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The Use, Safety and Cost of Bariatric Surgery Before and After Medicare's National Coverage Decision

Flum, David R. MD, MPH; Kwon, Steve MD; MacLeod, Kara MPH; Wang, Bruce PhD; Alfonso-Cristancho, Rafael MD, MSc; Garrison, Louis P. PhD; Sullivan, Sean D. PhD

doi: 10.1097/SLA.0b013e31822f2101

Objective: To determine the impact of the Centers for Medicare and Medicaid Services' (CMS) bariatric surgery national coverage decision (NCD) on the use, safety, and cost of care CMS beneficiaries.

Background: In February 2006, the CMS issued a NCD restricting reimbursement for bariatric surgery to accredited centers and including coverage for laparoscopic adjustable gastric band (LAGB).

Methods: A pre/postinterrupted time-series cohort study using nationwide Medicare data (2004–2008) evaluating rates of bariatric procedures/100,000 enrollees, 90-day mortality, readmission rate and payments.

Results: Forty-seven thousand thirty patients underwent procedures at 928 sites pre-NCD and 662 post-NCD. The procedure rate/100,000 patients dropped after the NCD to 17.8 (from 21.9 in 2005) increasing to 23.8 and 29.1 in 2007 and 2008, respectively. Open roux-en-y gastric bypass (ORYGB) and laparoscopic roux-en-y gastric bypass (LRYGB) were common pre-NCD (56.0% ORYGB, 35.5% LRYGB) changing post-NCD with LAGB inclusion (12.8% ORYGB, 48.7% LRYGB, 36.7% LAGB). 90-day mortality pre-NCD was 1.5% (1.8% ORYGB, 1.1% LRYGB) and post-NCD was 0.7% (1.7% ORYGB, 0.8% LRYGB, 0.3% LAGB; P < 0.001). The 90-day rates of readmission decreased post-NCD (19.9% to 15.4%), reoperation (3.2% to 2.1%) and payments ($24,363 to $19,746; P for all <0.001). Differences in outcome and cost were largely explained by a shift in procedure type and patient characteristics.

Conclusions: The NCD was associated with a temporary reduction in procedure rate and a shift in types of procedures and patients undergoing bariatric surgery. It was associated with a significant decrease in the risk of death, complications, readmissions, and per patient payments.

Supplemental Digital Content is available in the text.In 2006, the Centers for Medicare and Medicaid Services issued a national coverage decision (NCD) restricting reimbursement for bariatric surgery to accredited centers and allowing payments for adjustable banding procedures. The NCD was associated with a temporary reduction in procedures per year, shift in types of procedures and characteristics of patients, and sustained decreases in the rate of mortality, complications, and costs.

University of Washington Schools of Medicine, Pharmacy and Public Health, Seattle, WA.

Reprints: David R. Flum, MD, MPH, University of Washington, Department of Surgery, 1959 N.E. Pacific St. Rm AA 404, Box 356410, Seattle, WA. E-mail:

Disclosure: The authors are member of the writing group for the Bariatric Obesity Outcome Modeling Collaborative. The Bariatric Obesity Outcome Modeling Collaborative members are listed in the acknowledgment section. Supported by Department of Defense (DoD) Agreement FA 7014-08-0002 and National Institutes of Digestive Disease and Kidney (NIDDK) 1R21DK069677. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the DoD or the NIDDK.

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© 2011 Lippincott Williams & Wilkins, Inc.