Obe­sity epi­demic cre­ates sup­ply chain prob­lems for providers

Hos­pi­tals are car­ry­ing higher sup­ply-chain costs re­lated to larger num­bers of obese pa­tients, with much of that ex­pense not be­ing re­im­bursed

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Health sys­tem ex­ec­u­tive Deb­o­rah Tem­ple­ton re­mem­bers a time not so long ago when the max­i­mum-weight ca­pac­ity la­beled on tra­di­tional-size pa­tient beds, gur­neys and wheel­chairs topped out at about 350 pounds.

These days, how­ever, it’s not un­usual for such equip­ment to ac­com­mo­date pa­tients weigh­ing up to 500 pounds. And Tem­ple­ton, the vice pres­i­dent of sup­ply chain ser­vices at Geisinger Health Sys­tem, Danville, Pa., says her sys­tem is pur­chas­ing a grow­ing amount of equip­ment suit­able for even larger pa­tients. In ad­di­tion to beds, gur­neys and wheel­chairs, Geisinger or­ders gowns, blood pres­sure cuffs, spe­cially made sur­gi­cal in­stru­ments and other sup­plies to be used in car­ing for a bur­geon­ing pop­u­la­tion of obese pa­tients.

Geisinger is hardly alone in its ex­pe­ri­ence. Through­out the U.S., hos­pi­tals in­creas­ingly are buy­ing spe­cially sized equip­ment and sup­plies, ad­just­ing their phys­i­cal plants to ac­com­mo­date se­verely over­weight pa­tients, and pro­vid­ing a more in­tense level of care to obese pa­tients. All of which places greater de­mands on hos­pi­tals’ staffing and fi­nan­cial re­sources.

Ac­cord­ing to a June 2010 sur­vey per­formed by group pur­chas­ing or­ga­ni­za­tion No­va­tion, 61% of re­spond­ing fa­cil­i­ties have seen an in­crease in ad­mis­sions of mor­bidly obese pa­tients (with a body mass in­dex of 40 or higher). Some 87% of re­spon­dents said they have had to equip their emer­gency rooms to ap­pro­pri­ately care for obese pa­tients, and 28% said they have within the past year ren­o­vated their fa­cil­i­ties to ac­com­mo­date larger pa­tients.

“In the past sev­eral years, we’ve re­al­ized that we needed to build out a more ro­bust port­fo­lio of prod­ucts for tak­ing care of obese pa­tients,” says Cathy Den­ning, vice pres­i­dent of sourc­ing for No­va­tion, based in Irv­ing, Texas. That port­fo­lio in­cludes items such as big­ger op­er­at­ing ta­bles, stur­dier crutches and stress-test tread­mills, and spe­cially de­signed en­do­tra­cheal tubes.

Such equip­ment and sup­plies typ­i­cally cost providers 25% to 30% more than tra­di­tion­ally sized items, sup­ply chain ex­perts say. “When you get up to the higher-end beds and me­chan­i­cal lift­ing de­vices, it can be three to five times more ex­pen­sive,” Tem­ple­ton says.

More-costly sup­plies are only one as­pect of the ad­di­tional ex­pense that of­ten is at­tached to car­ing for pa­tients with a BMI higher than 30. Obese pa­tients typ­i­cally re­quire longer hos­pi­tal stays, a greater num­ber of clin­i­cal staff to at­tend to them and more costly in­ter­ven­tions to re­cover from an ill­ness than pa­tients who aren’t obese, clin­i­cians say.

A July 2009 study, “An­nual med­i­cal spend­ing at­trib­ut­able to obe­sity: payer-and-ser­vice­spe­cific es­ti­mates,” pub­lished on­line by the jour­nal Health Af­fairs es­ti­mated that obe­sity was re­spon­si­ble for ap­prox­i­mately $147 bil­lion in med­i­cal costs cov­ered by pub­lic and pri­vate pay­ers in 2008. That es­ti­mate does not ac­count for out-of-pocket pa­tient costs and non­re­im­bursable costs borne by providers.

