the Major Challenges
and Opportunities of 2014
2014 was a year of firsts. For the first time, sleeve gastrectomy became the most popular method of bariatric surgery, exceeding the number of gastric bypass operations by nearly 10 percent. This came during a year that saw the nation’s first summit on obesity care with bariatric surgery as its focus, the naming of the ASMBS to the American Medical Association (AMA) House of Delegates, the first official appointment of an ASMBS representative to the AMA CPT Advisory Committee as a primary CPT advisor, and new recognition and acceptance of metabolic and bariatric surgery as one of the safest operations in America.
2014 will also go down as the year the ASMBS broke records for attendance at the annual meeting during ObesityWeek 2014, developed its first textbook on bariatric surgery for health professionals, and its first video for patients considering surgery.
Here’s a look back on the year.
Representatives from more than 20 major health and medical organizations -- from family physicians, heart specialists and endocrinologists to orthopaedic, integrated health and bariatric surgeons – convened for a summit in Chicago in September for discussions about how health professionals can better collaborate on providing care to individuals affected
The inaugural “National Summit for the Provision and Coordination of Care of an Obese Population” was spearheaded and hosted by the American Society for Metabolic and Bariatric Surgery (ASMBS) and attended by representatives from groups including American Heart Association, American Diabetes Association, The Obesity Society, American Academy of Orthopaedic Surgeons (AAOS), American College of Physicians, and American Academy of Family Physicians. Representatives from health insurers Aetna, Blue Cross Blue Shield and OptumHealth also attended. ”
John Morton, MD
“We can’t solve the obesity crisis in a day and we can’t solve it alone,” said John M. Morton, MD, MPH, chairman of the summit and president, ASMBS. “That’s why an unprecedented number of medical societies, patient advocates and payors have come together to identify ways to better collaborate on the prevention and treatment of obesity.”
Dr. Morton added, “Obesity is our leading public health problem and we need all hands on deck to deal with it. In addition to preventing obesity, it is critical that we treat patients for obesity to improve their current health and decrease obesity-related complications of care. There’s so much more we can do together on behalf of our patients. This first summit is
Summit attendees discussed current guidelines on obesity prevention and treatment, opportunities for collaboration between medical specialties, and the need to develop a continuum of care for obesity, among other topics.
“In many ways, we’re all treating the same disease, yet there is a tendency to operate in silos,” Michael Parks, MD, Associate Attending Orthopedic Surgeon, Hospital for Special Surgery, who represented the AAOS at the summit, told connect. “We have to come together to intervene sooner and more effectively in the disease process.”
The struggle continues to achieve universal patient access and standard benefit coverage of metabolic and bariatric surgery, but the environment for coverage and reducing the stigma associated with obesity and surgery is improving thanks to efforts by the ASMBS and other groups. Earlier this year, the American Medical Association (AMA) passed the "Patient Access to Evidence- Based Obesity Services,” nearly a year after the AMA officially classified obesity as a disease.
Ninh Nguyen, MD
In a news release at the time, ASMBS immediate past president Ninh T. Nguyen, MD, said, “Obesity is perhaps the most undertreated disease in America despite the availability of safe and effective treatments. This is largely because insurance coverage is so limited. With this latest resolution, the drum beat for greater access and coverage is growing louder and we are hopeful that public and private insurers and policy makers are listening and will take quick action.”
ASMBS president Dr. John Morton added, “The AMA’s support of treatment for individuals with obesity underscores the national imperative to treat our leading public health problem. The time has come for equitable treatment for the millions of patients affected by obesity. There needs to be one America where treatment for obesity is available to all.
The ASMBS, American College of Surgeons (ACS), The Obesity Society (TOS), Obesity Action Coalition (OAC), American Association of Clinical Endocrinologists (AACE), American Society of Bariatric Physicians (ASBP), Society of American Gastrointestinal and Endoscopic Surgeons, Society for Vascular Surgery, American Society of Plastic Surgeons, and American Urological Association all helped support the passage of the AMA resolution.
The AMA resolution was passed on the same day the ASMBS was afforded a seat for the first time in the AMA House of Delegates (HOD). HOD, which includes more than 500 voting delegates, is the principal policy-making body of the AMA.
