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CoE certification

CoE certification does not limit access to surgery

Future studies should determine CMS’ change of policy impacted patient safety without addressing the real cause of limited access to healthcare

Center of Excellence (CoE) certification does not appear to limit access to bariatric surgery, according to a paper ‘Effect of Mandatory Centers of Excellence Designation on Demographic Characteristics of Patients Who Undergo Bariatric Surgery’ published in JAMA. “The CoE requirement limited bariatric surgery to designated locations, which potentially restricted access,” the authors write. “Because only high-volume hospitals could become CoE certified, it was feared that patients with limited resources would have difficulty accessing those hospitals. However, our analysis by income level, as identified by zip code, did not support this notion.”

However, the study authors from the Johns Hopkins School of Public Health, Baltimore, Maryland, and The George Washington University, Washington, DC, added that future studies should determine whether Centers for Medicare & Medicaid Services’ (CMS) change of policy in September 2013 - that removed the mandatory CoE certification for bariatric surgical insurance coverage - might impact patient safety without addressing the real cause of limited access to healthcare.

From February 2006 to September 2013, the CMS required that bariatric surgery should only be performed in hospitals that had been designated as a CoE. As the authors note: “The effect of this certification requirement on access to bariatric surgery has been reported only anecdotally.” Therefore, they decided to investigate whether the CoE certification requirement was a barrier to patients’ access to bariatric surgery.

Using the National Inpatient Sample, they retrospectively identified patients who underwent bariatric surgery from January 2006 to December 2011 and examine differences in patients’ sociodemographic characteristics over time including age, age category, sex, annual income, type of insurance, comorbidity, and race/ethnicity.

A total of 134, 227 bariatric surgical patients were identified and the proportion of the population who were older than 64 years increased from 2.9% in 2006 to 7.0% in 2011 (p<0.001) and there was a decrease in the proportion of patients who were 49 years and younger (p<0.001). The percentage of female patients who underwent bariatric surgery decreased from 80.4% to 78.1% (p<0.001) and the percentage of patients who were classified as black, Hispanic, or Asian or Pacific Islander increased from 12.3% to 15.1% (p<0.001), 9.7% to 12.5% (p<0.001), and 0.3% to 0.4% (p<0.001), respectively. The patient characteristics by year are shown in the Table 1.

Table 1: Patient characteristics by year 2006-2011

The proportion of patients with Medicare increased from 8.5% to 16.3% (p<0.001) and those with Medicaid from 6.6% to 11.8% (p<0.001). The percentage of patients with private insurance declined from 72.4% to 63.3% (p<0.001). The proportion of patients in the lowest income quartile increased from 20.7% to 22.9% (p<0.001) while those in the highest income quartile decreased from 25.8% to 23.9% (p<0.001).

“Our findings do not support the hypothesis that the National Coverage Determination (NCD) policy restricting patients who underwent bariatric surgery to CoE facilities reduced access to care or increased disparities”, they conclude. “Indeed, the decision by CMS to revoke the CoE restriction, based largely on anecdote, may have produced unintended harms by decreasing the importance of CoE standards. Future studies are needed to clarify the precise effect of the NCD on quality and access to care for patients who undergo bariatric surgery.”

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