Treating the Bariatric Client -- HME Business

Treating the Bariatric Client

Jan 01, 2007

Understanding the whole sometimes requires examining the sum of the parts. Recent reimbursement cuts have forced providers to sharpen their business savvy and explore other areas to manage profit loss. With the obesity epidemic well under way, gravitating toward bariatrics is a way to boost profit margins. Some providers may be wary of the initial investment — purchasing and storing larger products could require a ginormous pocketbook and storefront, not to mention specialized warehouse and delivery equipment.

Today's marketplace, however, encompasses much more than heavy beds and larger-than-life mobility devices. The medical community attests that bariatric clients suffer a wide gamut of conditions from hypertension to diabetes, enabling providers to choose how much or how little they want to be involved in this segment of HME.

If you're thinking about taking the leap, consider the medical evidence. H. Sugarman, M.D., American Society of Bariatric Surgeons council member, says, "There are about 30 conditions associated with severe obesity." Those conditions include type 2 diabetes, hypertension, liver disease, gastroesophageal reflux (GERD), asthma, obesity hypoventilation, urinary stress incontinence, sleep apnea, degenerative joint disease in the knees, hips and lower back, high cholesterol, heart disease, osteoarthritis and cancer, to name a few.

A recent report issued by Frost & Sullivan ("U.S. Specialty Bed and Support Surface Market for Bariatric") estimates that in 2005, around 15 million adults in the United States were considered morbidly obese (a BMI of 40 or greater). The Centers for Disease Control and Prevention (CDC) reports that 23.9 percent of U.S. adults were obese and 3 percent were extremely obese (a BMI of 40 or greater) in 2005. CDC indicated that obesity rose in all states between 1995 and 2005. That number is expected to rise even more between 2006 and 2012.

"In fact, 24 percent of children are obese and that number is predicted by year 2010 to double," says Dr. Neil Hutcher, bariatric surgeon and past president of the American Society of Bariatric Surgery, Richmond, Va. He says that in six years about one-half or 48 percent of all children will be overweight or obese.

Because of the myriad of health conditions associated with bariatrics, Sheila Ewing, industry analyst for medical devices at Frost & Sullivan, says bariatric equipment is now one of the fastest growing market segments.

"Over the past three years, the bariatric market has expanded almost as quickly as waistlines," Ewing explains. "Many manufacturers entered the market by increasing their standard weight capacity of equipment to 350 pounds, but now that is not nearly enough. We are seeing that capacity rise to 700 pounds and even 1,000 pounds" As an example, Ewing cites Mundlelein, Ill.-based Medline Industries, which two years ago had a dozen bariatric products. "Now, the company offers over 100 products, including beds, wheelchairs, walkers, bath safety products, stretchers and scales with capacities as high as 1,000 pounds," she says.

Still not sure if bariatrics is the way to go? Home Health Products has assembled a quick need-to-know guide to help you examine the parts necessary to treat the bariatric client. Find out what products address the varied needs of the bariatric condition, hear expert advice from the front lines and learn about the nuances of obesity from the physicians who treat your clients.

Mobility

Though it may be obvious that with greater weight comes decreased mobility, the reasons behind the change may not be so apparent.

Bariatric surgeon Hutcher explains, "It's a perfect storm in that there's not just one thing that affects their mobility." In fact, bariatric clients experience pain and find it harder to overcome pain because of shortness of breath and fatigue, he says.

Couple those problems with arthritic joint pain, back pain, high blood pressure and urinary incontinence, and mobility can become very difficult for some. Further complicating mobility is the fact that surgeons will not do joint replacements on people who are severely obese, says Hutcher.

"The benefits of a well-fitted wheelchair and seating system are many," says Sharon Pratt, PT, Sunrise Medical, Longmont, Colo. "To name a few; skin integrity may be preserved (and) the patient can get around their home and out of the house to carry out essential daily living activities which otherwise they could not do. They regain independence. Not only are there physiological benefits but also great psychosocial considerations. This person's overall quality of life can be dramatically improved."

Dave Jacobs, president of the Durable Medical Equipment division at Medline Industries, says weight determines the type of mobility equipment a bariatric client might need. For example, a cane might be good for someone around 300 pounds. But, "Somebody who starts to get over 400 pounds is going to be less mobile (and) so, they need more assistance," he says. "A wheelchair certainly would help and maybe a walker, which provides more support than a cane, for example, or crutches."

