Proper Care

Caring for obese patients can be expensive. But, careful planning and management can limit additional expenses.

In spite of widespread attention to nutrition, fitness and weight loss, a large percentage of the U.S. population is morbidly obese. In order to treat patients in this category, IDNs must acquire the right equipment and train their staff to use it properly. The unprepared facility may face some huge liabilities.

“Every patient that comes to the ER is a liability,” says Kay Hawn, bariatric program director, MBA, MSN, Summa Health System (Akron, Ohio). “An obese patient presents [yet] one more liability.” At the very least, IDNs must be equipped to handle obese patients in their exam rooms, ERs and waiting rooms. “But the hospital that takes on a bariatric [surgery] program as well must look at [related] complications and needs,” she adds.

An expensive venture
Bariatric surgeries are costly, as are the products and services that support them. But if procedures and follow-ups are well managed, costs can be kept within reason. Two procedures widely accepted in the United States include the Roux-en-y gastric bypass, introduced in the 1990s, and the adjustable band procedure, which has become popular in the last eight years, according to Hawn. Roux-en-y gastric bypass surgery involves cutting the patient’s stomach and rerouting the small intestine. It is considered a restrictive, malabsorptive procedure, such that the patient cannot eat as much and absorbs less food.

The adjustable band is a silicone band, which is placed laparoscopically around the patient’s stomach. The procedure is less complex than the bypass, and the surgeon can tighten or loosen the band as necessary, reducing the risk of adverse effects following surgery. There is no malabsorption involved in this surgery, and patients must work harder to lose weight through exercise and good nutrition.

Contracting professionals and hospital staff can take diligent steps to limit potential complications from surgery, thereby limiting unnecessary expenses. For example, it’s no secret that better training leads to more effective and efficient surgeries. Obese patients often are at higher risk for complications during intubation. And, it can be more difficult for the anesthesiologist to gauge what type and dosage of anesthesia to administer to such patients. Fellowship training programs that involve a full year of extensive training prepare a bariatrics specialist far better than a weekend or week-long mini-fellowship, notes Hawn.

A bariatrics program that favors less invasive surgery can also reduce patients’ risk for post-surgical complications. That’s why Summa Health System uses laparoscopy, such as the adjustable band, when appropriate. “We still have the initial cost of the surgery, but there is less pain [associated with it], shorter hospital stays (usually one or two days) and fewer complications,” says Hawn.

Surgery is only one step in the process of helping obese patients reduce their weight. Before and after surgery, patients must be thoroughly educated about the procedure and follow-up. “These patients need a tremendous amount of training,” says Hawn.

Prior to surgery, patients must be prepared for what to expect, she says. And, following surgery, they must learn about exercise routines and limitations on fluid and food intake. “These patients need a certain amount of protein, [as well as] a vitamin supplement for the rest of their lives,” she says. They also need to stop smoking if they are doing so, as smoking can inhibit wound healing. In fact, wound healing itself can be an issue for obese patients, many of whom have diabetes, which can slow the healing process.

To cover uninsurable expenses associated with patient education and support programs, Summa Health System bills the patient an out-of-pocket fee. “Much of pre- and post-operative testing is billable,” notes Hawn. “But, support groups and extensive time spent with the dietician, educative materials and exercise programs are not. These services are much too expensive for the hospital to give away. And, if the patient is financially invested in the program and feels a sense of ownership, [he] is more likely to follow up.”

Not quite there
Professionals need to understand the bariatrics market in order to make the best, most comprehensive purchasing decisions. There is more to the product search than lifts and tables, according to Lynne Mueller, manager for clinical resources and patient care services, Froedtert Hospital, Milwaukee, Wis. Surgeons need larger blood pressure cuffs, as well as larger retractors, urinary catheters, instruments and tools (e.g. longer laparoscopic tools). Drains, gowns and even waiting room chairs must be designed specifically for obese patients. Some technologies, such as MRI and CT scanners, have not yet been designed to accommodate the size and weight of obese patients.

Although bariatric products tend to cost more than their standard counterparts, less expensive products are available, Mueller points out. But, at what cost? “Is the quality of a chair there to hold 600 or 700 pounds?” she asks. If it breaks, the staff can’t easily move a 600-pound patient who falls. “In the long run, it’s better to pay a couple of hundred extra for safety.”

Patient mobility
Contrary to a common mindset that most obese patients are unable to move around, many can shower, bathe and turn over in bed, notes Hawn. Regardless, the hospital staff must be trained in lifting and transferring these patients. Injuries to staff from handling too much weight lead to increased hospital costs and staff dissatisfaction.

“Basically, the same mobilization devices can be used for all patients,” says Mueller. “We make these devices, as well as electronic devices, available. This helps [reduce] injuries. Of course, the hospital staff must comply with using these devices.”

Contracting strategies
The more bariatric patients a hospital sees each year, the greater its contracting/bargaining strength will be, according to Mueller. Still, hospitals need to find creative ways to reduce costs. Some companies permit hospitals to rent equipment with an option to purchase it later on. Other times, hospitals can work out creative contracts with vendors, such as capitated contracts.

At the very least, GPOs should offer their members dual-source contracts, she adds. “We need at least two [bariatrics] vendors to choose from,” says Mueller. Product quality and customer service are important considerations. And, it’s important that service reps treat bariatric patients in a respectful manner.”

A lifetime of changes
In spite of the challenge of reducing costs associated with bariatric surgery, clinicians and hospital administrators know that the benefits for the patient – including a reduced risk for high blood pressure, heart disease, diabetes and sleep apnea – are huge. “Bariatric surgery [comes with] a big return on investment,” says Hawn.

Still, the process is complicated. Patients must demonstrate they have attempted to lose weight before they have the option of surgery, explains Hawn. Adolescents have an even greater burden to demonstrate that they have attempted weight loss and can follow surgery with exercise, diet programs and healthy life choices. In fact, they cannot have bariatric surgery until they have achieved full growth, as a gastric bypass can interfere with the growth process. “We need to consider the impact on the patient,” says Hawn. “Bariatric surgery calls for a lifetime of changes.”

About Laura Thill

Laura Thill is a contributing editor for The Journal of Healthcare Contracting.

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