One Bad Apple Could Spoil the Whole Bunch (Girl!)

Photo by M Clock

(Yes, those are cherry tomatoes, not apples...but I think the same principle applies)

So, why is this post labeled the way it is?

I think it the saying truly can mean what it implies - that one small part of a whole group is capable of ruining the homogenous group via it's unique way of deviating from the norm. Just by the mere fact that it is, for it's greater part, a genuine part of the whole group doesn't free it from possibly doing damage to the whole. In fact, that characteristic can uniquely enable it to do so if not cared for in the proper way.

So where are we going with this?

Glad you asked.

"Way back" in 2006, the decision was made by CMS (Centers for Medicare and Medicaid Services) to require centers that provide Bariatric Surgery services to become certified to do so, as a Center of Excellence (COE), in order to approve of the location that provides the surgical service as well as clear payment to those centers for reimbursement.

The idea at the time was to encourage high volume centers to go through the process to become certified, and therefore be able to establish a a new standard benchmark, ensuring quality prospectively from that point on. Historically, Bariatric Surgery was becoming safer at that time, and the reason resided in the fact that the learning curve in going from open surgeries to laparoscopic procedures was being realized nationally.

Significant gains in safety and outcome have in fact been realized across the rapidly expanding Bariatric Surgery sub specialty, but the consideration of a new ruling on the matter by CMS has that situation potentially in a bit of jeopardy.

CMS is considering a new ruling this Fall that could lift the facility certification / COE designation as a requirement for coverage of approved services, which may open the door for access to non-accredited centers for these patients, it could substantially increase morbidity and mortality of these patients.

CMS is basing their consideration this issue as a result of a study that came out earlier this year showing "no significant difference" between designated COE's and non-accredited centers in terms of complications and outcome.

Just this week, the ASMBS, ACS, The Obesity Society, The American Society of Bariatric Physicians, and The Society of American Gastrointestinal Endoscopic Surgeons collectively wrote that they "strongly oppose" the CMS's decision to overturn the current established policy.

A counter argument to that study (and the current position of CMS on changing their policy), apart from reasonable intuition that higher volume centers have better outcomes, will be argued by a study currently in press,  in the journal of Surgical Endoscopy.  That study showed an alarming increased in-hospital mortality rate of 3X higher in non-accredited centers vs. those that were COE's (0.22% vs. 0.06%).

While access to care may be the effect that CMS is after by "freeing up" the ability of more centers to be able to do weight loss procedures, should more frequent events of morbidity and mortality occur than is currently the case, access may in fact be diminished as referring physicians once agin think twice, or more, about referring their patient for surgery in the first place.

In this specialty, what happens "globally" can certainly effect local perception of safety, which would be a shame after we, as a specialty, have come so far.  I will stay on top of any developments in this issue, and make you aware what, or IF, any changes occur.