The article by Weiner et al recently published in JAMA focuses on data derived from seven Blue Cross Insurance plans on patients who underwent bariatric surgery versus case-matched individuals in that plan who did not ("Studies question bariatric surgery health cost savings, October 2013, p. 1). The study found that although the patients who underwent surgery had lower non-hospital costs for the 6-year follow-up period overall, these costs did not overcome the initial expenditure for the operation and postoperative care or for other postoperative costs after surgery.

My initial reaction was: Why would we expect bariatric surgery to save money, or why must it? Name me three operations that are expected to save health care costs. Here are some procedures to consider:

• Joint replacements? Well, they certainly get people back on their feet but do we expect them to cut medical costs? No

• Hernia repairs? These operations may allow people to work more effectively, but actually cut health care costs?? I’ve never seen that study.

• Cataract surgery? These operations may or may not end up reducing health costs but they are not evaluated on cost savings

• Lung resections for cancer? Well, no but after all we are dealing with cancer. It’s not like obesity can kill you, right?

So why do we expect bariatric surgery to be cost effective? Who set that standard? Is it because of the innate societal bias against obesity as being a byproduct of character flaws and not a disease? Yet even though the American Medical Association and CMS have declared that obesity is a disease, treatment is under special scrutiny for cost savings. Even if bariatric surgery does not achieve cost effectiveness, I agree with the final conclusion of this paper that "studies should focus on the improved health and well-being of persons undergoing the procedure."

Bariatric surgery certainly does promote health and well-being in patients. It improves survival, decreases the incidence of cancer, puts most cases of type 2 diabetes into remission, decreases the need for multiple medications for hypertension, hypercholesterolemia, degenerative joint disease, and dramatically improves the overall quality of life for severely obese patients. Its benefits are well documented and undisputable.

And what about obesity? Dieting hasn’t been very effective against a disease that is rated the number two health threat in the U.S. today after cardiovascular disease. Recent news reports in fact said obesity may be the leading childhood risk factor for future cardiovascular disease. It certainly has increased the incidence of diabetes, renal failure, colon, breast, and prostate cancer as well as others. Today’s youth may live shorter lives than their parents due solely to this disease.

Since the data from this study were first collected, the incidence of postoperative death after bariatric surgery has dropped to one-fourth its level a decade ago. Large databases now demonstrate the fact that outcomes for bariatric surgery are much improved in the last decade. A significant percentage of the operations in this study were done using an open surgical approach, whereas today almost all metabolic and bariatric surgery is done with a laparoscopic approach. Laparoscopy is associated with lower morbidity, mortality, faster recovery, and shorter hospitalization. It is surprising that the transition to laparoscopic surgery did not show an improvement in costs when analyzed as an individual procedure compared to open surgery. Perhaps the double digit inflation of hospital costs over the years of the study may be a factor.

One also might contemplate the fact that an American can fly to some European and Asian countries, have a laparoscopic gastric bypass, stay for 2 weeks of convalescence afterward, and fly home all for less cost than for the hospital bill alone generated by most U.S. hospitals. Why is that? It would appear that even as our bariatric outcomes improve, our way of paying for health care in the United States system does not.

Many insurance companies do not cover bariatric surgery. As the Affordable Care Act is getting underway, it is not clear that even a majority of the states will have metabolic and bariatric surgery as a guaranteed part of the health insurance coverage. Yet scientific evidence shows that bariatric and metabolic surgery improve life expectancy and quality, and improve or put into remission many of the co-morbid medical problems associated with obesity. It does work for to the benefit of individuals.

We need to be asking the correct question about bariatric surgery. This operation may not save money, but it does save lives. So the question asked should not be whether it saves money but why it isn’t routinely covered by insurance plans?

Dr. Schirmer is an ACS Fellow and the Stephen H. Watts Professor of Surgery, University of Virginia Health Sciences Center, Charlottesville.

Bariatric surgery: Asking the right questions