The Role of Commercial Health Insurance Characteristics in Bariatric Surgery Utilization

Objective: The aim of this study was to understand relationships among insurance plan type, out-of-pocket cost sharing, and the utilization of bariatric surgery among commercially insured patients. Background: Only 1% of eligible persons undergo bariatric operations, and this underutilization is often attributed to lack of insurance coverage. But even among the insured, underinsurance is now recognized as a major barrier to accessing medical care. The relationships among commercial insurance design, out-of-pocket cost sharing, and elective surgery utilization, particularly in bariatrics, are not well understood. Methods: Retrospective review of 73,002 commercially insured members of the IBM MarketScan commercial claims database who underwent bariatric surgery from 2014 to 2017. The exposure variables were insurance plan type and out-of-pocket cost sharing. The outcome was utilization of bariatric surgery. We also examined seasonal trends in bariatric surgery utilization stratified by average levels of cost sharing. Results: Utilization of bariatric surgery was higher in plans with lower cost sharing, such as PPOs (20 operations/100,000 enrollees) than in HDHPs (high-deductible health plans, 12.1 operations/100,000 enrollees). Overall, every $1000 increase in cost sharing was associated with 5 fewer bariatric operations per 100,000 insured lives; this association was strongest in plans with high cost sharing (high-deductible and consumer-directed health plans). Members of all plan types had higher surgical utilization in quarter 4 relative to quarter 1 of each year; these seasonal variations were also most pronounced in plans with high cost sharing. Conclusions: Insurance plan types with higher cost sharing have lower utilization of bariatric surgery. Underinsurance may represent a newly identified barrier to surgical care that should be addressed by advocates and policymakers.