Patients and their insurers spent $4.3 billion last year for 171,000 bariatric surgeries at an average of $25,000 each, says the American Society for Bariatric Surgery. When you look at those numbers, it might be tempting to think you can rush in and begin hosting bariatric procedures. But the experts we talked to say weight-loss is a program you launch, not a surgery you add, an all-consuming endeavor that requires institution-wide backing and unwavering commitment.

'You can't operate on patients and set them free. You have to have a multidisciplinary, comprehensive approach to their care,' says Jill Meador, RN, BSN, the bariatric coordinator at the Virginia Commonwealth University Medical Center's 28-year-old Obesity Surgery Center.

It takes more than oversized chairs without arms and floor-mounted toilets that can withstand 500-pound patients. A successful surgical weight-loss program requires a skilled and sensitive team to heal body, mind and spirit. It requires a multi-disciplinary team to provide expert care through all stages: a great gastric bypass surgeon and nurse coordinator surrounded by a physician assistant, dietitian, psychiatric counselor, exercise physiologist, billing coordinator (more on her later) and a plastic surgeon (to remove the folds of hanging, drooping skin).

Just as morbidly obese patients who are multi-system diseased must make a lifelong commitment to a lifestyle change and behavior modifications, those who've launched successful programs say you, too, must view bariatrics as a long-lasting enterprise.

'You can't have a trauma surgeon dabbling in bariatric surgery. You can't have your nurse coordinator and surgeon in different offices. You have to be dedicated to it. It has to be all that you do,' says Nova Ebersole, RN, the bariatric program coordinator for Iowa Health-Des Moines, which just restarted its gastric bypass program. The program was suspended for 17 months after seven patients had died after undergoing the surgery at the hospital.

Iowa Health-Des Moines recruited Todd Eibes, MD, FACS, to resuscitate its bariatrics program. Dr. Eibes, who says he has performed 340 of the operations without a single patient death in the past four years, notes that the surgery itself is a midpoint between months of preparing the patient for surgery and years of following him afterward.

Due to the demand for weight-loss surgery, it's not uncommon, for example, for patients to have to endure a six-month wait for an initial consult, a three-month tug-of-war with their insurer and then another three-month wait for surgery. A year later, the patient might need body-contouring surgery. Five years later, the patient might present with a bowel obstruction. When Dr. Eibes speaks of the continuum of care, that bariatrics isn't something you jump into or dabble in, this is what he means.

'Patients have this new routing of their bowels for the rest of their lives,' he says. 'It's not like patients are cured a year later and you never see them again. You follow patients forever. You have to be prepared for that. Comprehensive centers follow patients indefinitely to ensure that they're maintaining long-term compliance with their programs.'

By the time they've called to schedule a consult, many patients likely have made up their minds to undergo the risky surgery. Still, Ms. Meador calls the built-in waiting time valuable. 'It allows them time to change their eating habits, consider risks and prepare for post-op recovery,' she says. 'They've been obese their whole lives and now they're ready to be skinny. But it took time to get to that point. And it takes time to get their solution.'

Clearing the insurance hurdle
Speaking of time, you'll need plenty of it to tussle with insurers, many of which require anyone seeking bariatric surgery to undergo a lengthy regimen of dieting, exercise and psychological counseling before getting coverage. For example, some insurers require proof of 12 consecutive months of dieting, says Ms. Meador. 'The problem with that,' she says, 'is that the scientific literature shows [dieting] programs aren't effective in the long run. But until insurance companies catch up, we're in a bit of a quandary.'

At Iowa Health-Des Moines, where the wait for insurance approvals is between six and eight weeks, the aim is 'to prove to the insurer that the patient needs the surgery' and to pre-certify the patient, says Ms. Ebersole. How to make that happen? The payer receives notes from the patient's family physician documenting different weight-loss attempts and physician-supervised diets, Dr. Eibes's consultation, the dietician's consultation and the psychiatric evaluation that says the patient doesn't have an eating disorder and is willing and able to follow instruction and make lifestyle changes.

'With this type of elective surgery, insurance is a huge piece. If you can't get [patients] verified for surgery even though you've worked them up clinically, you have nowhere to go with them,' says Janet Carlo, RN, BSN, the bariatric program manager at the Sacred Heart Institute for Surgical Weight Loss in Pensacola, Fla. For most patients, self-payment is prohibitive. At Sacred Heart, which began performing surgeries and admitting patients to a new nine-bed bariatric surgery unit in September, laparoscopic adjustable banding is $17,950 and Roux-en-Y gastric bypass is $26,650

In addition to having to meet strict requirements, patient eligibility varies by plan. 'It can be difficult - 10 different companies can have 10 different criteria,' says Dr. Eibes, whose backlog of patients waiting for insurance approvals stands at about 40. 'Some companies approve the surgery right away. Some won't approve any bariatric surgery at all.'

'Sometimes we tell patients to call the customer service number on the back of their insurance cards and ask if they have benefits for weight-loss surgery,' says Ms. Carlo, who developed an interest in bariatric surgery after undergoing the Roux-en-Y gastric bypass in 1998. 'If they do, they can call us back.'

