Developing a Bariatrics Program in an ASC

According to the American Society for Metabolic & Bariatric Surgery, around 220,000 people with morbid obesity underwent bariatric surgery in 2008. As recent reports have shown, performing these procedures in an outpatient setting is safe and effective for the right patients.

Many ASCs have considered adding a bariatrics practice to their centers in hopes of providing care for these patients. However, there are many special concerns that come along with this type of sensitive surgery.

Why should you add bariatrics?
Many reports have indicated that the number of people in the United States who are considered obese or overweight is growing. The ASMBS reports that 34 percent of adults in the United States are affected by obesity and that 67 percent are either overweight or obese. From 2000-2005, the society reports the following increases in the levels of obesity among American adults:

  • Obesity (BMI ≥ 30): 24 percent
  • Morbid obesity (BMI ≥ 40): 50 percent
  • Super obesity (BMI ≥ 50): 75 percent

For many of these patients who are looking to lose weight, bariatric surgery may be their best option. For surgery centers, this means that currently there is a patient pool of more than 100 million people who may be excellent candidates for bariatric procedures, particularly the Lap-Band surgery, says Tom Michaud, CEO of Foundation Surgery Affiliates.

In addition to growing the number of procedures your ASC performs by adding this new specialty, providing excellent care to this patient population can lead to more opportunities for other specialties at the center because many patients who come in for bariatric surgery will have other health issues, says Kent Sasse, MD, MPH, FACS, medical director of the Western Bariatric Institute in Reno, Nev., and author of the book, Outpatient Weight-Loss Surgery: Safe and Effective Weight Loss with Modern Bariatric Surgery. "Many of these patients will need arthroscopic orthopedic surgery, gynecological surgery or spine surgery," he says. "An ASC that is distinguished as a center that treats overweight and obese patients will often see these patients again as returning customers."

Other conditions that obese and overweight patients may have include osteoarthritis, joint degeneration, venous stasis disease, infertility, pregnancy complications, gastroesophageal reflux disease, chronic headaches, lower back pain and urinary incontinence, according to the ASMBS.

Mr. Michaud says ASCs may even see some ancillary revenue as a result of procedures performed to treat the complications bariatric patients face before and after surgery. Such procedures include EGD and colonoscopies, hernia repair and laparoscopic cholecystectomy, which Mr. Michaud says has a 35 percent post-op incidence rate. Plastic surgery to remove excess skin is often common after surgery as well.

Another reason an ASC should consider adding bariatrics to its services is that the procedures can reimburse very well. According to Dr. Sasse, the amount that payors cover and reimburse for bariatric surgery is on the rise. "Over the last two decades, payors have increasingly covered procedures they see as medically necessary and important," he says.

Mr. Michaud agrees. "With the growing public awareness of the obesity pandemic, bariatric surgery is becoming more accepted by both the general population and insurance companies as part of the treatment continuum," he says. For Lap-Band procedures, reimbursements can range from $12,000-$25,000, depending on insurance and the type of band used.

The economy, however, may also impact these reimbursement rates as it has with other specialties. "We are seeing tighter purse strings from some self-directed employer plans and from individual patients who must cut back on co-pays and variables," Dr. Sasse says.

Many types of bariatric surgeries can be performed in an outpatient setting

Here are three types of common, bariatric procedures that can safely be performed in an outpatient setting.

1. Lap-Band. The most common bariatric surgery that can be performed in an outpatient setting is a Lap-Band, or laparoscopic adjustable gastric band. In this procedure, a silastic "band," or belt, is placed around the upper portion of a patient's stomach, creating a small walnut/egg-sized pouch, which reduces the amount of food a patient needs to feel full, according to Mr. Michaud. The band can be adjusted through an access port by adding or decreasing the amount of saline in the balloon inside the band. These adjustments will be needed 3-6 times in the first year after surgery and then on an as-needed basis, Mr. Michaud says. If necessary, the Lap-Band can be removed, although the surgery is intended to be permanent.

Two types of bands are commonly used in this surgery — the LAP-BAND, manufactured by Allergan, and the REALIZE Band, manufactured by Ethicon Endo-Surgery. The Lap-Band procedure usually takes an hour to perform and requires 3-5 hours of recovery time, says Mr. Michaud.

2. Laparoscopic Roux-en-Y gastric bypass. Selected bariatric patients may undergo a laparoscopic Roux-en-Y gastric bypass, says Dr. Sasse. In this surgery, the patient's stomach is made smaller by creating a small pouch at the top of the stomach using surgical staples or a plastic band. The newly created smaller stomach is then connected directly to the middle portion of the small intestine and bypasses three to four feet of the small intestine. The bypassed section of the digestive tract (the stomach and small intestine) is connected to the lower part of the small intestine.

Dr. Sasse notes that these cases can only be performed in surgery centers that can provide 23-hour stays for motivated patients. The complications can include postoperative vomiting, dehydrations and, in rare cases, hemorrhage or anastamotic leak.

3. Laparoscopic sleeve gastrectomy. Laparoscopic sleeve gastrectomy is another procedure that can be performed in an outpatient setting, although only a few select patients will undergo this surgery, according to Dr. Sasse. In this procedure, the left side of the stomach (the greater curvature) is separated vertically from the rest of the stomach using surgical staples.

