2015-02-24 03:08:31 UTC

Is Gastroenterology Ready to Take a Bite Out of Obesity?

Feb. 13, 2015

Endoscopic obesity programs offer a timely and potentially attractive alternative to GI practices.

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Joel V. Brill, MD, FACP, AGAF, FASGE, FACG

Medical Director, FAIR Health, Inc.; AGA Advisor to the CPT Editorial Panel and the RUC Practice Expense Subcommittee

What does orthodontia have in common with laser vision correction? Patients have an incentive to shop for services based on price and perceived quality, as these services are elective, and at times, optional. Fees are often negotiable, providers offer payment plans, insurance coverage is limited or non-existent, different techniques abound, and reading the fine print is essential to determine whether the quoted fees include consultation, follow-up visits and care for complications. It is estimated that more than 1.1 million orthodontia and 800,000 to 1.2 million Lasik surgeries are performed yearly in the U.S., with the volume of procedures related to macroeconomic trends and consumer confidence. Could this be the future for endoscopic obesity procedures?

The American Society for Metabolic & Bariatric Surgery reports that approximately 150,000 to 200,000 bariatric surgeries are performed yearly; this is only 1 percent of the population eligible for weight-loss surgery.1 At present, there are two FDA-approved devices for treating obesity. In July 2014, ReShape Medical® submitted a premarket approval application to FDA for the ReShape Integrated Dual Balloon System for nonsurgical weight loss designed for people with a 30-to-40 body mass index (BMI), anticipated as the first of several devices for obesity to be considered by FDA in the coming years.

FDA states: “However, before medicine is prescribed or surgery is recommended, doctors will probably want their patients to demonstrate a healthy lifestyle that includes healthful eating and increased physical activity. Even with medical or surgical treatments, patients will need to maintain a healthy lifestyle for the rest of their lives.”2 Any gastroenterologist who is considering entering into the obesity market should carefully consider these words. Medical devices or bariatric surgery, by themselves, may not be the ‘cure’ for obesity. Successful weight-loss programs should include:

  1. A plan to keep the weight off over the long run.
  2. Guidance on how to develop healthier eating and physical activity habits.
  3. Ongoing feedback, monitoring and support.
  4. Slow and steady weight-loss goals.3

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a national accreditation standard for bariatric surgery centers from the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS), has established recommendations for a bariatric surgery program, including recommendations for pre-, peri- and post-operative care programs and data collection.4 NIH, ACS and ASMBS also recommend that surgery be performed at a center that has a multidisciplinary team of experts for follow-up care, which may include a nutritionist, an exercise physiologist or specialist, and a mental health professional.5 As several endoscopic trans-orifice bariatric procedures have been developed to be inserted and removed over a period of months, the gastroenterologist should strongly consider the development of a multidisciplinary program to support the obesity patient.


Medical devices or bariatric surgery, by themselves, may not be the ‘cure’ for obesity.


While we may see FDA approval of non-surgical weight-loss devices in 2015, there are several other factors for gastroenterologists to consider, including:

  • Whether approval or indications for the procedure differ from the 1991 NIH consensus recommendations for surgery for severe obesity.
  • Insurance may or may not cover services including the pre-operative evaluation and counseling, the peri-operative procedure including the endoscopist, anesthesiologist, facility and device, and the post-operative follow-up.
  • CPT and/or HCPCS codes are unlikely to be established at the time of FDA approval for placement of the device.
  • While there may be existing CPT codes for endoscopic removal of the device, insurance might not cover the costs resulting from a prior non-covered procedure.
  • Coverage of weight-loss services under a flexible savings account or health reimbursement amount may require a letter of medical necessity from the physician describing the specific medical condition(s) being treated, the need for the program and an outline of treatment options.

Planning ahead, gastroenterologists should begin now to cost out the components of an obesity program in order to consider offering financing options to patients.

The gastroenterology ecosystem is evolving. As Medicare reimbursement for colonoscopy might decrease in 2016, endoscopic obesity programs offer a timely and potentially attractive alternative to GI practices. Establishing high-quality programs for the management of obesity, with data collection and public reporting of results, will be essential to ensure that this opportunity is not lost.

Dr. Brill has no conflicts to disclose.

References

1. Berl RP. Weight-loss surgery: A cure for the morbidly obese? US News and World Report June 18, 2013 http://health.usnews.com/health-news/health-wellness/articles/2013/06/18/weight-loss-surgery-a-cure-for-the-morbidly-obese

2. Obesity Treatment Devices. US Food and Drug Administration http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ObesityDevices/default.htm

3. Weight-control Information Network (WIN), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Bethesda MD, December 2012 http://win.niddk.nih.gov/publications/choosing.htm

4. Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Standards and Pathways Manual. American College of Surgeons and the American Society for Metabolic and Bariatric Surgery. https://www.facs.org/~/media/files/quality%20programs/bariatric/resourcesforoptimalcareofthembspatient.ashx

5. American Society for Metabolic and Bariatric Surgery. Who is a Candidate for Bariatric Surgery? https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery

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