title: Bariatric surgery insurance requirements independently predict surgery dropout.
abstract: BACKGROUND
  Many insurance companies have considerable prebariatric surgery requirements despite a lack of evidence for improved clinical outcomes. The hypothesis of this study is that insurance-specific requirements will be associated with a decreased progression to surgery and increased delay in time to surgery.
  
  
  METHODS
  Retrospective data collection was performed for patients undergoing bariatric surgery evaluation from 2010-2015. Patients who underwent surgery (SGY; n = 827; mean body mass index [BMI] 49.1) were compared with those who did not (no-SGY; n = 648; mean BMI: 49.4). Univariate and multivariate analysis were performed to identify specific co-morbidity and insurance specific predictors of surgical dropout and time to surgery.
  
  
  RESULTS
  A total of 1475 patients using 12 major insurance payors were included. Univariate analysis found insurance requirements associated with surgical drop out included longer median diet duration (no-SGY = 6 mo; SGY = 3 mo; P<.001); primary care physician letter of necessity (P<.0001); laboratory testing (P = .019); and evaluation by cardiology (P<.001), pulmonology (P<.0001), or psychiatry (P = .0003). Using logistic regression to control for co-morbidities, longer diet requirement (odds ratio [OR] .88, P<.0001), primary care physician letter (OR .33, P<.0001), cardiology evaluation (OR .22, P = .038), and advanced laboratory testing (OR 5.75, P = .019) independently predicted surgery dropout. Additionally, surgical patients had an average interval between initial visit and surgery of 5.8±4.6 months with significant weight gain (2.1 kg, P<.0001).
  
  
  CONCLUSIONS
  Many prebariatric surgery insurance requirements were associated with lack of patient progression to surgery in this study. In addition, delays in surgery were associated with preoperative weight gain. Although prospective and multicenter studies are needed, these findings have major policy implications suggesting insurance requirements may need to be reconsidered to improve medical care.
authors.affiliation: Department of Medicine, University of Virginia, Charlottesville, Virginia.
authors.forename: Kaitlin M
authors.initials: KM
authors.lastname: Love
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: J Hunter
authors.initials: JH
authors.lastname: Mehaffey
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Dana
authors.initials: D
authors.lastname: Safavian
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Bruce
authors.initials: B
authors.lastname: Schirmer
authors.affiliation: Department of Kinesiology, University of Virginia, Charlottesville, Virginia; Division of Endocrinology and Metabolism, University of Virginia, Charlottesville, Virginia.
authors.forename: Steven K
authors.initials: SK
authors.lastname: Malin
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Peter T
authors.initials: PT
authors.lastname: Hallowell
authors.affiliation: Department of Medicine, University of Virginia, Charlottesville, Virginia; Division of Endocrinology and Metabolism, University of Virginia, Charlottesville, Virginia. Electronic address: JKD2A@virginia.edu.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Kirby
mesh_terms: D000328:Adult; D050110:Bariatric Surgery / Q000191:economics*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D019458:Insurance Coverage / Q000191:economics; D007348:Insurance, Health; D008297:Male; D009765:Obesity / Q000191:economics / Q000601:surgery*; D010352:Patient Dropouts; D011300:Preoperative Care / Q000191:economics; D012189:Retrospective Studies
keywords: Access to care; Bariatric surgery; Gastric bypass; Insurance requirements