A good rule of thumb when recommending mobility equipment is to consider the weight of the client. "There's a formula: For every extra pound of weight that they carry, that translates to 4 pounds on their joints," says Michael DiFranco, product manager, Bariatric Products & Solutions, Invacare, Elyria, Ohio. "So naturally, all of that is going to translate into mobility problems. It's going to encourage inactivity. So, that's why things like walkers and canes and crutches? we see them as a temporary assistive device, but they really help get (bariatric clients) up and mobile and take a lot of that stress off their joints." DiFranco says more extreme cases — those 400 or 500 pounds — may require wheelchairs to be more mobile.

Ewing reports that because of the obesity epidemic, bariatric manual wheelchairs have climbed to the largest segment of the manual wheelchair market, yielding revenues of more than $38 million in 2005.

The industry has come a long way since the days when a bariatric client could get only a 24-inch wide chair. In fact, Steve Cotter, president of Gendron, Archbold, Ohio, says today's bariatric client has a lot more choices. "Today, we've got one line of wheelchairs, just as an example, that we call XL 2000. And if you look at our catalog, or the Web site or the price list, I think we calculated (that) by the time you combine all of the variables in seat width, seat depth, back height, seat-to-floor height, arm styles, back styles, you'll have 360 different combinations," he says. "A prescription utlralightweight wheelchair, for example, that's for the active wheelchair user, that kind of product is literally built for the user. And bariatric mobility has evolved to be the same way. It's truly no longer one size fits all."

Mobility equipment also makes bariatric clients more ambulatory after surgery. Bariatric surgeon Sugarman says after surgery he recommends "at most and rarely a temporary electric bed, but we want most patients ambulatory and encourage them to go up and down stairs." Ambulatory aids such as canes, walkers and rollators help bariatric clients get back on their feet after surgery.

TIP: The design of quality bariatric products isn't just about extra strength. "In terms of design of the products, we've spent more time looking at the ergonomics of the product to make sure that (patients are) comfortable and they fit well for bariatric patients," says Dave Jacobs, Medline Industries. "We've increased the seat size of our rollators for example. We've also increased the thickness of our upholstery to make it more comfortable for bariatric patients, and in the next round, as we go forward, (we're) looking to make them look a little less institutional like we've done with some standard products."

Respiratory

Breathing doesn't come easy for the bariatric patient. In fact, many experience obstructive sleep apnea, hypoventilation and asthma, with sleep apnea topping the list.

"There's such a high incidence of sleep apnea in bariatric patients mostly because they have such a large neck circumference," says Invacare's DiFranco. The extra weight in the neck causes the wind pipe to collapse during sleep.

"If these same patients lose 10 percent of their weight, they tend to lose their sleep apnea and get on the path to recovery," says DiFranco, proof that the condition is tied to increased weight.

HME providers can play an important role in the treatment of sleep apnea for bariatrics. Bariatric surgeon Sugarman says that home health providers dealing with bariatrics should be in the know about nasal CPAPs above all other equipment requirements. Hutcher explains that before clients undergo bariatric surgery, they must have their sleep apnea under control.

Bariatric clients also require other types of respiratory equipment. The prevalence of asthma among obese individuals is high. On top of that, extra weight might also cause bariatric clients to have trouble breathing while awake. "Because they're so deconditioned, they may need oxygen," says DiFranco. "They're carrying so much weight on their sternum that they can't breathe properly."

As a result, nebulizers, oxygen concentrators and portable oxygen concentrators are sometimes a must for bariatrics.

TIP: While the market for bariatrics has shown significant growth over the years, Invacare's Michael DiFranco doesn't see many providers jumping on the trend. "They have to be shown a way," he says. DiFranco encourages providers to establish a reputation as a bariatric specialist in their area. By doing so, "they've diversified their business and created a new revenue stream for themselves in light of all the reimbursement issues."

While becoming a bariatric specialist has a certain appeal, Dave Jacobs, Medline Industries, considers offering bariatric products par for the course. "Bariatrics is a core part of (a) broad offering because the number of bariatric patients is increasing and generally so pervasive," he says. "So, if (providers) want to be seen as a full-service provider, even a basic DME, they need to provide bariatrics."

Beds & Support Surfaces

One of the most beneficial products for bariatric clients is the home care bed. Standard beds simply won't support weight effectively, and since many bariatric clients have mobility issues, the bariatric bed is invaluable.

"Very few of these patients self-propel," explains Gendron's Cotter. "For a true bariatric patient — somebody that's 600, 700, 800 pounds — first of all, they're not walking. Second, if they can't get transferred to a mobility device, a chair that someone can push or wheelchair or a recliner or some other seating product, they're going to spend their day in bed. A lot of bariatric patients, even if they can stand, can't bear their own weight."

A bed with an articulating frame has many therapeutic benefits, not to mention making it easier for an ambulatory client to get in and out of bed.

