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Governmental or Social Support of Bariatric Surgery in the Asia-Pacific Region

Herein we review the management status of governmental financial support of bariatric surgeries in several Asia-Pacific areas of Japan, Singapore, and Australia, which were discussed in the 2016 International Congress on Obesity and Metabolic Syndrome (ICOMES). Patient’s body mass index criteria of bariatric surgery for public support are different one another in the three countries. Whereas laparoscopic sleeve gastrectomy (LSG), Roux-en Y gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) are applicable in both Singapore and Australia, the coverage of insurance is limited to LSG in Japan. In addition, the surgical fees and equipment costs are not fully covered by public health insurance for performing sleeve gastrectomy in Japan, but patients with morbid obesity can still use public health insurance. In Singapore, the waiting time for surgery in public hospitals is longer on average than for private hospitals. However, patients can obtain subsidies of up to 80% of the costs of surgery in public hospitals, while particularly needy patients may even be able to obtain completely free bariatric surgery through Medifund. In Australia, bariatric surgeries in public sectors are publicly funded, but most bariatric surgeries occur in the private sector and Medicare only reimburses surgical costs in the private sector. Although certain characteristics need to be improved, the access to bariatric surgery has shown steady progress through public support in each of these countries.


INTRODUCTION
Nowadays, bariatric surgery is of great clinical importance in Korea. The prevalence of morbid obesity has markedly increased from 2002 to 2013, especially in young adults in their thirties and forties.

Health insurance coverage for bariatric surgery in Japan
There are two types of public health insurance in Japan. 4 One is Social Insurance (or Employee's Health Insurance), which is used by individuals working for a company. The other is National Health Insurance, which is used by those who are not covered by Social Insurance. With support from these two public health insurances, almost all residents in Japan receive a high level of medical services.
In 2016, laparoscopic sleeve gastrectomy (LSG) was the only bariatric surgery procedure that was financially supported by health insurance. Generally speaking for insurance coverage, any given medical treatment should be approved by the national council. In the case of an approved treatment, patients are supposed to pay 30% of the medical fees when they are treated. Newly developed medical technologies should be approved by the Advanced Medical Technology System in place in Japan in order to be covered by insurance. 5 In 2010, LSG was approved by Advanced Medical Technology, and after that, LSG was listed as being covered by public health insurance in 2014, which contributed to the increased number of LSG surgeries in Japan. However, other bariatric surgery methods have not been approved nor covered by health insurance.
Bypass surgeries are not covered by public health insurance, but they can be performed in some private hospitals.
Even though the number of facilities performing bariatric surgery has increased, the accessibility was still not good enough in 2016 in Japan. At present, there are only twenty facilities performing bariatric surgery. The number of bariatric surgeries performed in 2015 was 258. There are several reasons why the numbers of facilities performing bariatric surgery and of bariatric surgeries themselves did not increase under public health insurance coverage. First, the amount of money available through health insurance is not enough to perform LSG surgeries. Although the surgical fees were paid, the costs of surgical equipment, trocars, and staplers were not covered by public health insurance. Therefore, LSG resulted in a deficit for many hospitals when such surgeries were performed. In 2016, the surgical fees increased and five staplers were covered for LSG by insurance. Second, the criteria for facility approval are very strict. The criteria include: that the number of laparoscopic gastric surgeries should be more than 20 cases per year; surgeons should have more than five years of experience in general surgery; surgeons should have more than ten cases of experience with LSG as an operator; there should be physicians with more than five years of experience with treatments for diabetes, hypertension and hyperlipidemia; and full-time employed anesthesiologists and registered dietitians are mandatory. Third, the patient selection criteria are also strict. The body mass index (BMI) of patients should be greater than or equal to 35 kg/m 2 with at least one obesity-related comorbidity and the patient should have had an at least six-month medical treatment that did not work. While the Japanese system may guarantee the quality of the surgery, it may also work as a barrier to the bariatric surgeries. In conclusion, LSG is the only procedure covered by the public health insurance, and both the facility approval and the patient selection system are very strict in Japan.

Healthcare system for bariatric surgery in Singapore
Singapore has an efficient healthcare system in which the government ensures affordability through a subsidy system and where bariatric surgery is supported by the system, provided they fulfill certain BMI and comorbidity criteria in the Ministry of Health guidelines on obesity. All the Singaporeans who are treated in public hospitals can obtain healthcare subsidies in Singapore. The criteria for getting bariatric surgery in Singapore are obese patients with a BMI ≥ 37.5 kg/m 2 or a BMI ≥ 32.5 kg/m 2 with medical comorbidities of obesity. This follows the World Health Organization (WHO) expert consultation on BMI in Asian populations, which met in Singapore in 2002. 6 The supported bariatric surgery procedures are laparoscopic adjustable gastric banding (LAGB), Rouxen-Y gastric bypass (RYGB), and sleeve gastrectomy (SG). The public hospitals' ward classes are classified into A, B, and C. 81% of the public hospitals' beds of class B2 (5 or 6-bedded room) and class C (9-bedded room) are heavily subsidized by the remaining 19% with lower subsidies at 20% for class B1 (4-bedded room) and no subsidy for A class wards (single room); note that this is the same for bariatric surgeries as well. In some cases, government subsidies may even cover abdominoplasty after the weight loss induced by bariatric surgery. The waiting time for surgery on a regular weekday operating list is on the order of months at public hospitals.
Although patients at private hospitals receive no subsidies from the In short, bariatric surgery is supported by government subsidies and compulsory savings in public hospitals.

Private and public sectors of the healthcare system for bariatric surgery in Australia
The Australian health care system is composed of private and The patient criteria of bariatric surgery for public supports are somewhat different between each country (Fig. 1). Whereas the main surgical methods in Singapore and Australia are SG, RYGB, and gastric banding, the coverage of insurance is limited to SG in Japan (Fig.   2). In addition, the surgical fees and equipment costs are not fully covered by public health insurance for performing sleeve gastrectomy, and the facility criteria and patient criteria are also somewhat strict in Japan. However, the development of bariatric surgery in Japan has been making steady progress within the public health insurance system. In Singapore, the waiting time for surgery in public hos-

Singapore
Sleeve gastrectomy Roux-en Y gastric bypass Gastric banding

Australia
Sleeve gastrectomy Roux-en Y gastric bypass Gastric banding