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This story is part of a series called "Ozempic: Weighing the Risks and Benefits." It was produced in part through a grant from the .

Since she lost her job this summer as a bariatric surgeon, Lana Nelson, DO, has a phone message that tells callers, "I'm probably out on the trails" hiking near Grand Junction, Colorado.

For 19 years until this fall, Nelson worked at the Norman Regional Health System's "Journey Clinic," a large weight-loss surgery program 15 miles south of Oklahoma City. For the last 12, she was its medical director.

The 324-bed hospital system's two or three surgeons provided weight-loss surgery to more than 750 patients in each of the 2 years before COVID, she told 番茄社区app. She did more than half of those herself.

But the hospital was having financial woes, and caseloads dropped during the pandemic. Instead of bouncing back, they dropped to 387 in 2023. The chief reason: Many surgery candidates were trying the new GLP-1 receptor agonists if their insurance plans would cover them, she said.

Bariatric surgery can be a lucrative service line, especially in Oklahoma, one of the in the nation. And it looked like the clinic's business was picking up a bit in 2024. Administrators asked staff to reduce their salaries. But it wasn't enough.

On Monday, July 8, leadership abruptly pulled the plug, she said. They sent notices that all scheduled surgeries were immediately cancelled. That was it.

"Even patients who had completed their preparation were called the day before their scheduled procedure and told the clinic is closing," Nelson said.

Among the team's three physician assistants, a bariatrician, two nurse practitioners, and three dietitians, only two got other jobs within the hospital.

Nelson and the two other surgeons were given 90 days' notice, time to transition their patients elsewhere.

At age 51, Nelson is considering early retirement. She and her husband sold their home in Norman and moved to Colorado.

Across the country, many surgeons shared similar stories about what many described as, in so many words, "a time of fear and loathing in bariatric medicine."

Numerous programs have closed their doors, reduced their surgeons and staff, or transitioned to exclusive medical management. Sources pointed to many programs that had cut back their teams, but no hospital contacted acknowledged that they had.

Mount Auburn Hospital in Waltham, Massachusetts, affiliated with Beth Israel Lahey Health, said in a recorded message that it closed its Weight Management Center on February 9. Grand View Hospital's program serving Bucks County Pennsylvania has also shut down.

Norman Regional officials declined comment about the program, but a representative told a local organization in July, "We have observed a trend of less demand for surgical options and more demand for non-invasive medication options for about 2 years."

The GLP-1 drugs are "truly causing a lot of disruption for the surgeons and for the programs, and for patients," Thomas Tsai, MD, a bariatric surgeon at Brigham and Women's Hospital in Boston, told 番茄社区app.

"I've had to see patients who had surgery at a different facility for follow-up because the program they were in doesn't exist anymore," he said. Comprehensive nutritional follow-up is an important part of patient care, he emphasized.

Tsai's published in JAMA Network Open in October found a 25.6% decrease in bariatric surgery procedures in non-diabetic patients with obesity between the last 6 months of 2022 versus the last 6 months of 2023, but a 132.6% increase in patients prescribed GLP-1 drugs.

"I keep hearing about smaller programs where they're just so certain that this is going to impact their bottom line, they don't even want to put any resources into it. And that's deeply troubling," said Ann Rogers, MD, director of the Penn State Surgical Weight Loss program in Hershey and president of the American Society for Metabolic and Bariatric Surgery (ASMBS).

Scheduled patients "are cancelling surgeries at the last minute, not saying why," though she suspects their families urged them to try the drugs first, she said.

"Surgeons not near retirement are going to be hysterically looking around to find employment somewhere else in the same field," Rogers said. "There are jobs," just not necessarily in bariatric surgery or where they want to practice, she said.

Several bariatric surgeons told 番茄社区app they are frequently checking their specialty's job boards. Some said they're enrolling in refresher courses for other kinds of foregut surgery, such as hernia repair, gallbladder removal, or esophageal procedures. One surgeon has pivoted to telemedicine prescribing.

Helmuth Billy, MD, a bariatric surgeon in Ventura, California, said next year, he's "throwing out a lifeboat to expand his practice to cosmetic/plastic abdominoplasties and tummy tucks" to past surgery patients to help his bottom line. "We have a lot of patients who can't afford plastic surgeons."