Surgical, medical and patient advocacy groups including the ASMBS, continue to press federal and state officials to end what they see as discrimination and unnecessarily high barriers to care for patients with chronic health conditions.
These so called discriminatory practices include benefit designs that limit access, such as restrictive formularies and inadequate provider networks; unreasonably high co-payments; and a lack of transparency and clarity that interferes with a consumer’s ability to make informed decisions about his or her health plan.
Almost since the inception of the Affordable Care Act (ACA), the ASMBS has been trying to get HHS to address major gaps in bariatric surgery coverage among the majority of state health exchanges. Currently, only 22 of 50 states list bariatric surgery as a covered benefit within ACA, and only five states provide coverage for weight loss programs.
Despite several meetings over the years and providing the agency with clear examples of discriminatory benefit design language, HHS has yet to provide guidance to the state health exchanges over what many perceive to be discriminatory practices. ASMBS President John Morton, MD, MPH, and others have been sounding the alarm that the specific exclusion of obesity treatment is unusual and in conflict with the ACA’s own statute that state health exchanges may not exclude treatment on the basis of a health condition.
John Morton, MD
“Insurers should not be able to discriminate against people with the disease of obesity, period,” said Dr. Morton told connect earlier this year. “We were hopeful that the passage of the ACA would bring down barriers to care. Instead, new barriers have been created that must come down.”
In late July, in an attempt to bring more attention to the issue, the ASMBS in conjunction with the Obesity Care Continuum (OCC), sponsored a full-page ad in Roll Call, a Capitol Hill newspaper widely read by legislators and
In the ad, the groups take the state health care exchanges to task for excluding “treatments for the chronic disease of obesity, the number one public health issue facing Americans.”
The ASMBS, along with 14 other groups including the American Association of Clinical Endocrinologists, American College of Surgeons, The Obesity Society and Obesity Action Coalition (OAC), call for greater patient access “to the full continuum of care of evidence-based obesity treatment modalities such as behavioral, pharmaceutical, psychosocial, nutritional, and surgical interventions,” as outlined in recently adopted American Medical Association (AMA) official policy.
“We are making progress, but much more has to be done,” said Dr. Morton. “We can point to several successes including the recognition of obesity as a disease, greater acceptance among the public and providers that bariatric surgery is a highly safe and effective treatment, and wider coverage of bariatric surgery among insurers. However, we won’t stop until every patient that can benefit from surgery has the opportunity to do so. We owe this to
There was an important patient victory in North Carolina. Blue Cross and Blue Shield of North Carolina (BCBSNC) revised its coverage policy on July 15. The new policy eliminates the six-month requirement for patients to participate in a non-surgical weight reduction program prior to being considered for bariatric surgery. The move comes after months of discussions between local and national bariatric health professionals and BCBSNC officials.
“The real victory is for patients,” Ranjan Sudan, MD, president of the ASMBS Carolinas State Chapter, who spearheaded the efforts on behalf of the bariatric community in North Carolina and nationally, told connect earlier this year. “We laid out our concerns, backed it up with evidence and worked with BCBSNC in a highly constructive way that led to a change in policy. They were very receptive to what we had to offer and we were very responsive to their questions.”
A look at the numbers reveal the rapid rise of sleeve gastrectomy, which became the most common method of bariatric surgery in America in 2013, outpacing gastric bands by three to one, and surpassing gastric bypass, the perennial number one. Last year, sleeve gastrectomy accounted for 42.1 percent of the 179,000 procedures, followed by gastric bypass (34.2%), gastric band (14%) and Biliopancreatic Diversion with Duodenal Switch (1%). Revisions were about 6 percent of operations.
In 2011, gastric bypass and gastric band each accounted for more than one-third of procedures, while sleeve gastrectomy was less than 20 percent. Since then, gastric bypass numbers have been relatively steady, sleeve gastrectomy has surged and gastric band procedures, in relation to other procedures, have dropped precipitously. “I think there was some pent up demand for sleeve gastrectomy as surgeons and potential patients waited for the data and better coverage,” Dr. Jaime Ponce told connect. “That happened in 2012 and we saw a near doubling of the number of gastric sleeves.” Dr. Ponce was part of the ASMBS task force that calculated the new estimates.
