GLP-1 Agonists and the State of Outpatient Bariatric Surgery

Popular weight-loss drug’s disruption may be more of a short-term blip than an industry-changing bang.

A sleeve gastrectomy, also known as a gastric sleeve, is the most common bariatric surgery in the U.S. It’s also a procedure that an increasing number of providers — and payors — believe can be performed safely on an outpatient basis. With the recent surge in individuals taking Ozempic, Wegovy, Mounjaro or another GLP-1 agonist to lose weight, the question now becomes: What overall impact will these popular medications have on facilities that perform outpatient bariatric surgery?

Immediate impact

“In the short term, I think we’re seeing a decline in sleeve gastrectomy procedures, but long term I expect these cases to double over the next 10 years,” says John Magaña Morton, MD, MPH, MHA, FACS, FASMBS, DABOM, AGAF, division chief of bariatric and minimally invasive surgery for Yale School of Medicine in New Haven, Conn., and past president of the American Society for Metabolic and Bariatric Surgery (ASMBS).

Despite the GLP-1-influenced dip in outpatient bariatric surgery’s signature procedure that most facilities have experienced, Yale’s overall volume — its bariatric service line performs in an HOPD setting, the bulk of which are gastric sleeve surgeries but also including gastric bypass procedures, revisions, a small amount of SADIs and gastric band removals — has held steady. That’s something Dr. Morton attributes to the overall structure of the organization’s approach to weight-loss management. “We rely on an integrated approach in which specialists and surgeons work together hand-in-hand to treat patients,” he says.

Dr. Morton is not particularly fazed by the Ozempic Effect and its potential to disrupt his industry’s progress in providing sustainable, life-changing surgeries for obese patients. “There’s no doubt we’re talking about a paradigm-shifting drug, but only about half of the patients who are prescribed GLP-1 agonists are still taking it one year out,” he says. “More people are motivated to do something about obesity, and roadblocks along the way often lead to surgery. That’s where you’ll see the uptick in cases.”

Growth factors

The migration of gastric sleeve cases from inpatient settings to outpatient ones follows a similar trajectory to the path charted by other service lines — think total joints in orthopedics — where multiple factors drive the shift.

“Risk stratification is the primary reason for growth,” says Dr. Morton. “We know who the right candidates are and we know those who aren’t.” He cites the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), which collects data on bariatric surgical procedures and outcomes from accredited centers across the U.S. and has more than 800,000 patients in its database, as the reason why bariatric facilities can accurately pinpoint patient risk levels and consistently make the right care decisions for the right patients. You can find the latest summary of key MBSAQIP figures here. New data from the MBSAQIP will be released this summer.

Another factor driving the migration is fine-tuned, efficient Enhanced Recovery After Surgery (ERAS) protocols. “Bariatric surgery has always been a leader in PONV, nerve blocks and all the processes that lead to faster recovery and patients being discharged more quickly,” says Dr. Morton.

Technology and surgeons’ evolving technical approaches to bariatric surgery also play a key role. “Improvements in laparoscopic and robotic techniques have made bariatric surgery one of the safest and most effective operations in America,” says Ann M. Rogers, MD, president of ASMBS and director of The Penn State Surgical Weight Loss Program at Penn State Hershey Medical Center. Dr. Rogers, however, isn’t as bullish on the inpatient-to-outpatient push. “The ability to routinely perform these procedures on an outpatient basis remains elusive,” she says. “One study suggests that only about 7% of patients meet selection criteria and this likely includes patients kept for at least 24 hours.”

Payor preference

At the heart of any discussion on the future of bariatric surgery is payor preference, and Drs. Morton and Rogers see an increased desire from payors to move toward an outpatient setting. There’s certainly room for growth in the outpatient bariatric space — especially for surgery centers positioned to capitalize on growing demand from both patients and payors.

Dr. Morton says well under 10% of bariatric cases are currently outpatient, with an even smaller subset of facilities performing gastric sleeve surgeries that don’t require an overnight stay. “There are only a handful of centers doing it 100% same-day; most keep patients overnight,” he says.

Dr. Rogers sees plenty of problems with the current push from payors to cut costs, pointing out that insurers are now approving bariatric procedures to be done only on an outpatient basis despite successful lobbying efforts to keep bariatric surgery on Medicare’s Inpatient Only list. She argues that most patients cannot safely be discharged the same day because of their severe obesity and related conditions such as joint problems, obesity hypoventilation syndrome and many others. Because of this, patients approved as outpatients are still staying in the hospital for 24 hours or more, causing “profound” hospital underpayment.

“Physicians should be the ones deciding whether a procedure is or is not to be performed on an outpatient basis, not insurers,” says Dr. Rogers. “Insurers who try to make such decisions are essentially trying to practice medicine.” OSM