"If we lower the head of our bed and raise the foot of our bed, that shifts the pressure physically on a specific area or part of that patient's body to relieve pressure, say in the lung or the chest cavity," says Cotter.

Invacare's DiFranco says that in addition to respiratory conditions, electric beds offer help with medical conditions such as lymphedema and GERD. "It's not just getting them on the proper surface, which is important, but there are these therapeutic aspects," he explains.

"Then a step further, a lot of them suffer from skin breakdown and pressure ulcers," says DiFranco. "They perspire a lot more; they have skin flaps. There's so much friction between their skin, and then they're sedentary in a bed. All of that is just a recipe for skin breakdown."

Because of the increased risk for decubitus ulcers, support surfaces are vital for many bariatric clients. "Essentially what you're looking to do with any patient who is partially immobile or totally immobile is try to prevent the occurrence of pressure ulcers," says Jim Acker, vice president of sales and marketing, Blue Chip Medical, Suffern, N.Y.

Support surfaces help address interface pressure, heat, and moisture buildup between the user and the surface. "You're looking for a viable barrier between the surface and the patient's skin," says Acker. "You want a good cover that's going to help address the shearing forces and the friction forces."

In addition, Acker says support is imperative. "Obviously, you want something that's going to hold up under any patient, but with bariatrics it's even more important to really look at the quality of the product," he says. Be sure to consider the quality of the power system (can it support the weight?) and the air cells (will they leak under the weight?) as well, advises Acker.

But providing beds requires a lot of room for warehousing — a need that becomes more daunting when bed sizes increase in widths to accommodate bariatrics.

To address those concerns, many manufacturers are making it easier for providers to stock larger items by offering more warehouses across the country and quicker delivery, which frees up room in providers' warehouses. The trick is to have supply close by to meet client needs quickly.

TIP: When dealing with bariatrics, Blue Chip Medical's Jim Acker says, "Don't be afraid of a bariatric patient. A lot of people are. They pass on it; they give it to someone else." He says HME providers should coordinate with home health agencies and understand how to match the right product to individual clients. Manufacturers can help educate providers about support surfaces. "There's no reason to lose (business) to somebody else just because you're a little bit timid with servicing a bariatric client," he says.

Gendron's Steve Cotter agrees that talking with manufacturers about product selection is vital. "I think the bariatric HME provider needs to align themselves with somebody that can assist with the right selection, help them choose the right product and give a little direction, advice if you will, on what's appropriate and what's not appropriate," he says.

Diabetic Supplies

If you're already offering diabetic supplies, including glucose monitors, lancets, diabetic footwear and wound care products, perhaps it's time to target a new market.

In recent years, diabesity — a term coined to connect diabetes and obesity — has received a lot of attention. Statistics show that there is a major correlation between increased weight and the risk of type 2 diabetes. According to the U.S. Department of Health & Human Services, a weight gain of 11 to 18 pounds increases a person's risk of developing type 2 diabetes to twice that of individuals who have not gained weight. Another statistic shows that more than 80 percent of people with diabetes are overweight or obese.

Perhaps the greatest proof of the link between diabetes and obesity is the fact that bariatric surgery essentially cures diabetes, says surgeon Hutcher. "Bariatric surgery produces a 77 percent cure (of type 2 diabetes) — not improvement or control, but cure."

"If you're doing a bypass, most of the patients are off of (diabetic) medicines before they go home," says Hutcher. "In the next 10 years we're probably going to call type 2 diabetes a disease of the foregut not the pancreas? You get an almost immediate resolution (from bariatric surgery excluding lap band)." (Lap band responds slower with a decreased rate of resolution because results depend on weight loss and it takes longer to get beneficial effects than when bypassing the first part of the small intestines.)

Providing diabetic supplies is a low-cost way for providers to test the bariatric market.

TIP: The rise in obesity has sparked a rise in bariatric surgeries. "Each year, more than 200,000 bariatric surgeries are completed, far exceeding any other surgery performed," says Sheila Ewing, Frost & Sullivan. "Estimates predict this surgery will exceed 30 percent growth during the next few years." One way for providers to open up new avenues for referrals is to target bariatric surgeons. Many recovering patients need electric beds, bath safety equipment and ambulatory aids.

But don't think that surgery is the only cure for bariatric clients. "First of all, not every bariatric patient is a candidate for that surgery," says Gendron's Steve Cotter. "Second, a lot of the other disease conditions — respiratory, diabetic, wound care — are prevalent. Those things don't go away just because you are a candidate for bariatric surgery. As a matter of fact, those conditions make surgery much more of a risk."