One of the Journey Clinic's terminated surgeons, Azure Adkins, MD, got excited when she recently learned that a medical center just north of Charlotte, North Carolina, was recruiting a full-time bariatric surgeon. But after interviewing, they'd changed their minds, she told 番茄社区app. "They said they realized their volumes had diminished enough that 'we don't really need another full-time bariatric surgeon at this point.'"

Until she finds a surgery position that she likes, Adkins is now working in a non-clinical role, as a peer-to-peer utilization reviewer for hospitals.

Cautious Optimism

Rogers said that if surgeons think their hospitals are about to cut back or shutter surgery, they should try really hard to talk the hospital out of it, "because you know, it's going to turn around. It's going to turn around."

She's not alone. Many other bariatric surgeons interviewed said they see the GLP-1 agonists as "gateway drugs" that will bring more patients to surgery. Eventually.

A common lament among nearly all surgeons interviewed is that fear of surgery or social stigma have long kept 99% of patients with obesity who could be helped by bariatric surgery away from seeking any kind of help.

Now, patients are swarming in, said Fernando Elli, MD, one of four surgeons who performs bariatric surgery at the Mayo Clinic in Jacksonville, Florida. "They want to see us not because they're interested in bariatric surgery. They want the medications," he said.

But many of those patients are learning their insurance won't cover the drugs, or are alarmed that they would have to inject themselves every week indefinitely, or that if they stop, or take a drug holiday, they'll regain the weight.

"What we are seeing now with more exposure to these drugs is that patients start the medications but they don't tolerate the side effects. They drop it and say, 'Let's go for surgery,'" Elli said.

But that isn't happening a lot, at least not yet. His clinic's surgical volume dropped from 280 in 2023 to 220 this year, which he thinks will be stable until the limitations of the new injectable drugs become clearer, not just to patients but to their doctors as well.

Surgeons also think that patients will eventually choose surgery because experience and data show surgery produces a greater and faster weight loss after a year than 52 weeks of GLP-1 injections.

"At best the GLP-1s can get you to about 14% total body weight loss; surgery is more like 30%," after a year or 18 months, Rogers said, pointing to a 2022 in Advances in Therapy.

Elli thinks the comparison is 10% to 20% versus 50%, and other surgeons shared different estimates, depending on the patient and the drug.

Tsai said a head-to-head comparison hasn't yet been published, and perhaps the drug companies aren't eager to fund such a study. "But at some point the NIH will fund a direct comparison."

Sandi Petros, 33, a restorative dental specialist in San Diego, is an example. At 299 pounds, she never wanted to try the drugs because she knew surgery was faster and more permanent, and she wanted to lose the weight for her two young boys. Last week, 1 year after a Roux-en-Y gastric bypass, she had dropped 102 pounds. She no longer has type 2 diabetes, and her LDL, 140 before surgery, is now normal.

Teresa LaMasters, MD, a past president of ASMBS, expressed similar optimism. "In the long run, the drugs will actually help us."

"What's going to be the thing that holds patients back on medicines is their cost, access, availability, and how people will tolerate them," said LaMasters, who also is the medical director of bariatric surgery at Unity Point Clinic at Iowa Methodist Hospital in West Des Moines.

Another trend that can improve the prospect of surgery's revival is that several insurance companies have reportedly dropped some of their more rigorous requirements for bariatric preparation, and some have dropped the need for prior authorization review.

Additionally, some health plans are capping how much they'll pay for the GLP-1 drugs, if they cover them at all. The Mayo Clinic has capped that lifetime spending at $20,000, Elli said.

An Uptick Already

Farah Husain, MD, a bariatric surgeon at Banner University Medical Center in Phoenix, said her hospital has seen a small uptick in surgical patients from 550 in 2023 to about 580 this year.

"I'm seeing patients sometimes with BMIs of 60, 70, 80, and no one has ever mentioned surgery to them before," she said. "The only reason they come in is because they saw something about the medications. These are people who need such a significant amount of weight loss, they need surgery on top of the drugs."

Some private practice surgeons contracted with Kaiser Permanente to perform bariatric surgery for the health plan's enrollees are also reporting a bump in patients in recent months.

"The GLPs have thrust a huge new cost on the Kaiser system that is probably unsustainable," said Billy, a Kaiser contractor. Lately, he said, "we're seeing more Kaiser volume than we've ever seen before."

