The obesity epidemic has recently

Transcription

1 Tr ends Trends Use And Costs Of Bariatric Surgery And Prescription Weight-Loss Medications Treatment for obesity has skyrocketed since 1998, but coverage policies remain uneven across insurers. by William E. Encinosa, Didem M. Bernard, Claudia A. Steiner, and Chi-Chang Chen ABSTRACT: The extent of use of bariatric surgery and weight-loss medications is unknown. Using the Nationwide Inpatient Sample, we estimate that the number of bariatric surgeries grew 400 percent between 1998 and 2002; such surgeries were performed on 0.6 percent of the 11.5 million adults clinically eligible in Hospital costs for bariatric surgery grew sixfold to $948 million in The inpatient death rate declined 64 percent. Among employers that covered weight-loss drugs in 2002, less than 2.4 percent of adults clinically eligible for these drugs used them, with average annual spending of $304 per user. The obesity epidemic has recently been brought to the forefront of the national consciousness. As a result, much attention is now drawn to two medical treatments for obesity: bariatric surgery and bariatric pharmacotherapy. Bariatric surgery, one of the fastest-growing surgical procedures in the United States, involves restricting the size of the stomach and bypassing part of the intestines to reduce the absorption of food. Bariatric pharmacotherapy involves prescription weight-loss medications that either reduce the absorption of fat or suppress the appetite. Xenical (orlistat), a drug that blocks about one-third of ingested fat, was the third most heavily advertised drug in 1999: $76 million was spent on advertising it to consumers. 1 There are about twenty-two new anti-obesity drug compounds in the pharmaceutical pipeline, with two currently in Phase III development. 2 These bariatric treatments have substantial health benefits. A recent meta-analysis found that the percentage of excess weight loss was percent with gastric bypass, the most common bariatric surgery. As a result, diabetes was completely resolved in 76.8 percent of patients. 3 Another recent study found that gastric bypass patients had an 89 percent reduced relative risk of death. 4 Although bariatric surgery is recommended only for morbidly obese persons with a body mass index (BMI) of 40 or more, bariatric drug therapy is recommended for obese people with a BMI of 30 or more. 5 Arecent meta-analysis found that bariatric medications result in a net weight loss of fewer than ten pounds (over the placebo weight loss) at William Encinosa (wencinos@ahrq.gov) is a senior economist in the Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, in Rockville, Maryland; Claudia Steiner is a senior research physician there. Didem Bernard is a senior economist in the AHRQ Center for Financing, Access, and Cost Trends. Chi-Chang Chen is a postdoctoral fellow at the University of Maryland School of Pharmacy in Baltimore. HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r DOI /hlthaff Project HOPEThe People-to-People Health Foundation, Inc.

2 Health Tracking one year, but this amount may still be clinically significant in reducing diabetes and high blood pressure. 6 There are no national estimates of the use and costs of bariatric surgery and weight-loss prescription drugs. In this paper we address this data gap using national hospital and insurance claims data. Study Data And Methods Our first data source was the Nationwide InpatientSample(NIS)oftheHealthcareCost and Utilization Project (HCUP) for 1998 and The NIS is a nationally representative inpatient care database containing data from about 1,000 hospitals sampled to approximate a 20 percent stratified sample of U.S. community hospitals. charges reported in the NIS are used with hospital-specific cost-tocharge ratios to estimate hospital costs for bariatric surgeries. 