Can HME providers partner with sleep laboratories to boost sales of bariatric products? Exploring the OSA/obesity link yields some interesting possibilities.

Obesity is a sizable problem in America. These days, everyone from newborns to nonagenarians seems to be packing too many extra pounds. For some adults, the amount of excess weight is substantial—enough to be labeled profoundly obese—tipping the scales at 400 to 500 pounds or more. Dealers have typically responded by adding a variety of bariatric products (such as beds and wheelchairs) to their existing product mixes.

However, in serving the profoundly obese, some DME dealers also discover the opportunity to develop one other potentially significant line of business—sleep medicine. “There is a well-established link between obesity and obstructive sleep apnea,” says Gary Hamilton, RRT, clinical specialist manager for ResMed Corp, Poway, Calif. “Obesity is classified as the number one risk factor for sleep apnea.”

Indeed, in a fairly recent study, researchers at Brooke Army Medical Center in Fort Sam Houston, Tex, observed that an obstructive sleep-related breathing disorder was present in 88% of patients evaluated for bariatric surgery;  obstructive sleep apnea (OSA) was present in 71% of the cases and upper airway resistance syndrome in 17%.

Far from being an isolated discovery, the results of that investigation have been echoed in scores of others. “Some [of those other studies] have looked at particular indices to see if there are correlations that could make identifying these patients more accurate, such as neck size or body mass index,” says Hamilton, noting that “in men with a neck diameter of 17 inches or greater and in women with a neck size of 16 inches or greater, OSA is frequently identified.”

He goes on to say that additional studies are currently in progress to ascertain the prevalence and relationships between OSA and other diseases—hypertension, heart failure, and diabetes chief among them. “These seem to correlate highly with obesity,” he concludes.

POTENTIAL FOR PARTNERING
The primary conservative intervention for OSA is continuous positive airway pressure (CPAP) therapy, which, of course, many DME/HME providers already offer. At C&C Homecare Inc, Bradenton, Fla, for example, bariatric adults account for 5% to 10% of that provider’s patient base, but, of those, roughly 80% are or were CPAP users, reports owner Alan Cross, MHA, RRT.

Many OSA sufferers begin their journey back to healthfulness with a prescription for CPAP written by a sleep medicine physician on staff at a local sleep laboratory. It occurs to some observers and players that DME/HME dealerships stand to capture much referral business for bariatric items beyond CPAP devices, if only they were to forge stronger relationships with those laboratories. Hamilton plainly thinks so. But, he cautions, the success of any such partnering hinges on the dealer’s ability to understand what the laboratory requires. “The need could be to have bariatric equipment available for appropriate patients, or it could be to have sleep patients supported by a licensed health care professional,” he says.

— Ramon D. Paquette, RPSGT

Agreeing with that assessment is Ramon D. Paquette, RPSGT, owner of the Vermont Medical Sleep Disorders Center in Essex Junction, Vt, and the Adirondack Regional Sleep Disorders Center in Plattsburgh, NY. “Networking among specialties is so important, and I can see a situation where sleep labs and HME providers could work together to help patients with appropriate bariatric equipment,” he says. “However, any system of reciprocal referrals would work better as part of an overall care plan, because patients often feel isolated among specialties.”

Michael DiFranco, bariatric products manager for Invacare, Elyria, Ohio, likes the idea of DME/HME providers teaming up with sleep laboratories. However, in his view, the practicalities of the health delivery system will conspire to render these partnerings less fruitful than hoped. “On the surface, it does seem like it would be a great business opportunity for a DME provider because most bariatric CPAP patients are not being introduced to the full line of DME products that could really benefit their lives—products that could get them mobile, make their homes safer, and so forth,” he says. “However, the way it usually works is the sleep patient goes to their primary care doctor who comes up with an initial, tentative diagnosis of OSA and then forwards the patient to a sleep specialist for testing. If the diagnosis is confirmed, the sleep doctor issues a prescription for CPAP and then sends the patient back to the primary care doctor. So, really, the more appropriate partner for the DME provider in all this is the primary care doctor, because the doctor is the more likely one to explore with the bariatric patient issues involving their home environment and mobility.”

NEED FOR BETTER INNOVATION
In any event, the OSA-obesity link has not gone unnoticed—or unacted upon—by product manufacturers. “At Invacare, we are trying to help hospitals designated as bariatric surgery centers develop complementary sleep departments,” says DiFranco. “It would be our hope that any such sleep department would end up preferring Invacare sleep products, which would then allow us to introduce them to our DME lines.” Standing to benefit from that effort: home care providers carrying bariatric products.