As with Roux-en-Y patients, patients undergoing sleeve gastrectomy require a 23-hour stay. The most common complications are postoperative vomiting and, in rare cases, bleeding or leakage from the staple lines.

Bariatric patients are a unique patient population and have special needs
The most important consideration for surgery centers looking to offer bariatrics is that these patients will have special requirements and are not like typical ASC patients.

Dr. Sasse says that staff members at the surgery center should undergo extra training as caring for patients who undergo bariatric surgery is unique. This training goes beyond the standard training require to learn how to perform the procedures or use the equipment for the new surgeries.

"Sensitivity training is required because staff members need to learn professionalism in this field," he says. "They need to know how to show empathy and courtesy towards people who are overweight. It is important for a center and its staff to build the right ethos for these patients.

"A strong team can make a favorable impression on people considering weight loss surgery," Dr. Sasse says. "Conversely, off-handed comments can negatively affect the patient's impression of the center." It is important for all ASC staff, not just those who are working directly with the bariatric program, to undergo sensitivity training in this area.

Another aspect of offering bariatrics ASCs must consider is that before surgery, sleep studies are required to make sure that patients are receiving the proper amount of oxygen, says Mr. Michaud.

"Most patients who undergo bariatric surgery will have sleep apnea," Mr. Michaud says. "We require 100 percent of our gastric bypass patients to undergo these studies to see if they will need to be on a [continuous positive airway pressure] machine to make sure they have enough oxygen." If the sleep study indicates the patient has sleep apnea, he or she is then required to use a CPAP machine for two weeks prior to surgery to help ensure proper oxygen levels in the blood.

Patient selection is critical to the initial success of a program
Dr. Sasse says that when an ASC is just beginning its bariatric program, it should err on the side of caution and choose patients with lower BMIs until the center establishes a good track record and reputation.

"Centers should put an emphasis on quality, quality, quality," Dr. Sasse says. "Adverse outcomes would be potentially damaging when establishing the program."

The objective for centers when starting bariatric programs should be to "work hard with well-qualified patients, ensuring high-quality results," according to Dr. Sasse.

One way to minimize this risk is to build a team of surgeons and anesthesiologists who have worked together in the past to perform all bariatric surgeries, says Dr. Sasse.

"Our center focused from the beginning on becoming experts at the challenges of outpatient surgery [on] morbidly obese people," he says.

Bariatric surgery requires specialized equipment
Surgery centers that are interested in developing a bariatric program will need to purchase new equipment for these procedures and patients, and it can be a significant capital investment.

Because bariatric surgery patients are overweight, surgery centers should ensure that the seating in their waiting rooms can accommodate these patients comfortably, says Dr. Sasse. Likewise, ASCs should invest in operating tables that can accommodate increased weight.

Most importantly, because these procedures are performed laparoscopically, Dr. Sasse suggests that centers should invest in high quality and high resolution laparoscopy equipment.

Mr. Michaud notes that purchasing two of these instrument sets can cost $80,000 alone. Combined with the other considerations, the total cost can add up to $500,000.

Bariatric surgery is only one component of the weight-loss program
One of the biggest complications for bariatric surgery in the outpatient setting is that bariatric surgery is only a small part of a patient's overall weight-loss program. As many of these patients are coming from a sponsored program, it may be more difficult for these specialists to "give up" them, says Mr. Michaud.

For patients in these weight-loss programs, surgery is considered as the last resort. The programs, even for patients who do undergo surgery, include a variety of behavior modifications and lifestyle changes that require a team of healthcare providers including bariatricians, dieticians, exercise physiologists and psychologists, according to Mr. Michaud. Patients are often enrolled in these programs for 4-6 months prior to having surgery.

"Most weight-loss programs were independent up until now," Dr. Sasses says. "However, we are seeing the increasing possibility to ingrate."

Mr. Michaud says that most bariatric patients that elect to have bariatric surgery in an ASC are acquired and recruited through surgeon seminars, either at the ASC or through the weight-loss program.

"Surgeons and the ASC can develop a relationship with the program or volunteer to participate in the cost of the program," he says. "It is often beneficial to speak directly to the specialist."

Dr. Sasse notes that surgery centers can use the time it takes to develop a relationship with weight-loss programs to educate the staff on obesity training and treatment and to establish their program in order to prepare the center for these patients.

Becoming a Bariatric Surgery Center of Excellence
An important consideration for an ASC planning to add a bariatric program is to consider whether it wants to be recognized as a Bariatric Surgery Center of Excellence by the ASMBS, says Dr. Sasse. One of the significant benefits of this designation is that many insurers require an ASC to be a BSCOE in order to be covered under their plan, he says.

In order to qualify, an ASC must perform a minimum of around 125 bariatric cases annually, says Dr. Sasse. Additionally, the center must meet other high standards, including site inspections and proper patient selection. "A center should reflect before jumping in to achieving this goal and consider if the center has the capital investment and patient volume to meet these criteria," he says.

Contact Renee Tomcanin at renee@beckersasc.com.

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