Why do so few eligible patients undergo bariatric surgery?

Bariatric surgery is an effective and durable treatment for individuals with obesity and its related health conditions. However, only a tiny minority of eligible patients undergo bariatric surgery. Access to this potentially life-changing procedure is far from equitable, with geographic, racial and sex differences. The disparity in the utilization of bariatric surgery highlights significant issues in patient awareness of available treatments for obesity, insurance coverage of obesity treatments and proximity to centers of excellence focused on the multi-disciplinary treatment of obesity.

In our recent paper, we examine geographic and demographic factors associated with the utilization of bariatric surgery using a commercial claims database. In this cohort, fewer than 7% of eligible individuals with employer-funded health insurance have bariatric surgery. Earlier estimates studying patients from all payor types suggest that the national rate is even lower.

Socioeconomic status plays a crucial role in accessing bariatric surgery. Patients with lower incomes are more likely to face financial barriers, including high out-of-pocket costs and limited insurance coverage. Our study represents patients with a “best case” scenario, patients with employer-sponsored health insurance, and despite mitigating this barrier, the utilization of bariatric surgery remains low.

Geographic location also contributes to inequity. Rural areas often have limited access to bariatric surgeons and specialized care facilities. This lack of availability can significantly impact whether individuals in these regions undergo the surgery. In our study, eligible patients who live in urban areas were 35% more likely to have bariatric surgery. Furthermore, patients eligible for bariatric surgery were more likely to have bariatric surgery if they lived in the Northeast and less likely if they lived in the South.

Our study period was from 2016 to 2021, which included only six months in which semaglutide (i.e. Wegovy or Ozempic, an injectable weight-loss medication) was approved for weight loss. Recent data shows that access to semaglutide also varies substantially by individual characteristics. While additional obesity treatment approaches provide greater options for patients and their care providers, the introduction of semaglutide has not filled the gaps in equitable access to durable weight loss solutions identified in our study.

To address the issue of equity in bariatric surgery, a multifaceted approach is necessary. Increasing insurance coverage for the procedure, expanding access to care in underserved areas, and implementing patient education programs are essential steps. Healthcare facilities and clinicians also have a crucial role to play in promoting equity. Addressing implicit biases and ensuring culturally competent care is essential for building trust with patients from marginalized communities. Additionally, providing comprehensive support, including nutrition and psychological counseling and insurance navigation, can improve patient outcomes. Ultimately, achieving equity in bariatric surgery requires a collaborative effort involving policymakers, physicians, insurers and patient advocacy organizations.

By Drs. Feibi Zheng, assistant professor in the Michael E. DeBakey Department of Surgery, and Elizabeth Wall-Wieler, research scientist at the Manitoba Centre for Health Policy and assistant professor in the Department of Community Health Sciences