Hospitals Hunger for Losses
Jeanne Jones, a nurse at Orange Coast Memorial Medical Center, gingerly felt her way down the steps because she couldn’t see her feet beneath her broad belly. She waddled to the hospital lobby and pressed her plump frame into a chair. When she got up, she had to squeeze herself out.
As she made her way toward the hospital pharmacy, she spied a nurse she had worked with for years. She was about to say hello when the nurse looked away.
She didn’t recognize Jones, who helps manage the Fountain Valley hospital’s weight loss surgery program, because Jones made the rounds in an actor’s fat suit. Jones had rented the 35-pound disguise to get a sense of the physical obstacles her obese patients encountered at the hospital.
Feeling all but invisible when she was ignored, Jones confronted her colleague, saying, “ ‘Hey, don’t you know who I am?’ She said, ‘Oh, my god. I didn’t pay attention to you because you are so fat,’ ” Jones recalled. “I was so shocked.”
That’s when Jones retooled the weight-related sensitivity training at the hospital. There are no longer any “fat” people at Orange Coast. Overweight patients and visitors now are referred to as people “of size.”
In the hospital trade, big people have become big business.
Orange Coast performed 467 weight loss operations last year, up from 19 in 1997, the year it began with one surgeon. Since then, the hospital has added three surgeons to keep up with demand. Patients have flown in from as far away as Alaska, Japan and Germany for surgery.
Across the country, stomach stapling and other weight loss surgeries, with their promise of a trim physique, have grown nearly tenfold in a dozen years. More than 140,000 patients underwent the procedures in the U.S. last year -- at an average cost of $25,000 -- generating revenue of more than $3.5 billion.
For many of the nation’s hospitals, one-third of which are losing money, weight loss surgery is a welcome source of revenue. The surgeries help balance the costs of emergency rooms, providing care for the uninsured and other cash drains.
Some hospitals chase weight loss patients the same way casinos compete for high rollers.
Fourteen years after a federal advisory committee cautiously endorsed the risky surgery, the field is getting crowded, particularly in California, where about 10% of the weight loss operations are performed. At last count, the American Society for Bariatric Surgery said, at least 1,445 surgeons were performing the procedures at more than 450 hospitals across the country.
“It’s a gold rush in medicine,” said Roland Sturm, a senior economist at Rand Corp., a Santa Monica think tank. “No hospital or doctor wants to be left behind.”
Because the procedures are elective, a hospital can wait to verify insurance coverage, cash a patient’s personal check or help a patient line up financing before scheduling the operation. That makes it a tempting field for hospitals that are swamped by unpaid bills.
But some insurers are concerned that the rapid proliferation of weight loss surgery is jeopardizing patient safety.
“Many hospitals are setting up what we call their ‘neon sign,’ ” said Dr. Michael-Anne Browne, a regional medical director for Blue Shield in Southern California. “A lot of hospitals are trying to get into the game, and that concerns us.”
In California, HMO patients have a good chance of getting their surgery approved because their plans are required by law to cover any treatment a doctor deems necessary. However, preferred provider organizations have more latitude.
Outside of California, some insurers that were deluged by claims for weight loss surgery have stopped covering the procedures altogether. Other plans are delaying operations by requiring patients to enroll in medically supervised weight loss programs for six months to a year. Some plans pay for these diet programs; others don’t.
“It’s not like getting your appendix taken out,” said Dr. Sam Ho, medical director at PacifiCare Health Systems Inc., a Cypress-based insurer. “This is a very, very complicated procedure. There are lots of risks: blood clots, stroke [and] abscesses.”
Hospitals with inadequate pre- and postoperative diet and counseling programs and inexperienced surgeons can put patients at risk of complications and even death, insurers say. They point to studies showing that surgeons who have performed fewer than 50 operations have more patient complications and higher death rates.
A recent analysis by Rand Corp. of 150 weight loss studies found that one in five patients had complications, and most of them were minor. As for the serious complications -- such as intestinal leaks, blood clots and bowel obstructions -- they often require subsequent operations and prolonged hospitalization.
Reported death rates for weight loss surgeries range from 0.5% to nearly 3%, said Dr. Melinda Maggard, a UCLA surgeon on the Rand research team. A common cause of death in weight loss cases is infection stemming from bowel leaks, Maggard said.
Concern about such risks has prompted insurers to bypass hospitals and surgeons without long and stellar records. The American Society for Bariatric Surgery is developing a “centers of excellence” program. Orange Coast is among the first hospitals to win the group’s provisional approval.