8 Our second source of data was the Medstat 2002 MarketScan Commercial Claims and Encounter Database, which contains claims for inpatient care, outpatient care, and prescription drugs for enrollees under age sixty-five in the employer-sponsored benefit plans of fortyfive large employers across the country. The MarketScan data include 5.6 million people a 3 percent sample of Americans with employer-sponsored health insurance coverage (5.1 million of these have drug coverage). First, we used the NIS and the Medstat data to examine the use and costs of bariatric surgery. Next, we used the Medstat data to study use of and spending for prescription weight-loss medications. Study Results Bariatric surgery: use and costs. Exhibit 1 presents national estimates for use, total hospital costs, and cost per surgery by payer based on the NIS data. The total number of surgeries more than quadrupled, from an estimated 13,386 in 1998 to 71,733 in In 2002, privately insured patients accounted for EXHIBIT 1 National Estimates Of Bariatric Surgery Use And Costs, By Payer, 1998 And 2002 Payer/use and cost measure Percent change, Number of surgeries Private Medicare Medicaid Self-pay Other 13,386 (2,021) 10,167 (1,528) 1,106 (209) 940 (218) 704 (197) 469 (192) 71,733 (8,704) 59,497 (7,284) 4,261 (537) 3,463 (615) 2,479 (704) 2,033 (544) Hospital costs (millions) Private Medicare Medicaid Self-pay $157 (24) 117 (18) 15 (3) 12 (3) 8 (2) $948 (120) 777 (102) 67 (9) 52 (13) 25 (5) Mean cost per surgery All payers Private Medicare Medicaid Self-pay $11,705 (578) 11,494 (614) 13,865 (1,069) 12,785 (1,611) 10,866 (1,228) $13,215 (728) 13,048 (738) 15,903 (1,073) 15,051 (2,581) 9,828 (1,097) SOURCE: Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), 1998 and NOTES: All costs are in 2002 dollars and include inpatient costs only. Standard errors are in parentheses July/August 2005

3 Tr ends 83 percent of surgeries, while Medicare, Medicaid, and self-pay accounted for 6, 5, and 3 percent, respectively. The remaining 3 percent were paid for by other government sources, a military plan for civilians, and charity. National hospital costs for bariatric surgeries increased more than sixfold, from an estimated $157 million in 1998 to $948 million in 2002, in constant 2002 dollars. 9 Mean cost per surgery increased 12.9 percent, from $11,705 in 1998 to $13,215 in The largest increase in average costs was for Medicaid-covered surgeries,withanincreaseof17.7percent,despite a decline in length-of-stay from 5.8 days to 4.9 days (data not shown). Exhibit 2 presents national estimates of the number of surgeries, lengths-of-stay, and inpatient death rates, by age and sex. Focusing on 2002, patients ages 1854 accounted for 88 percent of all surgeries, while the near-elderly (ages 5564) accounted for 11 percent. Adolescents and the elderly accounted for the remaining 1 percent. 10 The fastest growth in bariatric surgeries between 1998 and 2002 a tenfold increase occurred among the nearelderly. Overall, lengths-of-stay declined 24 percent for all surgeries, and the inpatient death rate declined 64 percent (Exhibit 2). Both length-of-stay and mortality generally increased with age. Womenweremorelikelythanmentoundergo bariatric surgery in both years. In 2002 women accounted for 84 percent of all surgeries. However, both lengths-of-stay and inpatient death rates were higher among men. Although the inpatient death rate for men declined greatly between 1998 and 2002, it was still three times higher than the rate among women. Based on national estimates of surgeries for 2002,wenextestimatedtheprevalenceofbariatric surgery among those who were clinically eligible. 