Obesity a Growing Problem

The rise of obesity to epidemic proportions is bringing exceptional challenges not only to society in general, but also specifically to injured workers, the workers' compensation adjuster, and the nurse case manager.

There are a multitude of co-morbidities associated with the bariatric individual, including diabetes, heart disease, pulmonary complications, gallbladder disease, joint disease, vascular insufficiencies, and the increased risk of renal and liver disease associated with long-term medication management.

The estimated annual cost of overweight and obesity in the United States is $112.9 billion. This estimate accounts for $64.1 billion in direct costs and $58.8 billion in indirect costs related to the obesity epidemic. Direct health-care costs for obesity refer to preventive, diagnostic, and treatment services for obesity-related diseases and conditions.

Indirect costs related to the obesity epidemic include wages lost by people unable to work because of illness or disability, as well as the value of future earnings lost by premature death. Obesity and obesity-related conditions or ailments result in at least $62.7 million in doctors' visits and $39.3 million in lost workdays each year.

Increased Risks

How does this affect the claims industry? In a study conducted at the University of Manitoba, Canada, of patients of varying weight who underwent total joint replacement surgery, the research team found that highly obese patients were 2.3 times more likely to stay in the hospital more than five days and 2.6 times more likely to be discharged to a skilled nursing facility.

The study concluded that:

Obese patients take more time in the operating room

Obese patients are more likely to incur greater medical expenses secondary to post-operative complications

Obesity limits a patient's range of motion, prolongs recovery, and extends the need for physical therapy

Obesity conferred the highest risk of post-operative complications and the need for additional post-discharge care — 3.7 percent compared to 2.6 percent for non-obese patients, 2.6 percent for patients with hypertension, and 2.6 percent for patients with diabetes

The likelihood of a "non-routine" discharge from the hospital was 45 percent higher in the obese patient.

Additional research also shows that obesity is associated with a substantially higher risk for infection in women, which leads to more dislocations, results in more surgical revisions, and moderately lowers functional outcomes with slightly less satisfaction mostly due to a higher incidence of complications. Osteoarthritis in the obese population is four to five times higher than in the normal-weight population.

The obesity epidemic has led to an increase in the number of costly pre-operative diagnostic studies. While this may increase the overall claim costs, it ultimately could prove beneficial. When the underlying co-morbidities associated with obesity can be identified pre-operatively, the post-operative complications will be more obvious and predictable.

Once underlying co-morbidities are recognized, the claim examiner has a better base from which to begin setting appropriate reserves on the claim file. Often reserves will double and sometimes triple secondary to the myriad of co-morbidities or complications associated with the obese injured worker.

The myriad of complications does not just impact reserves for medical care and treatment. It has a significant impact on the indemnity reserves as well. With lower functional outcomes, a release to any type of gainful employment may be significantly delayed with the potential for greater restrictions and potentially higher impairment ratings.

Redesigning Equipment and Homes

Home accessibility for the obese patient can lead to costly intervention. The individual who normally has a 54-inch waist may not have experienced difficulty getting in and out of his home pre-injury. However, the wheelchair or stretcher that is wide enough to accommodate the obese patient may not fit through the front door.In one claim, the obese patient had to resort to living in his garage during the recovery period. Increased costs were also incurred for special equipment to support the individual's weight and girth.

Based on statistical data, as Americans continue to remain overweight or obese, we will continue to see an exponential rise in our claim handling costs secondary to the myriad of complex needs for the obese population. Health-care facilities may be forced to have a full line of heavy-duty bariatric equipment available to accommodate the increased number of obese patients.

In addition, our industry may need to focus on designing and building diagnostic equipment that will easily accommodate the 400- to 500-plus pound individual with a body girth exceeding 54 inches.

Based on a review of outpatient diagnostic centers, there are only a handful of facilities throughout Florida that can accommodate the obese patient. The problem does not always lie with the table or base of the equipment; sometimes it is the equipment itself. With magnetic resonance imaging, the coil that is placed around the abdomen or lower back is not constructed large enough to accommodate the full girth of an obese individual.

Medical equipment designed to accommodate the obese population is not only significantly larger than normal, but also weighs two to three times what a piece of equipment would weigh for the normal-weight population. This in and of itself can significantly impact the bariatric patient's ability to use the equipment properly.

In one real-life case, an obese female underwent knee surgery and had to use crutches after the procedure for six weeks. The bariatric or heavy-duty crutches weigh three times more than a standard set.

The patient did not have the upper extremity strength to lift each crutch in order to ambulate. As a result, an order had to be obtained for a bariatric walker and wheelchair to accommodate her post-operative needs.

In this instance the accommodations were temporary in nature and the bariatric female was able to maneuver within her home using the walker. However, because of the size of the bariatric wheelchair, she was unable to go through any doorways at her home.

Permanent modifications or retrofitting a home to accommodate the bariatric patient can run into the hundreds of thousands dollar range. If the bariatric patient resides in a manufactured home, the strength of the floor struts must taken into consideration to make certain that the floor will actually be able to support the weight of the bariatric equipment that can range anywhere from 60 to 1,000 pounds.

In another case study, a bariatric quadrapalegic weighing 485 pounds was using a bed constructed to support up to 600 pounds. However, the weight of the injured worker's significant other was not taken into account. Once both of them were in the bed, their combined weight exceeded the weight capacity, and the bed had to be replaced with one that would accommodate 1,000 pounds. In this instance, the total combined weight of the couple and the bed was closing in on 2,000 pounds.

As the epidemic of obesity in our society continues, we will be plagued with rising medical costs, longer periods of disability, and increased lost days from the workforce, resulting in decreased productivity and increased lost wages.

As claim examiners and medical case managers, we will need to work outside of the box to identify cost-effective solutions to manage and provide the medically necessary care and treatment to assist the bariatric patient in achieving maximum functional outcomes.