Bariatric surgery has been shown to help patients reduce their weight and reduce the incidence of diabetes—at least in the short term. Although recent reports show that obesity rates are leveling off, hospital administrators remain concerned about the weight of their patients, as obesity may increase costs for all hospital stays.
Hospitals looking to enter the bariatric surgery market are hampered by the high annual caseload of 125 cases per year needed to meet Center of Excellence (COE) requirements. Many administrators complain that this high threshold limits the number of centers in a market and is unattainable for all but the largest programs. Further, the simple volume cut-off did not take into account the acuity of the patients in the program.
However, the tide is turning. The American Society for Metabolic and Bariatric Surgery (ASMBS) released preliminary guidelines for the new COE requirements on December 19, 2012. These recommendations outline how new centers will be accredited in the new year. Centers already certified under the old system (ACS or ASMBS) will continue to be certified as COEs and do not need to reapply. For new centers looking to gain COE status, the requirements have shifted. I've outlined the three major changes to accreditation.
1. New volume thresholds and center categories
In an expansion of the options available to hospitals interested in COE accreditation, hospitals can now be certified as a “comprehensive center," “low acuity center," “band-only”, and “outpatient,” with each designation requiring different annual volumes (50, 25, none, and none, respectively).
While the ACS bases some designations on center volume (Level 1, 2, and OP), ASMBS had a single volume threshold. New COEs will choose a designation based on their volume and patient type. The “low acuity” center is only required to have 25 cases per year. Patients are restricted to those under 60 with a BMI of less than 55 for men or 60 for women, leaving the most obese patients to be treated at comprehensive centers.
Further, band-only centers may do non-band procedures but are only accredited based on the banding done. Given the recent negative attention given to Allergan’s Lap Band, we don’t think many hospitals will choose this option as many now favor the vertical sleeve over banding. However, outpatient centers may choose to only perform band procedures, and “band-only” could become the preferred certification for surgeon-owned facilities that do not want to handle complex cases.
2. Emphasis on quality
New requirements include the establishment of an "institutional collaborative" comprised of all surgeons within the bariatric program. These institutional collaboratives will be required to review outcomes data for the hospital as well as for individual surgeons.
The broader bariatric committee will also be responsible for the completion of at least two quality improvement projects each year. These can be on safety, effectiveness, or patient experience, but centers must show evidence of implementation and evaluation of each initiative.
3. Addition of the data reviewer role
As we have alluded to in an earlier report, new bariatric COEs will have to employ an individual in the role of a data administrator. This role carries two primary restrictions: the data administrator cannot be the program administrator and cannot be involved in patient care.
This individual will be the only person able to enter data into the new MBSAQIP database. They will be required to attend training sessions on data entry, complete an annual certifying exam, and attend quarterly committee meetings.
Amendments still to come
These changes are considered preliminary and may be amended following the period of public comment, which ends January 15. For hospitals considering bariatric surgery programs, the elimination of the annual caseload requirement of 125 cases likely comes as good news, as that standard was difficult for many programs to achieve.
Hospitals will now be able to reach COE status and receive reimbursement from Medicare and other private payers sooner. We will keep you updated on the final recommendation, and for more information, see our webconference detailing the outlook for bariatric surgery.