11 Using the clinical guidelines describedabove,weestimatedthattherewereat least 11.5 million adults eligible for bariatric surgery in Adjusting for multiple surgeries per patient, we estimated that there were a total of 70,124 adult bariatric patients in Thus, of the 11.5 million adults who were clinically eligible for the surgery, only 0.6 percent received the surgery in Bariatric surgery prices. Exhibit 3 presents use and spending by type of surgery, using the 2002 Medstat employer data. While Exhibit 2 presents hospital costs, Exhibit 3 EXHIBIT 2 National Estimates Of Bariatric Surgery Use And Outcomes, By Age And Sex, 1998 And 2002 Number of surgeries Length-of-stay (days) Inpatient death rate (percent) Age (years) Sex Male Female ,336 (636) 4,825 (638) 3,320 (472) 772 (114) 2,527 (365) 10,859 (1,650) 178 (31) 19,554 (2,202) 23,404 (2,667) 20,264 (2,124) 7,719 (941) 615 (107) 11,289 (1,530) 60,444 (6,976) 4.4 (0.2) 4.9 (0.2) 5.6 (0.3) 5.7 (0.5) 5.9 (0.3) 4.8 (0.2) 3.5 (0.3) 3.4 (0.1) 3.6 (0.1) 4.1 (0.2) 4.3 (0.2) 6.1 (1.1) 4.0 (0.2) 3.8 (0.1) 0.47 (0.21) 1.10 (0.40) 0.91 (0.38) 0.00 (0.00) 2.76 (0.65) 0.46 (0.15) 0.00 (0.00) 0.05 (0.04) 0.23 (0.07) 0.43 (0.11) 0.93 (0.26) 1.71 (1.23) 0.79 (0.18) 0.24 (0.05) 13,386 (2,021) 71,733 (8,704) 4.99 (0.21) 3.80 (0.13) 0.89 (0.20) 0.32 (0.05) SOURCE: Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), 1998 and NOTES: Standard errors are in parentheses. The number of surgeries in age groups 1217 and 65+ for 1998 is too small to provide a reliable estimate. HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r

4 Health Tracking EXHIBIT 3 Average Bariatric Surgery Spending In A Sample Of Large Employers, 2002 Average payments ($) Type of surgery Number of surgeries Hospital Physician Out of pocket Health plan Banding and gastroplasty without bypass Gastric bypass: Roux-en-Y Other gastric bypass Revision only Non-laparoscopic Laparoscopic Without revision With revision 117 2, ,988 15,704 19,375 19,914 22,387 19,346 13,320 16,781 16,566 19,293 16,679 2,385 2,595 3,348 3,094 2, ,032 18,733 19,310 21,967 18,710 2, ,988 19,623 17,608 19,346 16,977 14,813 16,679 2,646 2,795 2, , ,047 16,600 18,710 2, ,988 19,031 26,105 19,346 16,378 23,134 16,679 2,653 2,970 2, ,408 25,203 18,710 SOURCE: Medstat, MarketScan 2002 (5.6 million nonelderly covered lives in employer-sponsored health plans). NOTES: Other gastric bypass includes long limb bypass and bilopancreatic diversion. All payments are for inpatient hospital care. presents the prices actually transacted. In 2002theaveragepriceforasurgicalprocedure was $19,346. Physician payments accounted for 14 percent ($2,667), while hospital payments accounted for 86 percent ($16,679) of total payments. 14 On average, patients paid 3.3 percent of expenditures in the form of copayments or deductibles, and health plans paid the remainder. Detailed information in the Medstat data (CPT-4 codes for procedures) enabled us to examine use and spending by type of bariatric surgery. Exhibit 3 groups the surgeries into four types. The first type (gastric banding and gastroplasty without bypass) simply reduces the size of the stomach, either by stapling the stomach (gastroplasty) or by placing a tight band around the stomach. The second type (Roux-en-Y gastric bypass) includes a reduction in the size of the stomach and a bypassing of part of the intestines to reduce the absorption of food. The third type (other gastric bypass) is a more advanced technique in which longer lengths of the intestine are bypassed under bilopancreatic diversion or duodenal switch gastric bypass. 15 Thefourthtypeofsurgery (revision only) is a follow-up surgery that may involve readjusting the band, revising the surgical joining of the bypass, or dealing with a complication. The less intensive banding, or gastroplasty without gastric bypass, accounted for 4 percent of surgeries, while Roux-en-Y gastric bypasses accounted for 84.7 percent. Other gastric bypasses made up 9.2 percent of surgeries, while revision-only surgeries accounted for the remaining 2 percent. Payments increased as surgeries became more advanced from banding/gastroplasty to Roux-en-Y to other gastric bypass. Also, doctors were paid more as the surgeries became more advanced. We also found that payments varied by the type of health plan. For example, for Roux-en- Y, the average total payment was only $16,222 under capitated health maintenance organizations (HMOs). For fee-for-service plans, point-of-service HMOs, and preferred provider organizations (PPOs), the total payments were $17,749, $20,154, and $21,698, respectively. Length-of-stay was 3.9 days for all health plans. Bariatric surgeries may be conducted in two ways. The non-laparoscopic approach requires the abdomen to be opened, while the laparoscopic method is a less invasive method in which surgeons, guided by a video camera, 1042 July/August 2005