Between 2011 and 2013, the number of bariatric surgeries performed in the United States grew by nearly 15 percent. The biggest jump occurred between 2011 and 2012, while the number of procedures grew only slightly between 2012 and 2013.
"Obesity is one of the biggest preventable and treatable public health threats we face, yet we are only treating the tip of the iceberg, but the tide is turning,” said John Morton, MD, ASMBS president told connect, when the numbers were released. “Groundbreaking studies and major medical groups support metabolic and bariatric surgery, major guidelines urge doctors to refer patients for surgery and there is greater acceptance of obesity as a disease. There is more of a climate to seriously address obesity with proven treatments like surgery, and less of a climate for policies and medical decisions based on discrimination, bias and anecdotal information or experience. This is good for metabolic and bariatric surgery and it’s good
This year the ASMBS released its first textbook on metabolic and bariatric surgery. More than 110 ASMBS members contributed to two volumes that cover the basic principles of bariatric surgery, the latest information about metabolic surgery, reoperative surgery and various topics in integrated health.
“The textbook is a comprehensive and authoritative guide to bariatric surgery written and edited by the foremost experts in the field,” said ASMBS immediate past president Ninh T. Nguyen, MD, Chief, Division of Gastrointestinal Surgery, University of California (UC), Irvine, and one of the editors. “It will be an important educational resource for years to come.”
In addition to Dr. Nguyen, editors include Raul J. Rosenthal, MD, Cleveland Clinic Florida; Jaime Ponce, MD, Dalton Surgical Group in GA; John M. Morton, MD, Stanford University School of Medicine in Palo Alto, CA; and Robin Blackstone, MD, Scottsdale Bariatric Center in AZ. The editors were on hand at ObesityWeek 2014 for a book signing that proved popular among members.
Better Understand Bariatric Surgery
The ASMBS found three patients from across the country that couldn’t be more different in background or world experience, yet shared the some of the same struggles in treating their severe obesity. Their stories premiered in a video at ObesityWeek 2014.
Each spent years trying countless diet and exercise plans and weight loss programs before turning to the one treatment that changed their lives – bariatric surgery. To illustrated the problem and help other patients understand the consequences of their decisions about obesity (or the consequences of doing nothing), the ASMBS profiles an attorney and former naval officer, a nurse and a former NFL player about what led them down the path of bariatric surgery, after putting it off for years.
“I first considered bariatric surgery in 2011, but my sister talked me out of it. She thought I would die. She just told me to eat less and exercise more. It wasn’t that simple. Without it (bariatric surgery), I couldn’t succeed in the long-term. I would be destined to a lifetime of losing and gaining, while my health deteriorated,” said Eliot Avidan, the former navy officer.
Teresa Bell-Stephens, 41, who had a sleeve gastrectomy in 2012, gained more than 60 pounds during infertility treatment. She was successful in having a baby, but not so successful in her attempts to lose weight and participate in life until she had the procedure.
“I look at the world differently now because I feel I can engage in everything. And I felt that before I had to sit out on some things. Now I don’t have to sit out anymore,”
Jamie Dukes, an on-air analyst for the NFL Network and former NFL offensive lineman, talks sports for living and during football season splits his time between the NFL Network studios in Los Angeles and his home in Atlanta where he live with his wife and two children. He felt life after football could be a short one if he didn’t do something significant about his weight. Diet and exercise alone were only a part of the answer.
“I thought I was going to die. Guys who were 80, 100 pounds overweight just died. What would make me more special than them? I just had to do something.” That something was bariatric surgery. “It’s a procedure to get you where you need to go.” Dukes added, “I reached a turning point in my life. I had to make a life decision to change my lifestyle not only for myself, but more importantly, for my family. I want to be around for them and beating back obesity is going to help me do that.”
“We showed the video at ObesityWeek and many of our members were inspired by what they saw,” said John M. Morton, MD, ASMBS president. “Now we are looking forward to taking this inspirational message to the patients themselves and offering it to our members so they too can spread the word.”
