For people with obesity, surgeries that reduce, reshape, or otherwise change the anatomy of the stomach have long been the best way to lose weight. But in the last few years, with the approval of GLP-1 drugs like Wegovy and Zepbound, more and more people are choosing anti-obesity medications over gold-standard surgical treatments.
“At the population level, among a subset of commercially insured individuals, that’s the trade-off that’s happening,” said Thomas Tsai, the lead author of a new study that looked at the health records of 17 million privately insured Americans with obesity. It found that between 2022 and 2023, when prescriptions for GLP-1 drugs more than doubled, the number of bariatric surgeries fell by 25.6%.
The findingspublished Wednesday in JAMA Network Open, marks a sharp reversal from the trends of the past decade, and portends an uncertain future for hospitals and clinics that derive a significant portion of their revenue from such procedures.
Amid the growing realization that obesity is a chronic biological and therefore treatable disease, the number of bariatric surgeries has steadily increased from 158,000 people in 2011 to 280,000 in 2022. according to the American Society for Metabolic and Bariatric Surgery. For many surgical programs, 2022 was a record year due to pent-up demand caused by the Covid-19 pandemic, when many elective surgeries were suspended. “But that growth trajectory dropped precipitously in 2023, corresponding to a massive uptake of GLP-1 drugs,” Tsai said.
As a practicing bariatric surgeon at Brigham and Women’s Hospital in Boston, he had noticed an increase in last-minute cancellations, especially among patients who had recently started taking GLP-1 medications. After hearing similar stories from other doctors, Tsai, who is also a health policy researcher at Harvard Medical School and the TH Chan School of Public Health, wanted to know if what they were seeing on the front lines was part of a national shift from surgical procedures to medical care. towards pharmacological treatment of obesity.
“It’s clear that there is a decline in bariatric surgeries, and the assumption we’ve made as a field is that this is related to the increase in GLP-1s,” said Marc Bessler, chief of surgery at Northwell Lenox Hill Hospital in New York. York City and CEO of EndObetes, a startup focused on developing endoscopic devices to treat obesity and diabetes. “This study shows that they are clearly temporally related.”
What’s less clear is whether the downturn will be a temporary blip or a permanent part of the future of obesity medicine.
Some researchers believe what they see is the beginning of replacing bariatric surgery — an effective but more invasive (and permanent) intervention — with medications that are even easier to take and that offer additional benefits, such as reducing heart complications and protecting of the brain. of Alzheimer’s-related neurodegeneration.
Others think the rising popularity of GLP-1 drugs will have a “rising tide effect” and ultimately increase the number of patients seeking surgical treatment – which, as excitement over weight-loss drugs revises obesity as a disease in rather than as a cosmetic issue or problem. moral failure and reducing the weight stigma that still exists in many corners of the healthcare system, more people will seek proven weight loss therapies.
“Some of those people who now believe they deserve care will ultimately choose surgery,” Randy Seeley, director of the Michigan Nutrition Obesity Research Center, told STAT in an email. “Make no mistake: pharmacological use will dwarf surgery in terms of patient volume, but it remains a viable option.”
Some opt for surgery because they do not want to continue taking the medication forever, because of side effects or because the medication does not work for them; in clinical trials, about 15% of people did not see meaningful weight loss. Others may choose surgery because it is better covered by insurance.
Although GLP-1 drugs are catching up to bariatric surgery in their effectiveness in reducing obesity and related health problems, they are expensive — $900 to $1,350 per month — and must be used indefinitely to maintain weight loss. to maintain level. Medicare doesn’t cover these, and many insurers are cracking down on prescriptions or adding lifetime limits in an effort to rein in rising costs. Recent studies suggest that bariatric surgery, even though it has a higher initial cost, may be a better deal in the long run.
In one, researchers from the University of South Florida found that the cost of continued use of some GLP-1 drugs such as Saxenda and Wegovy surpasses bariatric surgery in 9 to 12 months. Another analysis, conducted by a team at Northwestern University Feinberg School of Medicine, found that bariatric surgery, which typically costs between $17,000 and $23,000, delivered two more healthy years of life and saved about $9,000 per yearcompared to GLP-1 drugs. The results, presented last week at the American College of Surgeons Clinical Congress, will likely inform how insurance companies decide to cover both treatments in the future.
“Right now there’s just a high degree of uncertainty about what this all means in terms of the volume of bariatric surgeries in the long term,” Tsai said. “But for patients, with all the different treatment options available now, this really is a golden age. The challenge for the coming years is to ensure that patients have access to it.”
In their latest analysis, Tsai and his colleagues found that among the commercially insured, fewer than 6% of people with obesity were treated with surgery or GLP-1 drugs. problem.
The new data also adds empirical weight to anecdotes about the closure of programs for obese people in Boston and other parts of the country due to a combination of declining demand and continued health care consolidation. Over the summer, when a major medical weight-loss clinic in Oklahoma abruptly shut down its bariatric surgery program — laying off staff, canceling procedures and abandoning patients — accused the explosive popularity of GLP-1 drugs such as Wegovy and Zepbound.
At Northwell, surgeons are not let go, Bessler said. But the hospital is also not hiring new people. “We’re not dramatically changing our mindset toward bariatric surgery,” he said. His expectations are that within the next three to five years, surgery volumes will return to baseline levels. “I think a lot of people are kind of betting on that and not closing.”
But many in the field remain concerned that even a short-term reduction in capacity could have ripple effects well into the future. Currently, only about 1% of patients eligible for bariatric surgery actually receive the treatment. “There are a lot of financial headwinds, and while surgical programs may not be able to wait long enough to get through this, this has the potential to create even more imbalances,” Tsai said.
In recent years, obesity medicine has moved toward a more precise model of medicine, identifying different subtypes and tailoring treatments to patients. “With volume in bariatric surgery decreasing so rapidly, we are almost re-fragmenting that more multidisciplinary approach,” Tsai added. “My concern is that people aren’t thinking about all the obesity and all the metabolic disorders and some of the tradeoffs.”