title: The use, safety and cost of bariatric surgery before and after Medicare's national coverage decision.
abstract: OBJECTIVE
  To determine the impact of the Centers for Medicare and Medicaid Services' (CMS) bariatric surgery national coverage decision (NCD) on the use, safety, and cost of care CMS beneficiaries.
  
  
  BACKGROUND
  In February 2006, the CMS issued a NCD restricting reimbursement for bariatric surgery to accredited centers and including coverage for laparoscopic adjustable gastric band (LAGB).
  
  
  METHODS
  A pre/postinterrupted time-series cohort study using nationwide Medicare data (2004-2008) evaluating rates of bariatric procedures/100,000 enrollees, 90-day mortality, readmission rate and payments.
  
  
  RESULTS
  Forty-seven thousand thirty patients underwent procedures at 928 sites pre-NCD and 662 post-NCD. The procedure rate/100,000 patients dropped after the NCD to 17.8 (from 21.9 in 2005) increasing to 23.8 and 29.1 in 2007 and 2008, respectively. Open roux-en-y gastric bypass (ORYGB) and laparoscopic roux-en-y gastric bypass (LRYGB) were common pre-NCD (56.0% ORYGB, 35.5% LRYGB) changing post-NCD with LAGB inclusion (12.8% ORYGB, 48.7% LRYGB, 36.7% LAGB). 90-day mortality pre-NCD was 1.5% (1.8% ORYGB, 1.1% LRYGB) and post-NCD was 0.7% (1.7% ORYGB, 0.8% LRYGB, 0.3% LAGB; P < 0.001). The 90-day rates of readmission decreased post-NCD (19.9% to 15.4%), reoperation (3.2% to 2.1%) and payments ($24,363 to $19,746; P for all <0.001). Differences in outcome and cost were largely explained by a shift in procedure type and patient characteristics.
  
  
  CONCLUSIONS
  The NCD was associated with a temporary reduction in procedure rate and a shift in types of procedures and patients undergoing bariatric surgery. It was associated with a significant decrease in the risk of death, complications, readmissions, and per patient payments.
authors.affiliation: University of Washington Schools of Medicine, Pharmacy and Public Health, Seattle, WA, USA. daveflum@u.washington.edu
authors.forename: David R
authors.initials: DR
authors.lastname: Flum
authors.forename: Steve
authors.initials: S
authors.lastname: Kwon
authors.forename: Kara
authors.initials: K
authors.lastname: MacLeod
authors.forename: Bruce
authors.initials: B
authors.lastname: Wang
authors.forename: Rafael
authors.initials: R
authors.lastname: Alfonso-Cristancho
authors.forename: Louis P
authors.initials: LP
authors.lastname: Garrison
authors.forename: Sean D
authors.initials: SD
authors.lastname: Sullivan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000713:Anastomosis, Roux-en-Y / Q000191:economics / Q000706:statistics & numerical data; D050110:Bariatric Surgery / Q000191:economics* / Q000401:mortality / Q000706:statistics & numerical data*; D002423:Cause of Death; D005260:Female; D015390:Gastric Bypass / Q000191:economics / Q000706:statistics & numerical data; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage / Q000191:economics* / Q000706:statistics & numerical data; D010535:Laparoscopy / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D006278:Medicare / Q000191:economics* / Q000706:statistics & numerical data; D008875:Middle Aged; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data; D061214:Patient Safety; D014481:United States; D014600:Utilization Review / Q000706:statistics & numerical data; D055815:Young Adult