5 Tr ends gain access to the abdomen through several small incisions. Fourteen percent of bariatric surgeries were laparoscopic (94 percent of these laparoscopies occurred in Roux-en-Y bypass). Laparoscopic surgeries were less costly than non-laparoscopic surgeries; however, doctors were paid 6 percent more for laparoscopy (Exhibit 3). Moreover, the patient s out-of-pocket payment was 75 percent higher for laparoscopy. Of all surgeries, 3.8 percent involved a revision; 2 percent had a revision during a followup surgery, and 1.8 percent, during the initial surgery. Surgeries with revisions were 37 percent more costly than surgeries without revisions (Exhibit 3). Prescription weight-loss medications. As of 2002, eight drugs had been approved for weight loss. Of these, sibutramine (Meridia) and orlistat (Xenical) are approved for up to two years of use. 16 The other medications are sympathomimetic amphetaminelike drugs: phentermine, phenylpropanolamine, benzphetamine, phendimetrazine, diethylpropion, and mazindol. 17 These amphetamine-like drugs are labeled for short-term use (up to twelve weeks). 18 Orlistat is a lipase inhibitor, which blocks fat absorption, while the other seven drugs are appetite suppressants. Exhibit 4 presents prescription weight-loss medication use and spending among the 2002 Medstatemployersample.Ofthe5.1million with drug coverage, about 4 million had bariatric drug coverage. Of that 4 million, 21,931 used bariatric prescription drugs. Among the users, 45 percent used orlistat, 30 percent used sibutramine, and 35 percent used sympathomimetics (10 percent used multiple drugs). Close to 71 percent of the sympathomimetic prescriptions were for phentermine. Although orlistat and sibutramine are recommended for long-term use (up to two years), the average number of days of medication supplied per patient per year was 110 days for orlistat and 102 days for sibutramine. This may suggest that the discomfort of side effects reduces adherence. 19 The average number of days of medication supplied per patient per year was 111 days for sympathomimetics. The average total supply of drugs per patient per year was 118 days, which reflects the fact that 10 percent of patients in the data took multiple weight-loss medications. Patients spent an average of $304 each for weight-loss medications each year; patients paid 26 percent of this amount, and health plans, 74 percent. This annual total payment per person increased with age, from $192 per person for ages 817 to $361 for ages Although only 22 percent of users were men, EXHIBIT 4 Average Spending For Prescription Weight-Loss Medications In A Sample Of Large Employers, 2002 Type of drug Number of patients Average number of days supplied per patient Average annual payment per patient ($) Out of pocket Health plan Lipase inhibitor Orlistat 9, Appetite suppressants Sibutramine Sympathomimetics 6,376 7, , SOURCE: Medstat, MarketScan 2002 drug file (5.1 million nonelderly covered lives in employer-sponsored health plans with drug coverage). NOTES: Number of patients and days supplied do not add up to the total since 10 percent of patients took more than one type of drug. Sibutramine is a long-term appetite suppressant. Sympathomimetics are short-term appetite suppressants that include phenylpropanolamine, phentermine, benzphetamine, diethylpropion, mazindol, and phendimetrazine HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r

