The global trend for obesity is accompanied by an increase in stomach stapling surgery. The impact of bariatric surgery is impressive: After the operation, patients lose weight rapidly and even accompanying conditions such as diabetes may heal. But how sustainable are the treatment results and what do they mean for risk analysis in life and health insurance?
The number of bariatric operations is increasing rapidly. No other surgical discipline is experiencing such high growth rates. The reasons for this are clear enough. The most important are: Worldwide, more and more people are suffering from being severely overweight, or obese. Doctors define this as patients with a body mass index (BMI) from 30 kg/m2. The incidence of extreme obesity cases (BMI from 50 kg/m2) is increasing particularly fast. In the USA, the incidence of extreme obesity increased by 120 percent from 2000 to 2010. The situation is hardly any better in many other industrialised countries.
Obesity is the key cause of many widespread diseases
Pathological obesity increases the risk of mortality and is frequently accompanied by severe secondary conditions such as diabetes, high blood pressure, cardiac and circulatory conditions, metabolic disorders, joint conditions and certain forms of cancer. Doctors therefore advise affected patients to lose weight sustainably. When conventional methods such as changes in diet, physical activity and medicinal therapies are unsuccessful, bariatric surgery is the treatment of choice for certain patient groups. The various operative procedures (see info box) all lead to significant and rapid weight loss and may also have an astonishingly positive effect on secondary conditions.
The most common bariatric surgical procedures
Bariatric surgery aims to limit the ability to absorb nutrients. To achieve this, the anatomy of the stomach must be altered. Surgery can either reduce the size of the stomach, bypass parts of the gastrointestinal tract, or combine these two approaches. Several different surgical procedures have now become established. The three most common are illustrated here.
Diabetes can abate within a few days
The positive effects of a bariatric intervention on obese patients with type 2 diabetes are particularly striking. Their insulin values can normalise even within a few days of the operation, that is, before significant weight loss. The reasons for this instant reaction are not yet clear. The change in digestive hormone release in the stomach and duodenum probably plays a role.
But the initial results of the operation are clear and undisputed. Studies have shown that in 70 percent of patients who suffer from diabetes mellitus (type 2) at the time of operation, the insulin levels are reduced to normal in the first two years after the operation. This high success rate does not last, however. In 50 percent of the apparently cured patients, insulin levels increase to pathological levels again within ten years. Obese patients who only developed diabetes shortly before the operation have the best prospects for a long-term cure.
Even after bariatric surgery, however, the total risk of diabetes for obese persons is still double that of the general population.
Life insurance perspective: Limited positive impact on morbidity and mortality
Studies also demonstrate rapid initial success with regard to weight loss. Depending on the surgical procedure, statistically patients lose up to 32 percent of their body mass in the first two years after the operation. Yet in the following years, individual weight gain occurs in all patient groups; this is most often the case in patients who previously had extremely high BMI values. The reasons for this are manifold and range from increasingly immoderate food intake to postoperative complications. Nevertheless, in the majority of cases, the long-term BMI stabilises at a significantly lower level than before the intervention - with a correspondingly positive effect on morbidity and mortality risks.
This is shown by, for example, the leading Swedish SOS Study (Swedish Obese Subjects). In this study, the data of about 2,000 obese patients who received surgery and the data of an equally large patient group in conventional therapy were evaluated over an observation period of 20 years. The results show that in the group which received surgery, the long-term mortality was reduced by 30 percent compared to the patient group who did not receive surgery. This is primarily attributable to the reduced frequency of secondary BMI-related conditions.
Yet studies registered increased mortality due to unrelated causes, such as suicide and unforeseeable or changed effects of medication, in obese patients who received surgery in contrast to the general population. For the persons concerned, the total mortality risk remains 50 percent higher even after an operation. Despite its generally positive impact, bariatric surgery is no cure-all for the consequences of extreme obesity. This is indicated by the long-term results mentioned and a look at the risks of the operation itself: While mortality during and shortly after the operation is less than one percent, in many cases more than one intervention is required as after the procedure various post-surgery complications may arise.
Furthermore, experience of claims cases, for example in occupational disability cover, indicates that the interventions are of no significant benefit from an insurance perspective. Thus insured patients who have received surgery apply for occupational disability allowances only slightly less frequently than insured parties who are obese and have not received surgery. A possible explanation for this may be the long-term damage that has already occurred before the operation, for example to the musculoskeletal system.
Conclusion from a health insurance perspective
Although bariatric surgery improves the health and wellbeing of patients and reduces co-morbidity risks, many studies indicate that it doesn’t reduce healthcare costs in the long term. On the contrary it may even increase the utilization of hospital services in the short term. Hence bariatric surgery is not an opportunity to expect long term financial benefits from a health insurance perspective. Since many health plans don’t cover obesity treatment costs, direct medical costs of bariatric surgery is not a concern for insurers.
Post-operative complications, especially the most feared complication “leak from operation site” may however result in large claim due to extended hospitalization, re-operations and intensive care costs. An exclusion for bariatric surgery usually excludes its complications too. However insurers may be exposed to the costs because of the difficulty to distinguish between complications directly related to bariatric surgery and treatment that occurs independently of it.
Due to the fact that costs for bariatric surgery are not covered, the insurer might be unaware of this procedure having taken place. Thus any complications arising from bariatric surgery can´t be related to this procedure. This can be a challenge for the claims management as one can miss bariatric surgery as underlying cause and therefore ineligible claims are paid out.