The Economics of Bariatric Surgery Program


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The Economics of Bariatric Surgery Program

Bariatric Surgery Program Survey Results

By: Susan Coleman, Vice-President, ESA Medical Resources

First of all, thank you to everyone who participated in ESA Medical Resources’ first Bariatric Surgery Program Survey. We received some great feedback which we will share with you here. If you did not have a chance to give us your feedback, you may still go to our blogsite: www.blog.esamedicalresources.com and take our survey. The more input from you, the better! We will follow up on your questions, concerns and suggestions in subsequent online newsletters.

I think that the headline of this survey is that the vast majority of respondents are very pleased that they made the decision to establish a bariatric practice/program, but they are very displeased with the insurance reimbursement process. Let’s take a closer look at the responses to each question:

Question 1: Given the challenges of running a quality bariatric surgery program, are you pleased that you undertook this endeavor with 1 being very displeased and 10 being very pleased?

The mean or average response to this question was 8.77 (with a range of 3 to 10). Almost half of respondents rated this question a 10. On the whole, you are glad you chose this much-needed specialty.

Question 2: How do you feel about the process of third party payor reimbursement with 1 being very displeased and 10 being completely satisfied?

The average of responses here was 3.26 (with a range of 1 to 8). Twenty-five percent of you rated this area a 1. On the whole you are very unhappy with this process.

Question 3: Has your program met the financial goals you set for it with 1 meaning very disappointed and 10 meaning expectations were exceeded?

This response mean was 6.03 (with a range of 1 to 9). While you are not on the whole displeased with financial outcomes, you certainly see opportunity to improve the revenue/expense balance. This is connected, of course, to insurance reimbursement. Some of you are pursuing more of the self-pay market.

Question 4: Are there any issues you would like to see resolved that would improve your financial outcomes?

Not surprisingly given the responses to Question 2, the overwhelming majority expressed concerns about the process of insurance reimbursement. Much criticism centered on the “hassle” (a term used in several surveys) of the pre-approval process.

One respondent expressed frustration at receiving an authorization number only to be told later that the authorization was given in error and therefore was withdrawn.

Another respondent stated that at times insurance companies can take 7 to 12 months to get a patient approved.

Another respondent criticized the staff hours required to “resubmit, resubmit, resubmit” insurance claims.

Many of you disagree with the requirements of 6 to 12 months of diets prior to approval and up to 5 years of documented BMIs. According to the Surgical Review Corporation’s website, Aetna, effective February 2008, dropped the 5 year requirement to 2 years which should be helpful. Again, according the SRC website, Blue Cross Blue Shield of Michigan has reduced its 12-month diet timeframe to 6 months and has waived this requirement altogether for super obese, high-risk patients with a BMI ≥ 50.

Several responses centered on the lack of reimbursement for sleeve gastrectomy. (BCBS of Michigan now covers this procedure for high risk patients with a BMI ≥ 50 as a first stage procedure, but it remains unpayable as a stand alone bariatric procedure.)

Several programs are not pleased with the amount of reimbursement especially regarding “ancillary staff and programs.

“Make it a cash only program” was the sentiment of a few survey responses.

Obtaining malpractice insurance without going to the secondary market is of concern to several respondents.

Question 5: Is there anything you would do differently to improve your patient care outcomes?

Nearly half of respondents replied that there was nothing they would do differently. One responded: “We are doing everything we can think of.” Here are some other responses:

Otherwise, more education –staff and patient, was important to many of you. “A more intense nutritional education … [and] give patients more time for questions.”

Better follow-up was a common theme for ways to improve. “Better access to information to help patients get ‘back on track’ as they start to regain after the first year or so.”

Better tracking was also mentioned as a way to improve patient care.

Several wanted more access to research.

Developing better insurance coordination was also deemed important. There is a great deal of concern as to how to maximize the approvals and minimize the turnaround time.

Question 6: If you could ask administrators from other programs any question, what would you ask?

Several respondents wanted to ask others in the industry how to best/most efficiently manage the patient through the entire process, starting with insurance approval and continuing through follow-up tracking. This question had many varied responses:

A few survey respondents asked whether anyone had been successful in “staying out of network from third party payors”.

Some programs had questions (non-specific) about support groups.“We are finding that patients are getting confused between laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y. We have implemented several strategies to combat this. Are other programs experiencing the same thing and if so, how are they responding and is it effective?”

“What is your process and with what support staff in place?”

“With rising health care costs, how do you maintain your costs at an affordable level?

What is the “best way to get near 100% follow up?”

From a bariatric surgeon in a bariatric surgery practice: “How do you “create a successful relationship with the hospital”?

“How do you negotiate with payors?”

“What are your methods for obtaining approval?”

“Have you determined whether or not your surgeries are cyclical, i.e. busier at certain times of the year… less busy at others? If they are cyclical…have you found anything that balances it a little more evenly?”

What are the best practices for “getting patients back on track if they start to regain weight”?

”

How is a sole practitioner supposed to be able to meet the requirements of COE without adding at least one FTE? Why is our specialty society trying to do away with the solo practitioner?”

“Why do they discriminate against Bariatric patients? These patients have fought weight for years and don’t need another 6 month insurance mandated, phone monitored, weight loss program.”

Question 7: Is there any bariatric surgery program data or information that you would like to have?

The answer is a resounding and collective: “Yes!” Outcomes data was listed most often. Here are some of your specific requests; many of these quotes represent the sentiments of several respondents:

“Best practices.”

“Complication rates/benchmarks.”

“Benchmarks for 30 day re-operation rates, re-admission rates, days in ICU, 30 day infection rates for each procedure.”

“Access to the SRC database for research.”

“Any kind of statistical information on everything from financial to patient outcomes…patient mix, payor mix, age mix, marketing, etc.”

“Staffing information.”

Average and range of salaries paid for staff: Bariatric PA, Bariatric MA, Program Coordinator/Manager, Bariatric Nurse Educator, Office Manager, Dietician, and Exercise Physiologist.”

“Outpatient surgery data, surgi center data.”

Follow-up on this survey will be two-pronged. First of all, please utilize ESA’s blogsite: www.blog.esamedicalresources.com to communicate with one another. You can begin discussions sharing successes and even failures on a variety of salient issues. Secondly, I will contact experts in the field of bariatric medicine, including our own consultants, to obtain answers to many of your questions and concerns. On the issue of insurance, in the short-term, we are operating within a given set of constraints, but I will try to obtain as much information as I can, to help you operate in the most efficient and profitable way possible within these parameters. I will communicate with bariatric industry advocates like the SRC and ASMBS to get their insight on how the insurance industry may be evolving and (hopefully) improving as more data is gathered through their BOLD initiative.

Please look for upcoming newsletters from ESA Medical Resources which will provide you with information concerning the issues you have indicated are important to you. Again, thank you for taking time from your very busy schedules to respond to our survey. If you have any questions please feel free to contact me at susan@esamedicalresources.com

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