Mortality Risk Associated with Insurance Denials in Bariatric Surgery Candidates

Introduction: Increasing numbers of Americans meet medical candidacy criteria for bariatric surgery; however many are denied or delayed because of absence of insurance benefits or administrative hurdles in the pre-approval process. In many cases, patients endure months of delay before coming to a surgical date or giving up. Since morbid obesity carries inherent medical risk, we set about to define the mortality rate among those patients who were deemed acceptable candidates by our surgeons but who were declined or delayed in the insurance process.
Methods: Retrospective review of a single institution bariatric surgery database between June 2002 and December 2008 was performed. Of 538 total patients who were deemed surgical candidates in our preoperative clinic, 114 were denied and did not undergo surgery (subject group) compared with 424 who came to operation (control group) during the same time frame. Following IRB approval, patient identifiers were used to query the Social Security death index to assess whether patients were dead or alive as of August 10, 2009. Survival analysis with Kaplan-Meier plot was performed using SPSS (SPSS Inc. Chicago, IL) with log-rank test for statistical significance.
Results: The subject group and control group were similar demographically (85.3% vs 85.6% females, mean age 44.7 vs 45.9 years). Mean follow up was 44.3 (range 8-86) months for subjects and 44.5 (range 4-108) months for controls. Two medical deaths occurred in the subject group and 12 deaths occurred in the surgical group. Of these, 3 occurred within 30 days of surgery for a perioperative mortality of 0.71%, but 9 others died during extended follow-up. Cumulative survival analysis using Kaplan-Meier plot is shown below. Curves are statistically similar.

Conclusions: About 21% of patients who satisfy medical and surgical criteria for bariatric surgery failed to achieve insurance approval and follow-through with operation at our institution. Among these, there was a 1.8% mortality rate over 44.3 months follow-up, which is similar to the risk in early postoperative surgical patients. Over time, those patients with insurance denials are expected to suffer increasing mortality, although our data do not yet demonstrate this separation in survival curves. Longitudinal studies are necessary.

Session: Podium Presentation

Program Number: S096

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