Who Should Pay for Obese Health Care?

Bariatric ambulances, services are more popular, but some patients pay the bill.

ByLAUREN COX<br>ABC News Medical Unit
July 1, 2009, 5:59 PM

July 2, 2009&#151; -- When paramedics come to the rescue, they typically look for vital signs first -- breathing, a pulse. But in more communities each year, paramedics might also be sizing up the patient to see if a bariatric ambulance specially designed to carry severly obese people needs to be called.

Topeka, Kan., is one of at least 30 communities across the United States that has commissioned ambulances with a specialized cot, ramp and winch to lift patients who weigh more than 350 pounds, according to ABC News affiliate KTKA in Topeka.

Patients who need the special ambulances in Topeka will be charged more money for the service -- $1,172 rather than $629, plus $16 per mile rather than $11.

After a decade of spiraling weight problems in America, hospitals across the country are responding with bariatric specialized care -- from floor-mounted toilets to specialized prenatal clinics for obese women.

"We really think this helps provide dignity to a patient," said Douglas Moore, public relations manager for American Medical Response, a private ambulance service that operates in 43 states and is the developer of the "bariatric" ambulance used in Topeka's Shawnee County. The company's first bariatric ambulance debuted in 2002, and they have spread across the country ever since.

"A lot of our profession is lifting patients from the cot into the bed," he said.

Moore said clients across the country, including fire departments, occasionally have had to call for backup to lift severely obese patients.

Obesity activists reacted with disdain to the practice of charging more for use of the new bariatric equipment, especially in a service funded by taxpayers.

"Increasing that rate from $629 to $1,172 is price gouging, and it's targeting a particular group of people," said Barbara Thompson, vice chairman of the Obesity Action Coalition in Tampa, Fla. "It can be looked at no other way than discriminating against them."

AMR markets the higher charge as a solution to cities, counties and towns that respond frequently to such patients at an extra cost to ... someone.

"We don't advertise this as a bariatric ambulance. ... You wouldn't know that it was a different ambulance on the outside," said Moore. "We do advertise it to the hospital."

Paying for Specialized Obesity Care

Many ambulance services and hospitals do not charge the patient directly for the specialized services. But it will cost something to continually serve such patients or keep up with the obesity rates. In 1999, 32 states had an obesity rate below 20 percent. Today, only one state has an obesity rate below 20 percent.

"We look at it as an investment in service and quality versus an additional cost that we have to pass off on somebody," said Steve Lawler, president of Pitt County Memorial Hospital in Greenville, N.C.

Similar to a sub-specialty in geriatrics, Lawler said Pitt County Memorial Hospital has worked with the American Nurses Association to develop an accreditation for bariatric nursing. The hospital also has invested in lifts and special beds to accommodate bariatric patients in or outside of the bariatric surgery center.

"It [the change] really has been over the last two years," said Lawler. "It's reflective in regards to what's going in health care and what's going on in health reform."

Perhaps spurred either by the idea of changing the focus of hospitals and health care, or by sheer logistics, hospitals in many areas are implementing similar renovations.

When Baptist Hospital East in Louisville, Ky., opened a 144-private-room tower, the administrators kept weight in mind.

"Each nursing unit [floor] includes two bariatric rooms equipped with an overhead lift to assist the patient from the bed, or even all the way to the handicapped accessible bathroom," wrote Kit Fullenlove, public relations manager for Baptist Hospital East, in an e-mail to ABCNews.com.

Such lifts are intended for 440 to 660-pound patients, and the renovations have extended to older areas of the hospital.

"We are renovating many of our older nursing units and converting many semi-private rooms to private rooms. In the process, we are creating one bariatric room per nursing unit, each of which features a larger doorway to better accommodate the use of a larger, bariatric bed," Fullenlove said.

Treating Obese Patients in Obstetrics and More

The hospital is adding to the number of bariatric wheelchairs, blood pressure cuffs and gowns it already had.

"None of these costs have been passed on to the patients," Fullenlove said.

Alongside the movement to revamp equipment is a move into specialized treatment for bariatric patients in other specialties. Both the University of Michigan Hospital and St. Louis University Hospital developed special units for obstetric care for obese mothers.

"We want to monitor these patients very closely," said Dr. Raul Artal, a professor and chairman of the department of obstetrics, gynecology and women's health at St. Louis University Hospital in Missouri. "We see them more frequently. We have a dietician who works full time and [will] dedicate more time to these patients."

Artal explained that women who are obese, especially if they have a Body Mass Index of 40 or higher, are more likely to have miscarriages, babies with birth defects and "a multitude of problems."

"For some of these patients, they are so obese for the last weeks of their pregnancy [that] they cannot walk, so they are confined to a wheelchair," he said.

But the clinic has good news, too. Artal said about 40 percent to 50 percent of his patients are able to fully comply with nutrition, diet and exercise programs during their pregnancy and, overall, 70 percent to 80 percent of patients make some progress.

"We see patients who have had hypertension when they enter the program, and when they exit the program their blood pressure is normal," he said. "We have success stories, but we would like to extend this clinic."

Artal said the patients at his clinic pay no more for their extra care than any other woman with a high-risk pregnancy.

Activists have felt that while additional charges might be considered discriminatory, specialized bariatric care, in general, might be supportive.

"Women who are at a BMI of 40 -- they may have special care available because they are at a greater health risk," said Thompson. "It strikes me as good medicine, and I applaud them for not charging a higher rate."

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