At the Memorial Medical Center in Springfield, Ill., an insurance coordinator meets with every patient. 'Her job is to understand the patient's insurance plan and coverage. By the time the patient presents for surgery, we know whether the surgery is covered and what the co-pay [from $100 to $3,000] is,' says Rebecca Anderson, PhD, a clinical psychologist and the bariatric surgery program coordinator.

Health plans are scrambling to set up networks of experienced doctors and hospitals with high standards and good results, refusing to pay for the surgery unless it's performed at an American College of Surgeons or ASBS Center of Excellence (see 'Medicare to Cover Obesity Surgery' on page 31) Deborah Cox, RN, chair of the allied health sciences division of the ASBS, asks why insurers are pulling back coverage when evidence suggests bariatric surgery cures diabetes in 90 percent of cases and significantly resolves such conditions as sleep apnea, asthma, cardiac disease and arthritis.

'People classify this as elective surgery, but people are slowly dying from their obesity,' she says. 'Over the next five years, how many patients are going to die if you deny them surgery?'

Laying the groundwork
Perhaps more so than other specialties, a bariatric program requires a tremendous amount of planning before you make the first cut.

'Set up the program to be as close to perfect as you can before you start,' says Ms. Meador.

'The worst thing that can happen is you say, ?We'll add that in later.' That's the time something can happen,' adds Ms. Cox, the manager for outpatient services and bariatric coordinator for North Ridge Medical Center in Fort Lauderdale, Fla.

Here are some pieces you should have in place before you begin seeing patients.

• A great surgeon. Don't start a bariatric surgery program until you've recruited a surgeon who has extensive training, expertise and a proven track record in weight-loss surgery, say experts. 'It's very important to bring in a highly trained surgeon with tremendous experience in the laparoscopic approaches to weight-loss surgery,' says Paul Baroco, MD, chief medical officer for Sacred Heart Health System. Laparoscopic surgery for obesity is one of the most difficult surgeries to perform, say experts.
• A structured program. Upon referral, Iowa Health-Des Moines patients are scheduled for an educational class at the bariatric office, which the nurse coordinator, dietitian, psychiatric counselor and surgeon teach. All patients receive at least one year of dietary and psychiatric counseling, an exercise program ('these patients don't know how to exercise,' says Ms. Ebersole) and a monthly support group (open to patients and their relatives). The program follows patients indefinitely for post-bariatric surgery issues such as vitamin deficiencies, exercise guidelines and reconstructive surgery. Dietary meetings at the Sacred Heart Institute for Surgical Weight Loss engage patients via nutritional trivia games.
• A great coordinator. Hire somebody who's empathetic as well as energetic to run the program, says Ms. Meador - preferably, she adds, a nurse who's good at patient relations and can lead.

• A great team. Here's Dr. Anderson's message to surgical coordinators: This is a hospital-wide endeavor. You are not the expert. 'Your job is to be the coordinator. Make sure all the pieces are in place. Get investments and interest from your departments and delegate to them. If you can bring people in and get them excited about bariatric surgery - which is a task, because there's a lot of uneasiness and trepidation about doing bariatric surgery - let them be a part of your team and help you problem-solve,' she says. Form a multidisciplinary task force, a group of leaders representing engineering, finance, public relations, nursing, psychology, physical therapy, anesthesiology and OR leadership. Ask these leaders what they'll need to set up and run a bariatric surgery program, says Dr. Anderson.
• A bariatric?friendly environment. Several companies specialize in extra-long laparoscopes, bariatric seating, OR tables, stretchers and beds, but a bariatric-friendly environment means more than extra-large wheelchairs, gowns and blood-pressure cuffs. It means being sensitive to the emotional needs of bariatric patients. 'You can't have a radiology transporter commenting, ?I guess I should have brought the fat wheelchair,'' says Ms. Meador. 'The patients have faced discrimination their whole lives. The hospital's not the place to find it,' adds Ms. Cox. 'From X-ray to admitting to med surg, each specialty area must understand the needs of the bariatric patient. ? It's a very unique patient population. You need to look at what they need to feel supported, safe and cared for.'
• A limit to what you'll do. Start with a moratorium on higher weights, says Ms. Cox. 'If you've never done bariatric surgery, it doesn't make sense to start with 800-pound patients. Start with 350-pound patients. Do a few, work out the glitches and then add heavier patients,' she says. Iowa Health-Des Moines requires patients to have a BMI of at least 40, or at least 35 with co-morbidities such as diabetes, hypertension or sleep apnea.

A lucrative specialty
A bariatrics program can be very profitable, so long as you limit the number of complications. 'If you do 100 surgeries and have 10 complications, that's going to eat up all your profits,' says Dr. Eibes. But profit is not the reason to get into the field. 'You go into it because you want to give good service to a very deserving group of patients,' says Ms. Meador. You may also discover that they're the most educated and grateful patients you'll ever meet, says Ms. Ebersole. 'They've looked into every option before surgery. They know you've saved their lives. Literally.'