Currently, the number of dealers who do carry bariatric products to any serious extent from any manufacturer is relatively small. Even so, were a dealer to contemplate making an initial foray into that arena, it might be ill advised to stock products without first “proactively promoting your enterprise as a bariatric resource,” DiFranco cautions. “Most providers who accept bariatric business have taken a somewhat passive position, taking orders only as they come in the door. What they don’t realize is that the case managers, discharge planners, and other referrers have not yet established a strong supplier preference for bariatric products. Invacare is trying to help DME/HME outlets become the provider of choice by partnering with them on in-services programs for discharge planners and case managers. The aim of these in-services is to acquaint those referrers with the bariatric products now available.

“Our position is that the bariatric market is growing, that it is not a niche. And there is going to eventually be a tidal wave of demand—but it will be demand captured only by the right providers.”

DiFranco’s assessment of the market leads him to conclude that many dealers shy away from the bariatric market because they have convinced themselves the products are too expensive to stock. Cost is an issue for Cross, but he surmounts it by relying on the just-in-time method of inventorying. “Although I don’t keep bariatric beds on hand, if someone came in and asked for one, I could have it at his home within 72 hours,” he tells. “That’s obviously not as quick a response as it would be if I had a bed in stock, but it is an acceptable amount of time for the patient to wait because a bariatric bed is not a product anyone is probably going to be needing on an emergency basis. But, if the patient is willing to pay the freight costs himself, we can shave time off by shipping direct to his home.”

As to the products themselves, DiFranco contends manufacturers could do better insofar as design and features are concerned. “In a lot of instances, what the industry has done is simply take products designed for the geriatric population and made those bigger,” he explains. “The industry needs to pay more attention to product innovation in the bariatric segment. Some of that is going to involve designing for dignity. By that, I mean we have to build into the products a greater degree of stylishness—a lot of obese patients are youngish and do not want a walker that looks like something for grandma or grandpa.”

CRISIS WAXING OR WANING?
Although Cross welcomes bariatric business at his store, he is not convinced that obesity is the way of the future. “I think the obesity crisis is going to diminish in the years ahead,” he predicts. “I am not seeing any increase in the number of patients requiring both a bariatric bed and CPAP, and I believe that is directly tied to the growth in the number of bariatric surgeries being performed. Bariatric surgery has become simpler and less expensive. It has advanced from complicated gastric bypass surgery to stomach stapling and now to less-invasive lap-band surgery. To me, this means we can expect to see more obese people requesting surgery, which will result in a reduction of the number of people who are obese.”

Still, there is always sleep therapy—and that is likely to remain a growing market because OSA is a problem that affects people of all shapes and sizes, as Cross attests.

Adds Hamilton, “Sleep therapy can be a rewarding business for the home care provider. As a clinician, it is exciting to see how a patient’s life can be turned around completely by allowing them to get an uninterrupted night of sleep. As a business person in this market, it can be rewarding to know you are building your business by taking care of your patients and supporting them over the long term.”

Rich Smith is a contributing writer for Dealer/Provider.

How to Suggest a Scooter
Profoundly obese patients—adults weighing in excess of 400 pounds—occasionally venture into a DME/HME dealership in search of a simple mobility aid when, in reality, what would be more appropriate for them is a powered scooter. Is there a way to make such a recommendation without hurting the individual’s feelings or otherwise giving offense and losing the sale?

Sure, says Alan Cross, MHA, RRT, co-owner of C&C Homecare Inc, Bradenton, Fla. “First of all, profoundly obese people are already only too aware of their condition and the functional limitations that go along with it,” he offers, “so it is not like it will come as breaking news when you frame the discussion in terms of them needing equipment designed for the profoundly obese. They have come to you looking for help in identifying and selecting products that are going to be right for their particular situation. All you have to do is make some suggestions.

“However, here in my store, when a person who is over 400 pounds stops by, we like to refer them to a dealer that specializes in power mobility. The big players—Permobil, Pride, Jazzy, Hoveround, and Invacare—all have specialized scooters for these types of patients,” continues Cross. “We feel this is the best way to make sure the bariatric patient is provided the right item. Also, there are reimbursement issues involved—with all the hoops you have to jump through to get something like this taken care of, the patient really needs to be working with an expert in bariatric mobility.”