Bath Safety

Bath safety products, generally thought to be the forte of geriatrics, now serve an array of bariatric clients.

When Invacare launched its comprehensive bariatric line, DiFranco learned a lot about bariatric clients. "The first thing I discovered is it's really a younger population," he says. "If you look at the statistics for the morbidly obese, it's really people between the ages of 40 to 50."

"Something that may have originally been designed, like a shower chair, for an elderly person who has a hip replacement, is now being used by a bariatric patient because they have hygiene issues or they have limited strength and muscle tone inside a shower and they need a product like that," says DiFranco.

When you think about the purpose of bath safety equipment, bariatric use makes sense. "Bariatric patients are moving around the house, and they really want to be more mobile," says Medline's Jacobs. "The bathroom is one of the most dangerous places in a house or in a nursing home, so it's important to have bariatric products that can support folks more safely."

Bath safety equipment, such as shower chairs and transfer benches, also makes bathing easier for caregivers. "From a caregiver perspective, it allows that caregiver to more thoroughly wash the patient because now (bariatric patients are) elevated out of the tub and (the caregiver) can actually access them better," says DiFranco.

TIP: Invacare's Michael DiFranco recommends that dealers partner with primary care physicians, home health agencies, and visiting nurses and physicians who can recognize home equipment needs, such as bath safety, for their clients. "A lot of those doctors are seeing the patients for their diabetes or for their joint disease, and that's really all they treat them for," he says. "But if the dealer goes in and says, 'Hey, listen. Ask a question about why they actually fell down in the home. Don't just treat the symptom, treat the root cause.' And that way they can start to expand their business through primary care."

Patient Lifts

The number one reason many bariatric clients require a patient lift is caregiver safety. In fact, patient lift demands are changing, explains Medline's Jacobs, because of growth in the bariatric segment and also increased awareness in terms of safe handling by caregivers.

More so for bariatric clients than any other segment of the HME population, patient lifts are a necessity. "Visualize trying to transfer a bariatric patient from a bed to a recliner," says Gendron's Cotter. "How are you going to do that? You have to have a lifting device."

Jacobs says Medline's most popular lift is a 400-lb. lift, which targets the low end of bariatrics. "But we're seeing the fastest growth in the 600-lb. area," he says.

"Unfortunately, patient lifts are not well reimbursed in the home setting," says Invacare's DiFranco. "It tends to be more of the affluent end-user who can really afford such a device, but they are critical in terms of getting that patient around."

TIP: As demographics change for obesity, Sunrise's Sharon Pratt expects the demand for HME products and services also to increase. She advises that providers involved with bariatric clients practice the utmost sensitivity. "Be sensitive to the needs of bariatric clients from both a physical and mental sense," says Pratt. "Be well prepared in terms of education so the unique needs of this patient can be best served while maintaining dignity and safety."

How Well Do You Know the Bariatric Client?

An estimated 30 percent of U.S. adults age 20 years and older — more than 60 million people — are obese. (The Centers for Disease Control and Prevention)
In 2005, around 15 million adults in the United States were morbidly obese and the number is expected to rise even more from 2006 to 2012. (Frost & Sullivan)
More than 65 percent of adults in the United States are overweight or obese. (The Weight-Control Information Network, an information service of the National Institutes of Diabetes and Digestive and Kidney Diseases, and National Institutes of Health)
The cost of obesity in the United States in 2000 was more than $117 billion. (Surgeon General)
Recent estimates show that the cost of obesity-linked illnesses to the Medicare and Medicaid programs in the United States is more than $40 billion. (Frost & Sullivan)
Approximately 300,000 deaths each year in the United States are associated with obesity. (U.S. Department of Health & Human Services)
Individuals who are obese have a 50 to 100 percent increased risk of premature death from all causes, as compared to individuals with a healthy weight. (U.S. Department of Health & Human Services)
High blood pressure is twice as common in adults who are obese than in those who are at a healthy weight. (U.S. Department of Health & Human Services)
A weight gain of 11 to 18 pounds increases a person's risk of developing type 2 diabetes to twice that of individuals who have not gained weight. (U.S. Department of Health & Human Services)
More than 80 percent of people with diabetes are overweight or obese. (U.S. Department of Health & Human Services)
For every 2-lb. increase in weight, the risk of developing arthritis is increased by 9 to 13 percent. (U.S. Department of Health & Human Services)
Bariatric procedures performed in 1998 totaled 13,386. In 2002, 71,733 bariatric procedures were performed, resulting in a 436 percent increase. (www.medpagetoday.com)
In 2003, more than 103,000 bariatric procedures were performed, an increase of more than 30 percent in a single year. (American Society for Bariatric Surgery)