‘Sunken’ costs

Get­ting at the costs that providers bear to care for over­weight pa­tients is no easy task, how­ever. De­spite sig­nif­i­cant anec­do­tal ev­i­dence that hos­pi­tals pay more to care for se­verely over­weight pa­tients and stud­ies that show obese Amer­i­cans rack up more in health­care costs than their coun­ter­parts of healthy weight, hos­pi­tals are hard-pressed to quan­tify obe­sity’s ef­fect on their bot­tom lines.

“I don’t know of a hos­pi­tal in the coun­try that can cap­ture all of their obe­sity-re­lated costs,” says Paul Keck­ley, ex­ec­u­tive di­rec­tor of the Deloitte Cen­ter for Health So­lu­tions. Keck­ley says that a good many of the costs as­so­ci­ated with car­ing for an obese pa­tient are “sunken”—mean­ing they are buried and dif­fi­cult to tag with a spe­cific price. For ex­am­ple, obe­sity cost es­ti­mates don’t ac­count for a hos­pi­tal’s lost pro­duc­tiv­ity when it has to as­sign two em­ploy­ees in­stead of one to help bathe or get an obese pa­tient out of bed.

“I don’t think the cur­rent es­ti­mates of obe­sity costs have come close,” Keck­ley says. “We’ve not looked, for ex­am­ple, at the cost of the back prob­lem that some­one de­vel­ops be­cause they’ve been help­ing a pa­tient out of chairs.”

Still, while hos­pi­tals, GPOs and health­care data or­ga­ni­za­tions haven’t quan­ti­fied the ex­pense that hos­pi­tals in­cur when car­ing for obese pa­tients, there is con­vinc­ing ev­i­dence that those costs are sub­stan­tial.

Joanne Reid, ad­min­is­tra­tive di­rec­tor of the Sur­gi­cal Weight Loss In­sti­tute at 160-bed Cas­tle Med­i­cal Cen­ter in Kailua, Hawaii, says that among her hos­pi­tal’s gen­eral pa­tient pop­u­la­tion, 80% to 90% of pa­tients who are di­ag­nosed with sleep ap­nea de­velop the con­di­tion be­cause they are over­weight. In re­sponse, the hos­pi­tal has gone from own­ing two con­tin­u­ous pos­i­tive-air­way pres­sure ma­chines in 2005 to cur­rently own­ing 10. The ma­chines typ­i­cally cost $2,000 to $14,000 apiece, Reid says.

“And we’re still rent­ing ad­di­tional ones on a weekly ba­sis be­cause we aren’t meet­ing the need” with cur­rent stock, she says. “We haven’t done a cost com­par­i­son anal­y­sis on obese pa­tients, but anec­do­tally, our clin­i­cians would tell you it’s sub­stan­tially more.”

A big­ger ticket

A grow­ing body of stud­ies is doc­u­ment­ing the di­rect health­care costs as­so­ci­ated with obe­sity and con­firm­ing that pa­tients who strug­gle with sig­nif­i­cant weight prob­lems are likely to have higher health­care costs. Ac­cord­ing to data from the Eco­nom­ics of Obe­sity, a yet-to-be-pub­lished re­port from the con­sult­ing firm McKin­sey & Co., an obese pa­tient with a BMI be­tween 30 and 34 will rack up about $725 more per year in health­care costs than some­one with a healthy BMI of 25 or lower. Those ad­di­tional an­nual costs hit $2,170 for some­one with a BMI be­tween 35 and 39 and a whop­ping $3,605 in ad­di­tional yearly costs for an in­di­vid­ual with a BMI of 40 or higher (See chart, this page).

“Ev­ery point of BMI above 30 was cor­re­lated with roughly $300 per year, per capita in in­creased health­care costs,” says Steven Gip­stein, the McKin­sey as­so­ci­ate prin­ci­pal who com­piled the re­port.

