When the adjustable gastric band (Lap-Band) was approved for marketing in June of 2001 few people noticed. But by 2004 it became the most searched term in weight loss. By 2007 it was responsible for being the major method people chose for their weight loss surgery.
Then, the perfect storm hit. The Lap-Band went from the darling of Allergan’s portfolio, to a business they are trying to sell.
When Allergan purchased the Lap-Band product line, a company called Inamed, it is said they were more interested in the breast implant that they sold than they were the band. But still, the band out performed sales estimates every year. As with most companies that begin to ride a winner, Allergan pushed harder for the device to be sold more and more. When Johnson and Johnson’s surgical division, Ethicon, announced it purchased the “Swedish Band” and obtained approval, suddenly Allergan had competition, and while they didn’t lose sales, 1/3 of the band market was instantly belonging to Ethicon.
Allergan made a deal with the other large stapler company, Covidien (Then US Surgical) to help market the band to their bariatric surgeons. The reasoning was that if the non-Lap-Band surgeons who were in Ethicon’s camp would use the Johnson and Johnson brand, then Allergan would go to the other camp, Covidien, and have that group of surgeons trained to use their band.
Allergan was more focused on Sales than Aftercare
In the background there was a group of surgeons talking to the heads of the Allergan division saying this was a mistake. By pushing the band, and training everyone to use the band, it ignored a simple fact: band success is less about surgically placing the band and more about follow-up. Many of the surgeons who were placing the band were more interested in the surgery and less interested in the follow up. That if the patients were not followed up on a regular basis and provided support and adjustments, they would become discouraged. The surgeons also warned Allergan that many of these surgeons were not band-friendly- that they loved having the people come to their office for a band and then pulling a “bait and switch” talking them into another weight loss operation.
Riding the wave of sales, Allergan ignored those surgeons. It turned out that a small per cent of Allergan surgeons were doing the vast amount of bands.
Allergan’s Lap-Band site, lapband.com, listed every surgeon that had been proctored to place the bands. At one point there were over 1500 surgeons on their website. All a prospective patient had to do was put in their zip code and up would come the surgeons in their area who were doing seminars. Some surgeons learned to “game” the site- offering daily seminars, not by them, but by their staff so that the site was flooded with their seminars.
Low BMI Study
One shining study was Allergan funding a study about low-BMI patients. By doing a careful low BMI study Allergan showed that they could have remarkable success, and they didn’t fit the classic “need to be 100 pounds overweight.” The study was done by surgeons who knew the band, knew how to take care of patients following the surgery, and had remarkable results.
Allergan also had good news from the bariatric outcomes database put together by the first attempt at Centers of Excellence. In spite of a number of surgeons not knowing how to care for patients after surgery, the first year weight loss for band patients was 53%, slightly lower than RNY. The complication rate and mortality rate showed it was the safest surgery.
On September 15, 2008 the first blow to Allergan’s sales happened when the recession hit. When the economy was overheating many people would get second mortgages or easy financing and get a lap-band. Suddenly this financing was gone.
With the recession and unemployment many people were out of jobs, often affecting the group of individuals most likely to be obese. For the first time in 15 years the number of weight loss operations, of all kind, declined. The Lap-Band division did not make their sales numbers, and would continue losing sales over time.
During this time the direct-to-consumer advertising from Allergan stopped. It was expensive to purchase television, and the company with falling sales projections, stopped marketing in television. They focused on their website, social media, and a number of attempts which did not get the same result. As the recession moved into its second and third year, Allergan forgot what got them there.
Thinking many surgeons didn’t like aftercare, Allergan sought to get primary care doctors to do adjustments. The core group of surgeons said this wasn’t a good idea- not only would those primary care doctors not know how to do an adjustment properly, they wouldn’t be able to deal with complications. That the surgeon talking to the patient was every bit as important as properly placing the Lap-Band, and removing this from the follow-up would result in poor results.
Meanwhile a large group of surgeons had been “trained” on the Lap-Band had offered the band simply as an adjunct to their practice. Someone would come to their practice wanting a band, and they would try hard to change their minds. Some of these surgeons had been concerned by the outcomes from the Roux-En-Y gastric bypass, and were hopeful the band would offer an alternative.
In 2002 Michel Gagner was talking about removing 90% of a patient’s stomach as a new approach to weight loss. More and more surgeons became interested in this as a surgical alternative to weight loss from the RNY. The American Society for Metabolic and Bariatric Surgery members (the parent organization for bariatric surgery) worked hard to have this covered by major insurance groups. Pushed by staple companies, as it would use their product, this became the new “darling” operation.
A number of surgeons liked it because it involved little aftercare. The patients would have an operation, they wouldn’t require “adjustments” to it, and the operation was simple, good results at one year, and the leak rate from staples – at 2.5%, while devastating for those, was a small enough number that it became less of an issue.
The original model for the Lap-Band was it made a person “feel full with less.” This was preached by the sales force at Allergan to the surgeons who were placing the band. If you were not feeling “full” eating less, then they need to have their band tighter.
Out of Australia the research was showing something different. The band was not making people feel full with less. In fact, the band worked best when it was a bit loose and food went past the band. As much as John Dixon preached this, the only ones who kept up with that data were those surgeons whose main interest was the Lap-Band, but not the entire bariatric community.
As a result, patients were getting heart burn, band slips, not losing weight, and feeling miserable. Especially among surgeons who didn’t learn how the band worked. As these patients got into trouble, their bands were removed, or ex-planted.