6 Health Tracking men spent more on average on the drugs than women ($327 versus $297), because men used these drugs longer than women (122 days versus 117 days per year) and because a greater proportion of men than women used the most costly drug, orlistat (44 percent versus 36 percent) (data not shown). Finally, we estimated the prevalence of bariatric medicine use among obese adults with employer coverage for the drugs. From our 2002 MarketScan sample, we estimated that 918,000 nonelderly adults with bariatric drug coverage were clinically eligible to use bariatric prescription drugs. 20 However, only 21,797 (2.4 percent) of these adults took bariatric medications. Discussion And Policy Implications As bariatric surgeons perform more surgeries and outcomes continue to improve, it is likely that more people will opt for the surgery. This potential demand may be quite large since the number of bariatric surgeries has grown 400 percent in just five years. This growth will likely continue, given that only 0.6 percent of the 11.5 million eligible people underwent the surgery in Use of weight-loss medications declined in 1997 with the removal of fenfluramine and dexfenfluramine from the market (because of heartvalueabnormalities),butitpickedup againin1999,whenorlistatenteredthemarket. 22 The industry reports that total U.S. sales for weight-loss medications in 2002 were $362 million. 23 In 2002 an estimated 63.3 million U.S. adults were clinically eligible for weightloss medications but these drugs were used by less than 2.4 percent of those eligible. Thus, usage could greatly increase, given that many new, more effective prescription weight-loss medications are being developed. 24 Some of the new drugs in the pipeline, such as rimonabant (Acomplia), will block a pathway in the brain that produces the craving for food. In recent trials of rimonabant, 44 percent of subjects If Medicare decides to expand coverage for bariatric surgery in the near future, the potential demand by the elderly may be quite large. lost more than 10 percent of body weight at one year compared with 10 percent of subjects taking placebo. 25 Other new drugs will block the hormone ghrelin, which is sent from the stomach to the brain to create an appetite. 26 Some drugs will instead stimulate beta 3 receptors to increase fat burning within the body. 27 These new medications will likely increase the demand for weight-loss drug therapy. For the elderly, the Medicare program covers bariatric surgery only for those patients with coexisting conditions such as diabetes. 28 Therateofincreasein bariatric surgery between 1998 and 2002 was highest among the near-elderly (ages 5564), at 900 percent. An estimated 395,000 elderly people (ages 6569) will be clinically eligible for bariatric surgery in By 2010 this number could grow to 475,000. Thus, if Medicare decides to expand coverage for bariatric surgery in the near future, the potential demand by the elderly may be quite large. Bariatric drugs are not included in the final version of U.S. Pharmacopeial Convention (USP) Model Guidelines created under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of The act excludes agents used for weight loss. However, according to the final rules recently released by the Centers for Medicare and Medicaid Services (CMS), bariatric drugs can be covered by Medicare Part D if they are prescribed for a medically accepted indication such as morbid obesity. Thus, it is not yet clear to what extent the 500 potential drug plans in Medicare Part D will choose to include bariatric medications on their formularies. We estimate that about 3.3 million Medicare beneficiaries ages 6569 will be clinically eligible for bariatric drugs in Our results show a clear difference between the sexes in the use of bariatric treatments. We estimated that 43 percent of the adults clinically eligible for drug therapy in 2002 were men; however, only 22 percent of 1044 July/August 2005

