• Junun Bae, Jaime Shade, Amanda Abraham, Brianna Abraham, Leigh Peterson, Eric B Schneider, Thomas H Magnuson, Michael A Schweitzer, and Kimberly E Steele.
• Department of International Health, The Johns Hopkins School of Public Health, Baltimore, Maryland2Department of Biochemistry & Molecular Biology, The Johns Hopkins School of Public Health, Baltimore, Maryland.
• JAMA Surg. 2015 Jul 1;150(7):644-8.

ImportanceFrom February 21, 2006, through September 24, 2013, the Centers for Medicare & Medicaid Services (CMS) required, via the National Coverage Determination manual, that bariatric surgery be performed only in hospitals that had been designated as a Center of Excellence (COE). The effect of this certification requirement on access to bariatric surgery has been reported only anecdotally.ObjectiveTo investigate whether the COE certification requirement proved to be a barrier to patients' access to bariatric surgical procedures.Design, Setting, And ParticipantsUsing the National Inpatient Sample, we retrospectively identified patients who underwent bariatric surgery from January 1, 2006, through December 31, 2011.ExposureBariatric surgery.Main Outcomes And MeasuresLogistic regression and χ² tests were used to examine differences in patients' sociodemographic characteristics over time.ResultsA total of 134,227 bariatric surgical patients were identified. The proportion of the population who were older than 64 years increased from 2.9% in 2006 to 7.0% in 2011 (P < .001) and there was a decrease in the proportion of patients who were 49 years and younger (P < .001). The percentage of female patients who underwent bariatric surgery decreased from 80.4% to 78.1% (P < .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 < .001), 9.7% to 12.5% (P < .001), and 0.3% to 0.4% (P < .001), respectively. The proportion of patients with Medicare increased from 8.5% to 16.3% (P < .001) and those with Medicaid from 6.6% to 11.8% (P < .001). The percentage of patients with private insurance declined from 72.4% to 63.3% (P < .001). The proportion of patients in the lowest income quartile increased from 20.7% to 22.9% (P < .001) while those in the highest income quartile decreased from 25.8% to 23.9% (P < .001).Conclusions And RelevanceThe COE certification requirement by CMS did not appear to limit access to bariatric surgery. Future studies should determine whether CMS's recent (2013) change in policy (ie, removing the mandatory COE certification for bariatric surgical insurance coverage) might sacrifice patient safety without addressing the real cause of limited access to health care.

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