The re­port also found that in to­tal, Medi­care, pri­vate pay­ers and pa­tients dished out about $160 bil­lion in 2008 to pay for care that was the re­sult of obe­sity-re­lated co­mor­bidi­ties and com­pli­ca­tions, in­clud­ing high blood pres­sure, di­a­betes, heart dis­ease and sleep ap­nea.

Such obe­sity-re­lated con­di­tions can have cost rip­ples be­yond the ex­pense of man­ag­ing the dis­ease, how­ever. Pa­tri­cia Wrobbel, di­rec­tor of nurs­ing for sur­gi­cal, med­i­cal spe­cial­ties, emer­gency ser­vices and nurs­ing qual­ity at New York’s 1,039-bed Mount Si­nai Hos­pi­tal, notes, for ex­am­ple, that con­di­tions such as di­a­betes and sleep ap­nea can neg­a­tively af­fect re­cov­ery of pa­tients who have un­der­gone surgery.

“Now, you’re not just man­ag­ing the sur­gi­cal is­sue; you also have to man­age all these other is­sues as well,” Wrobbel says. “The surgery can go well, but be­cause of anes­the­sia and other stres­sors on the body, it could in­crease their length of stay.”

When pos­si­ble, some providers are at­tempt­ing to ad­dress the added clin­i­cal costs of car­ing for obese pa­tients and pro­vide for a quicker re­cov­ery by man­ag­ing cer­tain con­cerns pre-op­er­a­tively, Wrobbel says. “Maybe pre-op­er­a­tively some­one goes to an anes­the­si­ol­o­gist for an as­sess­ment,” she says. “Or we will put off the surgery to ag­gres­sively man­age their con­di­tions pre-op­er­a­tively.”

While payer-doc­u­mented costs give some hint of how obe­sity-re­lated con­di­tions can drive up health­care costs, those fig­ures don’t ac­count for the sig­nif­i­cant non­re­im­bursable ex­penses that providers in­cur to care for se­verely over­weight pa­tients.

Daniel Soud­ers, sur­gi­cal ser­vices prod­uct man­ager for the Ket­ter­ing Health Net­work in

Day­ton, Ohio, says those costs can in­clude higher prices for longer nee­dles and sur­gi­cal clamps ca­pa­ble of pen­e­trat­ing and han­dling a greater mass of skin; en­larged door­ways and spe­cially con­structed bath­room fix­tures to ac­com­mo­date larger pa­tients; and added staff to bathe, trans­port and monitor se­verely over­weight pa­tients.

There can be other hid­den costs as well. Geisinger, for ex­am­ple, has a staff train­ing pro­gram that ad­dresses sen­si­tiv­ity is­sues as­so­ci­ated with car­ing for se­verely over­weight pa­tients. It also teaches care­givers to prop­erly lift and trans­port obese pa­tients.

“There are cer­tain con­cerns there, be­cause we want to make sure we don’t in­jure the pa­tient or the work­ers,” says Geisinger sup­ply chain ex­ec­u­tive Tem­ple­ton.

Providers also can in­cur ad­di­tional costs for sur­gi­cal sup­plies such as anes­the­sia and su­tures since sur­geons typ­i­cally need to use greater quan­ti­ties or more-ex­pen­sive ver­sions of those items when op­er­at­ing on se­verely over­weight pa­tients. But, be­cause the costs of such items are in­cor­po­rated into a bun­dled fee charged to pay­ers, hos­pi­tals re­ceive no ad­di­tional re­im­burse­ment to cover those ex­penses.

“Pay­ers don’t pay more for car­ing for obese pa­tients even though we have ad­di­tional costs,” Soud­ers says.