7 Tr ends adults taking bariatric prescription drugs were men. In contrast, while 57 percent of those clinically eligible were women, women accounted for 78 percent of drug users. Also, 31 percent of adults eligible for bariatric surgery in 2002 were men, but only 16 percent of procedures among adults were performed on men. 31 In contrast, while 69 percent of those eligible for surgery were women, women accounted for 84 percent of the surgeries. Moreover, men had worse in-hospital mortality rates than the women in their same age group. The higher inpatient mortality for men is consistent with higher coexisting illnesses or higher BMI at the time of surgery. 32 This research was funded by the Agency for Healthcare Research and Quality (AHRQ). The views herein do not necessarily reflect the views or policies of AHRQ, or the U.S. Department of Health and Human Services. The authors thank the thirty-five data organizations in states that contributed data to the Nationwide Inpatient Sample. They also thank the editors, two anonymous reviewers, and Scott Smith for their insightful comments. NOTES 1. L. Bymark and R. Waite, Prescription Drug Use and Expenditures in California: Key Trends and Drivers (Oakland: California HealthCare Foundation, 2001). 2. Datamonitor, Commercial and Pipeline Perspectives: Obesity (London: Datamonitor, June 2004). 3. H. Buchwald et al., Bariatric Surgery: A Systematic Review and Meta-Analysis, Journal of the American Medical Association 292, no. 14 (2004): N.V. Christou et al., Surgery Decreases Long- Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients, Annals of Surgery 240, no. 3 (2004): Bariatric surgery is also recommended for a BMI of 35 or more with serious medical conditions (such as severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, or diabetes mellitus). Bariatric drug therapy is also recommended for a BMI of 27 or more with two or more comorbidities (such as hypertension, diabetes, or hyperlipidemia). 6. P. Shekelle et al., Pharmacological and Surgical Treatment of Obesity, Evidence Report/Technical Assessment no. 103, Prepared by the Southern California-RAND Evidence-based Practice Center, Santa Monica, Calif., under Contract no , Pub. no. 04-E028-2 (Rockville, Md.: Agency for Healthcare Research and Quality, July 2004). 7. Healthcare Cost and Utilization Project, Databases, October 2003, databases.jsp (11 April 2005). 8. Cost-to-charge ratios are obtained from standard accounting files at the Centers for Medicare and Medicaid Services. For the estimation of costs in HCUP, see B. Friedman et al., Practical Options for Estimating Cost of Hospital Inpatient Stays, Journal of Health Care Finance 29, no. 1 (2002): We used the Consumer Price Index for all urban consumers (CPI-U). 10. In fact, patients age sixty-five and older accounted for only 14 percent of Medicare bariatric surgeries in 2002 presented in Exhibit 1 (compared with 7 percent in 1998). Thus, patients under age sixty-five accounted for 86 percent of the surgeries covered by Medicare in 2002 (through the Medicare disability insurance program). 11. We did not include adolescents, since surgery is recommended for only a small subgroup: those at least age fifteen with a BMI of 50 or higher. See T.H. Inge et al., Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations, Pediatrics 114, no. 1 (2004): Of these adults, 10.6 million have a BMI of 40 or more. About 868,000 have a BMI between 35 and 40 with diabetes, the most common comorbidity that makes this group eligible for surgery. This is based on 2002 obesity rates for adults reported in A.A. Hedley et al., Prevalence of Overweight and Obesity among U.S. Children, Adolescents, and Adults, , Journal of the American Medical Association 291, no. 23 (2004): Diabetes rates among the obese can be found in A.H. Mokdad et al., Prevalence of Obesity, Diabetes, and Obesity-related Health Risk Factors, 2001, Journal of the American Medical Association 289, no. 1 (2003): In the Medstat data presented in Exhibit 3, 2 percent of bariatric surgeries were follow-up surgeries. We applied this rate to bariatric surgeries for the national population presented in Exhibit The hospital prices in Exhibit 3 are for large employers, which tend to have generous benefits, while the cost estimates presented in Exhibit 1 are representative of the U.S. privately insured population as a whole. Therefore, we caution the reader against making direct comparisons of prices and costs across these exhibits. 15. R.E. Brolin, Bariatric Surgery and Long-Term Control of Morbid Obesity, Journal of the American Medical Association 288, no. 22 (2002): ; HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r