Now the group of surgeons who used the band a bit, were getting a bad feeling about the band. Those surgeons who used the band as the major focus for their practice, took the new information to their patients, and continued to have good results.
1-800- The LA Market
It seemed like manna from heaven. In the height of the recession two brothers figured something out: the band could be marketed to consumers easily, and if they had insurance that had “out of network” benefits, they could charge a fortune and make tens of thousands of dollars on a band. Typically an insurance company might pay a hospital $10,000 to place a Lap-Band, with a tidy hospital profit, and yet if a patient was out-of-network, they would pay almost five times that amount.
With a 5 million dollar a month budget, LA was flooded with radio advertisements, billboards, and some television. Almost every place there was a billboard, there was a sign for the Lap-Band.
The advertising increased band sales not only for that group, but for every Lap-Band surgeon in LA and San Diego.
A reporter for the LA Times was upset at seeing the billboards around his subdivision and began to “investigate” the band business. Several highly published deaths became public and the LA Times continued to pound at this marketing machine. A local US Congressman asked to investigate it- and Allergan made the decision to stop selling to this group.
The billboards came down, the advertising stopped, and the LA Market, which was the west coast jewel of sales, took a major hit.
The local LA surgeons not involved in that group noticed a decline in patients coming in and asking for the band. Not understanding marketing, they blamed the bad press from the LA Times, instead of realizing that even bad press raised awareness of the band.
Out Of Network Sleeves
Not only was the sleeve a simple operation for a surgeon to do with minimal aftercare, it was much more lucrative than a band. Insurance companies were paying very little to have a band placed into a patient, but almost three times as much to have a sleeve performed.
They paid even more if the surgical center did it. Out-of-network sleeves were paying over 100,000 dollars to some surgical centers. And now they had a new market– their patients who had the band, but didn’t do well with it, now wanted something better and these surgeons offered them a sleeve. They had the same out-of-network benefits, and now they could get a sleeve.
Since the sleeve does not involve an FDA device, there was no reporting requirement for complications. The 5.5% leak rate which could cause devastating consequences, was only reported in the literature. Publications were coming out about how to deal with sleeve leaks, from using stents, to drains. The leaks could happen anytime in the first 30 days
Allergan – It isn’t Working
Allergan’s numbers continued to slide. The loss of the LA market, the bad press, and lack of direct-to-consumer marketing was hurting them. They made the decision to sell the Lap-Band division.
In the mean time, that small group of surgeons talking to Allergan provided some feedback:
(a) Stop trying to sell everyone the Lap-Band.
(b) Surgeons who are doing bait and switch are ruining the band’s reputation
(c) By putting all those surgeons on the site who are not interested in after-care of the Lap-Band you have fueled the rise of the sleeve surgery.
(d) You have the safest surgery – don’t try to compete with sleeve, stop playing defense, tell your story
Nordstrom not Wal-Mart
In the last few months Allergan has quietly removed surgeons from its lapband.com website. Those surgeons who are not doing many bands, or who actively promote other operations have been removed. They began to concentrate on a the group of surgeons who have been band friendly.
The key to the band is good aftercare, and knowing how the band works. It means patients have to come back a lot in the first year and have their band adjusted, and talked to about what they are eating.
Band surgeons knew that at five years, their data and weight loss was every bit as good as any other operation. They knew that the key was lifestyle change, and by seeing patients frequently it meant having a chance to affect change in their patients.
Instead of focusing on being the Wal-Mart of the weight loss surgery, band surgeons learn that lifestyle is the key to great results and have become more like Nordstroms or Four Seasons than a quick check out.
The band will ultimately become either known for what it is, the safest weight loss operation that promotes lifestyle change – or a major failure by a company that didn’t listen to its core group of surgeons.
Re-tooling the band, and focus on aftercare and marketing to consumers began to have an effect.
No longer was Allergan sending patients to surgeon offices who didn’t care about the band. On their site there are now less than 400 surgeons listed, down from over 1500, and probably more surgeons will be removed.
Patients, who inherently understand they have to change their lifestyle, and know that losing fat mass slowly over a couple of years is safer, continue to seek the band.
Of all google searches for weight loss surgery the Lap-Band is still the most sought after search by two to one over the sleeve. The major push for the sleeve are those surgeons who don’t like the band.
Allergan’s new commercial features George Fielding, a surgeon who had the band placed a number of years ago, does all the operations, and recommends the band over all other operations. The commercial is sincere, well done, and because the advertising budget was so small from Allergan to the Lap-Band division it was written by the Vice-President.
But it is working, and new companies are interested in purchasing that division. Having the governor of New Jersey getting the band was a major coup.
Teaching that the band works two hours after a person eats, not over filling the band is key. Sales have started to increase.
The new Lap-Band will come back smaller, but focused on after-care. Those surgeons not interested in doing that will do other operations, but the data from the Low BMI study, from those who have great results, continue to show that the cure for obesity isn’t just an operation, it is lifestyle change. 64% excess weight loss at one year.
Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and went to medical school. Dr. Simpson, a weight loss surgeon is an advocate of culinary medicine. The first surgeon to become certified in Culinary Medicine, he believes teaching people to improve their health through their food and in their kitchen. On the other side of the world, he has been a leading advocate of changing health care to make it more "relationship based," and his efforts awarded his team the Malcolm Baldrige award for healthcare in 2011 for the NUKA system of care in Alaska and in 2013 Dr Simpson won the National Indian Health Board Area Impact Award. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit www.terrysimpson.com.