programs should have substantial face-to-face component.22 Longer preoperative medical weight management programs (six vs. three months) have been associated with patients leaving the program and not proceeding to surgery.23 Furthermore and unfortunately, some of commercial insurance plans completely exclude coverage for the surgical treatment of obesity.22
Preoperative assessments prior to bariatric surgery need to be evidenced based. Unfortunately, few are. The requirement of preoperative medical weight management prior to surgery, theoretically implemented to produce a modest weight loss that either gives the patient an opportunity to learn and practice the dietary and behavioral requirements of surgery, or makes the surgical procedure easier from a technical perspective, has only modest support.24 Yet, the practice endures.
Reduction of cost-sharing among patients with severe obesity and type 2 diabetes (T2D)20 and application of value-based insurance design7,15 may enhance the access to bariatric surgery among patients who’d benefit the most from the procedure. Nevertheless, changes in insurance benefits design might not be easy to implement for certain types of payers and insurance plans, due to regulatory barriers.15
A particular strength of this study is its design which allowed for the examination of these associations without potential confounding effects of key socio-demographic factors. The study highlights the role of insurance benefit design as a predictor for access to bariatric surgery. It also sets a stage for further investigations into specific components of health insurance plans that may contribute to underutilization of bariatric surgery in the United States.
The study also has limitations. The data set contained inpatient and outpatient data from five counties in Pennsylvania. Coverage for bariatric surgery by Medicaid varies in some states,25 other insurance-related and demographic factors may also vary across the United States, which may limit generalizability to other areas of the country.
CONCLUSIONS
Results of the present study suggests that the insurance plan design, rather than the more general payer type, may be a more important factor associated with bariatric surgery utilization. Future studies could explain what components of insurance plan design have the largest influence on the utilization of bariatric surgery.
Highlights.
Insurance plan is a stronger predictor of bariatric surgery uptake than payer type
Commercial insurance is the most common payer for the surgery, followed by Medicaid HMO plan
Insurance plan design may play an important role in the uptake of bariatric surgery
Acknowledgments
Disclosure Statement
Dr. David B. Sarwer’s work on this paper was supported, in part, by grant R01-DK108628-01 from the National Institute of Diabetes, Digestive, and Kidney Disease as well as PA CURE funds from the Commonwealth of Pennsylvania. He also discloses consulting relationships with BARONova, Merz, and NovoNordisk.
Dr. Gabriel Tajeu was supported by NIH/NIDDK 3R01DK108628-05S1. He has no conflicts of interest to disclose.
Dr. Hamlet Gasoyan and Dr. Michael T. Halpern do not have anything to disclose.
The Pennsylvania Health Care Cost Containment Council (PHC4) is an independent state agency responsible for addressing the problem of escalating health costs, ensuring the quality of health care, and increasing access to health care for all citizens regardless of ability to pay. PHC4 has provided data to this entity in an effort to further PHC4’s mission of educating the public and containing health care costs in Pennsylvania.
PHC4, its agents, and staff, have made no representation, guarantee, or warranty, express or implied, that the data—financial, patient, payor, and physician specific information—provided to this entity, are error-free, or that the use of the data will avoid differences of opinion or interpretation.
This analysis was not prepared by PHC4. This analysis was done by the authors at Temple University. PHC4, its agents and staff, bear no responsibility or liability for the results of the analysis, which are solely the opinion of the authors.
APPENDIX
Appendix 1:
Procedure and diagnostic codes used for exclusion of records from the sample of eligible patients who did not undergo bariatric surgery
| Procedure or diagnosis |
ICD-9 | ICD-10 | HCPCS CPT-4 |
|---|---|---|---|
| Received bariatric procedure | 43.82, 44.38, 44.68,44.95, 44.96, 44.97,44.98 | 0DB64Z3, 0D164ZA,0DB60Z3, 0D164Z9,0D160ZA, 0DB64ZZ, 0DV64CZ, 0DP64CZ | 43644, 43645, 43770-43775, 43842,43843, 43845 - 43848, 43886 - 43888 |
| Congestive heart failure | 428.0 | I50.9 | |
| Coronary artery disease | 414.01 | I25.1 | |
| Lung cancer | 162.9, 162.3, 162.5 | C34.90, C34.10, C34.30 | |
| Breast cancer | 174.2, 174.4, 174.9 | C50.219, C50.419, C50.919 |
|
| Colorectal cancer | 153.3, 153.6, 153.9, 154.1 | C18.7, C18.2, C18.9, C20 | |
| Prostate cancer | 185 | C61 | |
| Portal hypertension | 572.3 | K76.6 | |
| Crohn’s disease | 555.0, 555.1, 555.2,555.9 | K50.00, K50.10, K50.80, K50.90 | |
| Impaired intellectual capacity | 319 | F79 |
Footnotes
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