A grow­ing num­ber of clin­i­cal and health­care-pol­icy ex­perts are sug­gest­ing that, given the ris­ing rates of obe­sity and its as­so­ci­ated com­pli­ca­tions and costs, it may be time for pay­ers to ad­dress the is­sue of ad­di­tional re­im­burse­ment. Last year, sev­eral com­menters weigh­ing in on the CMS’ then-pro­posed hos­pi­tal re­im­burse­ment rules sug­gested that the agency re­clas­sify obe­sity as a com­pli­ca­tion or co­mor­bid­ity un­der the 2010 Medi­care in­pa­tient prospec­tive pay­ment sys­tem rule. That re­clas­si­fi­ca­tion would al­low hos­pi­tals to bill the CMS for ad­di­tional re­im­burse­ment when car­ing for pa­tients diag- nosed as obese—a BMI of 35 or higher. The com­menters, ac­cord­ing to a May 4 Fed­eral Reg

is­ter no­tice, said obe­sity added “to the com­plex­ity of care for pa­tients” un­der­go­ing cer­tain pro­ce­dures such as or­tho­pe­dic surgery.

Ac­cord­ing to a CMS spokes­woman, the agency re­con­sid­ered the obe­sity re­clas­si­fi­ca­tion request for the 2011 in­pa­tient PPS rules. But af­ter re­view­ing avail­able cost im­pact data, the agency—which was sched­uled to pub­lish its fi­nal rules for 2011 on Aug. 1, 2010—said it was not propos­ing such a re­clas­si­fi­ca­tion.

The data found, for ex­am­ple, that hos­pi­tal costs for a mor­bidly obese pa­tient with­out a sec­ondary di­ag­no­sis such as di­a­betes or hy­per­ten­sion was not sub­stan­tially more ex­pen­sive than the ex­pected cost of care for all pa­tients with a par­tic­u­lar con­di­tion. The cost ra­tios pro­vided by the CMS in the pro­posed in­pa­tient PPS rule were un­clear how­ever, and

Mod­ern Health­care was un­able to use them to de­ter­mine a per­cent­age dif­fer­ence in care costs be­tween obese pa­tients and the gen­eral pop­u­la­tion. A CMS spokes­woman was also un­able to pro­vide an ex­pla­na­tion.

Lack of re­search

But some clin­i­cians and pol­icy ex­perts feel that avail­able data doesn’t ad­e­quately re­flect the costs of car­ing for obese pa­tients. They say the CMS and other pay­ers aren’t cap­tur­ing in­for­ma­tion that could more ac­cu­rately re­flect those costs.

“There is a lot of guess­work go­ing on,” says Keck­ley of Deloitte. But he adds that the new In­ter­na­tional Clas­si­fi­ca­tion of Dis­eases cod­ing sys­tem—an update of the sys­tem used by providers and pay­ers to iden­tify dis­eases and con­di­tions—set to take ef­fect in 2013 should do a bet­ter job of cap­tur­ing obe­sity-re­lated health­care costs. The broader use of elec­tronic health records should also fa­cil­i­tate com­pil­ing such date.

Cur­rently, how­ever, ef­forts to win ad­di­tional re­im­burse­ment ap­pear ham­pered by a lack of pub­lished re­search com­par­ing the care-episode costs of se­verely over­weight pa­tients to those healthy-weight pa­tients who check into hos­pi­tals with iden­ti­cal con­di­tions.

Michael Parks, a hip and knee sur­geon with New York’s Hos­pi­tal for Spe­cial Surgery and an as­sis­tant pro­fes­sor of or­tho­pe­dic surgery at Weill Cor­nell Med­i­cal Col­lege, has be­gun ini­tial re­search com­par­ing the out­comes and cost of care for obese or­tho­pe­dic surgery pa­tients to pa­tients who aren’t obese. He says he has been sur­prised by the dearth of prior re­search in this area.

“As we’ve looked at the work oth­ers have done, there’s not been a lot of in­for­ma­tion, and what does ex­ist is di­ver­gent” in its find­ings, he says.

Over­sized wheel­chairs to ac­com­mo­date bariatric pa­tients are just one spe­cial­ized item adding to the sup­ply­chain costs at Cas­tle Med­i­cal Cen­ter in Kailua, Hawaii.

Den­ning: No­va­tion has added prod­ucts to care for obese pa­tients.

Hos­pi­tals now stock spe­cial equip­ment to care for obese pa­tients, such as this longer

la­paro­scopic nee­dle holder, shown at right above a reg­u­lar

sized model.

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