Surgery for Obesity and Related Diseases (SOARD), the official journal of the ASMBS, rose one spot in the rankings of surgery journals, according to a new report from Journal Citation Reports® (JCR), published by Thomson Reuters. Last year, the journal was ranked eighth. This year, it was number seven out of more than 200 surgery titles, in terms of research influence and impact. Annals of Surgery retained the top spot.
The ASMBS has a new President-Elect and Secretary/Treasurer and two Councilpersons-at-Large, and Integrated Health also elected new leaders.
“Our annual election is a way to infuse new ideas and energy into the current and future direction of the ASMBS,” Robin Blackstone, MD, chair of the ASMBS Nominating Committee and ASMBS Senior Past President, told connect prior to the election. “The election also ensures that those in leadership positions continue to represent the priorities and values of our membership. Every member has a voice and that voice is heard every election through their votes.”
Raul Rosenthal, MD is the new president-elect; Stacy Brethauer, MD is Secretary/Treasurer; Aurora Pryor, MD and Eric DeMaria, MD are Council-at-Large. Karen Flanders, MSN, ARNP, CBN is the new president-elect of Integrated Health; Jill Meador, RN, BSN, CBN is Secretary/Treasurer; Nathaniel Sann, MSN, CRNP and Stephanie Sogg, PhD, are members-at large.
Ninh Nguyen, MD
“2014 was a year of wins for bariatric surgery. We won for our organization by being elected to the AMA House of Delegates, we won for our patients with access to sleeve gastrectomy for Medicare recipients in all 50 states, and we won with our medical colleagues by engaging them in our summit for the provision and coordination of care of the obese. More work ahead, but 2015 is bright for the ASMBS.” -- Ninh T. Nguyen, Immediate Past President, ASMBS
“As 2014 comes to an end and we begin to look to 2015, the landscape of obesity treatment has drastically changed for the better with new treatment options now available and even more on the way. The field of bariatric surgery continues to lead these advances, and we’re now learning that the metabolic process plays an integral role in treating and managing obesity. Additionally, awareness of the disease of obesity continued to gain momentum not only in the media, but also in the healthcare community. It is vitally important that we maintain this momentum and continue to educate healthcare professionals on the importance of addressing obesity with their patients and how to reduce the prevalence of weight bias in that important discussion of weight.” -- Joe Nadglowski, President/CEO, Obesity Action Coalition
Philip Schauer, MD
“By end of 2014, 14 RCT’s involving nearly 1,000 patients and up to three years follow-up show bariatric surgery to be superior to medical treatment for advanced type 2 diabetes. The current evidence of benefit of surgery is astounding. Look for major international guideline changes for diabetes surgery in 2015 at the London Diabetes Surgery Summit, September 28-30, 2015.” -- Philip R. Schauer, MD, Professor of Surgery, Lerner College of Medicine, Director, Advanced Laparoscopic & Bariatric Surgery, Bariatric & Metabolic Institute, Cleveland Clinic
“2014 was exciting and progressive. New and important research studies, growing recognition outside our field regarding the benefits of metabolic surgery, and great leadership in our specialty made 2014 an outstanding year.” -- Stacy Brethauer, MD, ASMBS Secretary/Treasurer
Jaime Ponce, MD
“2014 was a year of evolution, awareness, growth, collaboration and more recognition for Metabolic and Bariatric Surgery." -- Jaime Ponce, MD, ASMBS past president
“Bariatric surgeons continue to make strides in documenting the excellent results achieved with bariatric surgery. The STAMPEDE trial clearly demonstrated that the most popular surgical treatment modalities such as GBP and SG are superior to medical approaches when dealing with the obesity disease and its related comorbidities.” -- Raul J. Rosenthal, MD, President-elect, ASMBS
Georgeann Mallory, RD
“When I think of the past year I think of how we reconnected to our roots and reaffirmed the values on which Dr. Ed Mason founded the ASMBS - science, excellence, integrity and compassion. With all that we have accomplished this year and in the years past, we have a foundation to be proud of, the best members any organization could ask for and a meaningful and bright future. –- Georgeann Mallory, RD, Executive Director, ASMBS