At the hospital, Jones’ concern for how overweight patients were being accommodated was piqued one day when she spotted an obese patron trying to stand up, only to see a lobby chair rise with her. “I almost cried,” Jones said. One of her patients also complained that normal-size people like Jones “just don’t understand what we go through.” So Jones rented the fat suit.
Her experiences sped up design changes at the hospital.
Obese patients at Orange Coast used to have to trek outside to the loading dock to weigh in on a freight scale. Now, they are weighed inside on a special scale. The hospital also is replacing porcelain toilets that could snap off of their anchor walls under too much weight with floor-mounted stainless steel models that can hold more than 400 pounds. Extra-wide gurneys and wheelchairs regularly ply its hallways. And in the lobby and meeting rooms, steel beams hidden beneath floral upholstery reinforce the seats of some chairs that are as wide as love seats.
Weight loss surgery is paying off for Orange Coast. In 2003 the nonprofit hospital had a razor-thin operating margin of $864,000 on $90 million in revenue. Without the weight loss cases, it would have been in the red. Its 433 weight loss procedures that year generated about $12,000 each (the rest of the fees go to doctors). All told, the procedures produced about 6% of the hospital’s revenue.
The margin on the procedures is slim, but it’s better than nothing, Jones said. “It helps support some of the things that don’t pay,” she said.
Weight loss surgery is one of the few procedures on which hospitals can make a profit, said Sheryl Skolnick, a healthcare analyst with Fulcrum Global Partners in New York. “There are not many other places left to make money,” she said.
Hollywood Presbyterian Medical Center launched a weight loss surgery program 11 months ago and is now up to five cases a month, with about half of its patients paying out of pocket. “Our volume is going up pretty rapidly,” said Albert Greene, the hospital’s chief executive.
Another source of revenue occurs when weight loss patients return to the operating room for plastic surgery to have extra folds of skin removed. This procedure may be covered by insurance if it’s medically necessary, such as when yeast infections develop in the skin folds.
Much of the demand stems from the buzz over celebrities’ experiences, starting with pop singer Carnie Wilson, whose weight loss operation in 1999 was beamed over the Web. “Today” show weatherman Al Roker said he lost 105 pounds after his weight loss surgery. Beach Boy Brian Wilson and “American Idol” judge Randy Jackson have had the surgery.
And in Los Angeles, hip-hop DJ Big Boy appears on billboards holding up the weight loss badge of honor -- tent-like pants. He has said he lost 250 pounds.
Also stoking demand are studies that have shown surgery is more effective for severely obese people than dieting and exercise alone, and it can defeat diabetes, high blood pressure, sleep apnea and elevated cholesterol.
When Barbara Skinner started to develop diabetes, she decided to investigate weight loss surgery.
The owner of a staircase-parts manufacturing business in Long Beach, the 5-foot-4-inch Skinner weighed 260 pounds last year. “I looked gruesome,” she said.
An avid golfer, Skinner, 64, could no longer walk from a cart to the tee. She had to stop to catch her breath while walking from her garage to her home. For years, she resisted because of a fear of major surgery. In the end, Skinner felt she’d run out of options. “I had tried every diet,” she said.
A friend told her about Orange Coast hospital. In February Skinner had a gastric bypass procedure there. A surgeon created a small pouch by stapling Skinner’s stomach just below her esophagus. A piece of her intestine was attached to the pouch so that food bypasses her stomach. The smaller pouch holds less food and absorbs fewer calories.
Gastric bypass is the most common of several procedures that are known as bariatric (from the Greek word “baros,” for weight) surgery. A newer, increasingly popular type of surgery, known as banding, limits food intake by constricting the stomach with an adjustable band.
Postoperative patients lose weight the old-fashioned way: They diet. But their smaller stomachs make it easier to eat smaller portions.
For three weeks after surgery Skinner drank only liquids. She still eats mostly bland pureed food, steering clear of hard-to-digest items that might upset her remodeled digestive tract. “I make sure I get meat and vegetables even though a lot of times it’s baby food,” she said.
She may never have more than half a cup of food at a time. And Skinner stays away from fat and sugar because even small portions of such high-calorie foods can scuttle a surgeon’s best handiwork.
Skinner lost 45 pounds in six weeks and is confident she will lose 80 more to reach her target weight of 135. She recently played 18 holes of golf. “I’m a changed woman,” she said.
