NAASO, The Obesity Society, generally supports the Centers for Medicare and Medicaid Services' (CMS) National Coverage Determination (NCD) for Bariatric Surgery. This represents an important step that will positively affect the health and well-being of select Medicare recipients who suffer from extreme obesity.
Bariatric surgery clearly is the most effective treatment for persons with extreme obesity who have failed to lose weight using less intensive interventions. The steady growth in the number of surgeries performed each year reflects both the increasing rate of extreme obesity in the United States (now nearly 5 percent of adults), as well as an increase in the number of medical centers, hospitals, and surgeons now offering bariatric surgery.
We join our colleagues at the American Society for Bariatric Surgery (ASBS) in recommending that this NCD require that Medicare patients undergo bariatric surgery only at high-quality surgical centers with appropriate credentialing and certification. We further believe that ASBS is well qualified to develop an accreditation program for Bariatric Surgery Centers of Excellence. To receive accreditation, ASBS requires that Centers perform at least 125 surgeries a year and that individual surgeons perform at least 50 operations yearly. These criteria are based on findings that mortality and morbidity rates decline as the number of surgeries performed yearly increases.
NAASO, The Obesity Society, applauds CMS for requiring that bariatric surgery centers "have an integrated program for the care of the morbidly obese patient that provides: ancillary services such as specialized nursing care, dietary instruction, counseling support groups, exercise training, and psychogical assistance as needed." Such multidisciplinary care is needed to ensure an optimal outcome for all individuals. With its recognition of the need for such services, it is critical that CMS authorize payment for each of the therapies listed, as well as for others that may be required.
We are concerned by the NCD's limitation of bariatric surgery to only those Medicare recipients who are under 65 years of age. We agree with CMS that there has not been adequate study of the effects of bariatric surgery in older individuals. However, there is reason to believe that such intervention, when conducted by experienced (high-volume) surgeons, is likely to be associated with a favorable outcome, as suggested by Sugerman and colleagues1. Further evidence of the benefits of weight loss in older adults is provided by the Diabetes Prevention Program2. Modest weight loss, achieved with diet and exercise, decreased the risk of developing type 2 diabetes by 71 percent in persons 60 years and older, as compared with only 44 percent in participants 25 to 44 years of age. A recent joint position statement on Obesity in Older Adults, issued by the American Society for Nutrition and NAASO, The Obesity Society, concluded that weight loss therapy improves physical function, quality of life, and medical complications of obesity in older adults3.
NAASO, The Obesity Society, strongly supports CMS's proposal to extend bariatric surgery to persons 65 years and older under the "Coverage with Evidence Development" (CED) option. This option provides an excellent means of providing surgery to appropriately selected individuals whose outcomes will be carefully evaluated. Completion, in this manner, of several hundred surgeries should begin to provide the data needed to make evidence-based practice decisions concerning individuals >65 years. Failure to adopt the CED option would prevent older Medicare recipients from receiving potentially optimal care for their extreme obesity with its attendant health complications. There is minimal evidence to suggest that a 65-year old person, who receives optimal surgical intervention, is at greater risk of morbidity and mortality than a 64-year old. This is also true for individuals who undergo other surgical procedures that are currently covered by Medicare, such as orthopedic joint replacement and coronary revascularization. Thus, the 65-year age cut-off is arbitrary and potentially discriminatory. As our nation's population continues to age, increasing numbers of persons who are 65 years or older will suffer from extreme obesity and its associated health complications. Thus, we believe that the potential benefits and risks of bariatric surgery must be examined in this population.
In summary, NAASO, The Obesity Society, generally supports CMS's National Coverage Determination for Bariatric Surgery. However, we urge CMS to use the CED option to extend bariatric surgery to persons 65 years and older who are treated at accredited institutions.
1. Sugerman HJ, DeMaria EJ, Kellum JM et al. Effects of bariatric surgery in older patients. Ann Surg 2004;240:243-247.
2. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention and metformin. N Engl J Med 2002;346:393-403.
3. Villareal DT, Apovian CM, Kushner RF, Klein S. Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO - The Obesity Society. Am J Clin Nutr 2005;82:923-934
NAASO, The Obesity Society
Thomas Wadden, PhD
Robert Kushner, MD
Chair, Clinical Committee
David Sarwer, PhD Chair, Section on Bariatric Surgery