Many clinicians interviewed said that just as cancer treatment often requires a combination of surgery and drugs, combination therapy will be the treatment plan for many patients with obesity. They may take the medications to lower weight to better prepare them for surgery, or after surgery after they reach a plateau.

A possible offsetting factor is the Centers for Medicare & Medicaid Services proposal last month that it would pay for the new weight loss drugs in 2026, if the new administration approves.

Making Adjustments

The Mayo Clinic has made adjustments to respond to the change in surgical volume, Elli said. "We have shifted our practice so that we have more non-surgical practitioners to accommodate those patients who don't want surgery."

Nationally, he expects many bariatric surgeons will adjust as well, diversifying their surgical repertoire. "Surgeons who are only doing bariatric surgery need to reconfigure," he said. "Current bariatric fellowship graduates may find it difficult to obtain a pure bariatric practice and may need to alternate with acute care surgery."

For many bariatric surgeons, the prospect of taking on general surgery -- where often it's one-and-done -- goes against the reason they chose weight-loss surgery as a specialty. They wanted longer-term relationships with their patients.

"We operate on the patients and ideally follow them for as long as they're willing to come back, to make sure they're maintaining weight loss and healthy habits and help them along the way," Husain said. "The theme in our world is that obesity is a chronic disease."

The Payers Aren't Helping

Benjamin Clapp, MD, a bariatric surgeon at Hospitals of Providence Memorial Campus in El Paso, Texas, chairs the ASMBS task force that tracks bariatric surgical volume every year.

He said neither the official totals for 2023 nor estimates for 2024 are collected yet. However, data from centers accredited by the American College of Surgeons, which perform about 80% to 83% of all bariatric surgeries in this country, show that volumes were down by 5.5%, or more than 12,000 weight-reduction surgeries, in 2023.

But 2024 is expected to be "much, much worse because of the overwhelming impact that the GLP-1 drugs have had, which really took off this year," Clapp said.

This year in El Paso he expects to perform 120 bariatric surgeries, compared with 180 in 2023. "These are massive decreases in volume, at least for me," he said. "I went from seeing 15 to 20 new bariatric patients weekly to one to three."

The at Columbia University said earlier this year that it expected a 10% to 20% decline in 2024 from 2023.

That drop in bariatric demand is one of two big reasons why Clapp has made a career decision to leave the solo practice he has built up for the last 18 years.

Sometime next year, he plans to either take an academic job and devote more time to studying how brain receptors function in rats with obesity, or become an employed hospital surgeon. On staff, he would do any variety of procedures and probably far fewer bariatric procedures on which he has built his practice.

The other reason is declining reimbursement. Clapp said Medicare rates for common bariatric surgery CPT codes have dropped since 2019, despite rising inflation in practice costs. A check with Medicare's physician fee lookup tool shows he's right. For example, the national payment amount for a laparoscopic gastric bypass with small intestine reconstruction dropped from $1,937.82 to $1,842.13 between 2019 and 2024. Insurance companies generally follow Medicare.

What's worse is that consultation pay has also been going down or has disappeared. "Things are bundled more, so you get paid less overall," he said. "It's like death by 1,000 cuts." Solo private practice "has just become a model that's not sustainable, for myself or for my family."

Clapp has filled in some of the blanks with other foregut surgeries, such as cholecystectomies and hernia repairs, but reimbursement rates have dropped for those, too, especially relative to his own practice costs.

San Diego bariatric surgeon William Fuller, MD, said Scripps Mercy Hospital, one of the largest programs on the West Coast, will have performed around 800 bariatric surgeries in 2024, down from the prior year's 1,000. But he doesn't expect a year-over-year decline in perpetuity as some of his counterparts fear.

"Who knows when there will be a stabilization of this whole phenomenon?" he asked rhetorically during an interview with a public relations representative present. "But we see patients who tried some of these medications -- when they had access to them -- and they haven't had the same success. They had some rebound, regained weight, or just didn't have success to begin with."

Bottom line: "It's all about sustainability, which is always the case with medications," he said. "How long can you remain on them, and for efficacy purposes and economic purposes, how are these medications going to be funded, with what kind of subsidies? There's still a lot of moving parts."

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