8 Health Tracking and R. Steinbrook, Surgery for Severe Obesity, New England Journal of Medicine 350, no. 11 (2004): American Society of Health-System Pharmacists, AHFS Drug Information (Bethesda, Md.: ASHSP, 2004). 17. In November 2000, the FDA requested that phenylpropanolamine be removed voluntarily from the market. In our 2002 data, only 2 percent of bariatric drug claims were for this drug. 18. Mosby, Mosby sdrugconsult,14thed.(st. Louis, Mo.: Mosby Inc., 2004). 19. Orlistat is recommended for one year, with treatment continued after one year if the patient tolerates the drug well and sustained weight loss is documented. D.C. Dale and D.D. Federman, eds., ACP Medicine (Danbury, Conn.: American College of Physicians, 2005). In a 104-week clinical trial, 12.9 percent of patients on orlistat dropped out of the study because of adverse effects and treatment failure. See J. Hauptman et al., Orlistat in the Long-Term Treatment of Obesity in Primary Care Settings, Archives of Family Medicine 9, no. 2 (2000): This is based on a 30.6 percent obesity rate among adults in 2002, reported in Hedley et al., Prevalence of Overweight and Obesity. 21. This growth trend may be dampened by recent health plan decisions to drop coverage for bariatric surgery. Blue Cross and Blue Shield of Florida and Nebraska have recently dropped coverage. See R. Stein, As Obesity Surgeries Soar,SoDoSafety,CostConcerns, Washington Post, 11 April Some health plans are instead carving out bariatric coverage as an optional benefit. Blue Cross and Blue Shield of North Carolina introduced a new benefit, Healthy Lifestyle Choices, designed specifically to deal with bariatric treatments. See B. McKay, Blue Cross of North Carolina to Cover Cost of Treating Obesity, Wall Street Journal, 13 October R.S. Stafford and D.C. Radley, National Trends in Antiobesity Medication Use, Archives of Internal Medicine 163, no. 9 (2003): Datamonitor, Commercial and Pipeline Perspectives: Obesity. 24. See J. Korner and L.J. Aronne, Pharmacological Approaches to Weight Reduction: Therapeutic Targets, Journal of Clinical Endocrinology and Metabolism 89, no. 6 (2004): ; J. Proietto et al., Novel Anti-Obesity Drugs, Expert Opinion on Investigational Drugs 9, no. 6 (2000): ; and H. Bays and C. Dujovne, Anti-Obesity Drug Development, Expert Opinion on Investigational Drugs 11, no. 9 (2002): Korner and Aronne, Pharmacological Approaches. 26. Bays and Dujovne, Anti-Obesity Drug Development. 27. S. Vansal, Beta-3 Receptor Agonists and Other Potential Anti-Obesity Agents, American Journal of Pharmaceutical Education 68, no. 3 (2004): Centers for Medicare and Medicaid Services, National Coverage Decision 40.5: Treatment of Obesity, 1 October 2004, mcd/m_ncd.asp?id=40.5&ver=2 (11 April 2005). For tracking CMS updates to its bariatric surgery coverage, see viewncd.asp?ncd_id=100.1&ncd_version=1& basket=ncd%3a100%2e1%3agastric+bypass+ Surgery+for+Obesity (11 May 2005). In 2004 the CMS removed the language obesity itself cannot be considered an illness from its manual. In late 2004 the CMS gathered the scientific evidence on bariatric surgery. Its next step is to decide whether to expand coverage for bariatric surgery to all morbidly obese elderly people, not just those with comorbidities. 29. This is based on a 3.9 percent morbid obesity rate for adults age sixty or older, reported in Hedley et al., Prevalence of Overweight and Obesity. 30. This is based on a 32.9 percent obesity rate among adults age sixty or older, reported in ibid. 31. This is based on obesity rate estimates by sex in K.M. Flegal et al., Prevalence and Trends in Obesity among U.S. Adults, , Journal of the American Medical Association 288, no. 14 (2002): E.E. Mason, K.E. Renquist, and D. Jiang, Perioperative Risks and Safety of Surgery for Severe Obesity, American Journal of Clinical Nutrition 55, no. 2 Supp. (1992): 573S576S July/August 2005