Bariatric surgery causes your body to lose weight by limiting the amount of food your stomach can hold. This weight loss surgery is becoming increasingly common. Our State’s health care leaders and Bree Collaborative members asked us to look into helping to make this surgery safer and more standard across Washington State.

The Centers for Disease Control and Prevention defines obesity as having a body mass index (BMI) of equal to or greater than 30 kg/m2.[1] According to this definition, over one third of adults are obese in the United States. Obesity is associated with increased likelihood of type II diabetes, high blood pressure, high cholesterol, cardiovascular disease, disorders in breathing during sleep, heartburn, and other disorders.[2] Obesity and its consequences are expensive for patients, our country, and the health care system with annual costs approaching $150 billion.[3]

We decided to create a bundled payment model for bariatric surgery, similar to the models that we have created for total knee and total hip replacement, lumbar fusion, and coronary artery bypass surgery. Read more about our previous work and get a sense for what bundled payments look like in our previous blog post Bundling Payments, Improving Care. One of my favorite ways of explaining bundled payments is with this video. Our goal with this workgroup is to provide a community-based standard for bariatric surgery based on available evidence and quality.

Our Accountable Payment Models workgroup is charged with developing bundled payment models and warranties. You can learn more about this workgroup here. Our workgroup starts by looking into how to make sure that bariatric surgery is appropriate for a patient. Like all surgeries, bariatric surgery does have some risks and we want to make sure that a patient has tried traditional weight loss strategies such as diet and exercise, unless there is an immediate need for surgery. This is our first phase of the bundle, called cycle I or “disability despite non-surgical therapy.” We make sure to capture BMI and diagnoses that can happen because of high BMI such as type II diabetes, disorders in breathing during sleep, high blood pressure, and others.  We also want to make sure that a patient will be safe during and after the surgery. This is our second phase of the bundled payment model and will look at important steps like screening for and managing depression, alcohol use, and smoking. We call this cycle II or “fitness for surgery.”

Our workgroup will also look at what makes a good surgery during cycle III and how to take care of patients after surgery during cycle IV. We call this last phase post-operative care and return to function.

We are lucky that our State’s Health Technology Assessment Program has already examined the evidence behind bariatric surgery in their 2015 review. We will be using this document and the 2013 American Heart Association, American College of Cardiology, and Obesity Society’s Guideline for the Management of Overweight and Obesity in Adults as we develop our standards.

Is bariatric surgery important to you? Let us know – email me at or come to our workgroup meeting – we are meeting on Thursday, May 5th from 3:00-4:30 PM at the Foundation for Health Care Quality | 705 Second Avenue, Suite 410 | Seattle, WA 98104.

Ginny Weir, MPH
Bree Collaborative Program Director

Emily Wittenhagen
Bree Collaborative Program Assistant

[1] Centers for Disease Control and Prevention. Defining Adult Overweight and Obesity. Updated: April 2012. Accessed: April 2016. Available here:
[2] Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014 Jun 24;129(25 Suppl 2):S102-38.
[3] Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Aff (Millwood). 2009 Sep-Oct;28(5):w822-31.