How Exercise Physiologists Can Maneuver Into a Solid Health Care Niche With Bariatric Patients
Eric Durak, MS
Medical Health and Fitness
Santa Barbara, CA

Introduction
My neighbor Bob is a CEO of a major bariatrics company.  After speaking with him at breakfast last month - I learned two things.  First, that hot chocolate is loaded with antioxidants, and second, that bariatric surgeries are looking for wellness as part of their patient offerings.

Bob knows of what he speaks.  As the CEO of one of the nation's largest bariatric consulting firms, he has placed over 17 new programs in hospitals and clinics over the past three years.  He is looking to expand his patient services from simply offering surgeries and counseling, to adding (perhaps), an exercise and lifestyle components.

It seems as though bariatric patients undergo a large battery of profile tests to see if they are good candidates for the rigorous type of surgery they are about to undergo.  Hence, there may be some efficacy to adding an exercise component to persons who may be at the high end of compliance to specific medical and health promotion prescriptions.  Also, for each patient who is accepted, CMS (Medicare), and most major health plans will pick up almost ALL of the $25,000 (or higher) bill for this type of medical procedure.  

Just think about adding $1-2,000 for a year's worth of exercise services, and you are talking about a program that is destined to succeed at perhaps twice that of surgery alone.  For the savvy CEO or finance director, adding the cost of lifestyle management would not add that much to the cost of overall treatment (5-6%).  But, it may save much more in terms of prevention of a multitude of co-morbidities due to circulatory and/or psychosomatic aspects of the struggle to maintain the weight change in a short period.

Working with bariatric patients is a niche that could spell instant employment or contracts for many in the field of wellness and exercise physiology.  After years of being told that exercise is not really part of healthcare (and believing it in many circumstances), many exercise physiologists are looking for specific areas to excel in.  In my opinion - exercise management for bariatrics is a gold mine!  

It offers a patient base in the millions.  It offers a medically based program that really has not been tapped into in terms of both consulting and exercise prescription.  And, it has a strong physician interaction - but the long term exercise care would be up to trained exercise instructors.  In essence - this type of program is hinged on the professionalism of exercise physiologists.  They are the masters of their own destiny.

After discussing this idea with a colleague from Arizona - I am convinced that bariatrics is one place that exercise physiologists should be.  Another fact is that for each patient who is accepted into the rigorous surgery and counseling program - three are turned away.  These patients still need assistance in loosing (in many cases) large amounts of weight.  They need extra care, and in some cases it may be possible to work with their insurers for specific amounts of physical exercise therapy.

How would the exercise - bariatrics arrangement work?  Let's dissect it from
its component parts.

Physician Relationship
In 1992 there were approximately 16,000 bariatric surgeries in the United States.  In 2002 - there were 47,000.  Today, there are closer to 60,000.  As mentioned above, for every patient who qualifies for surgery, there are four who do not.  A search of the Internet brings up many physician bariatric centers nationwide.  A listing of such programs is seen in Table 1:

Table  1 - Physician Related Bariatric Web Sites

www.BariatricDocShop.com 
www.surgicalcenteronline.com 
www.123 skindoctor.com/bariatric
www.iirusa.com/obesity/index 
www.SurgicalWeightControl.com 
www.ObesitySolutions.com 
www.shs.com 
www.usbariatric.com 
www.obesityhelp.com 

Finding a surgery center in your hospital or city should be easy enough.  The next phase is to create a portfolio - and set up a presentation for the group of physicians.  Your program would entail long term exercise for qualified (and rejected) surgical patients.  Your outcomes would be measurable from both clinical and cost-containment strategies.

Referrals
Setting up referrals should take place based on your ability to provide three times per week exercise in personal or small group settings.  You may solicit referrals based on square footage, staff qualifications (we are assuming one clinically trained exercise physiologist), outcomes measurement tools (software, forms, etc.), and pricing structure (to be discussed in the next section).  You should be receiving referrals each week from your physician practice.  Assuming a practice performs 2-3 surgeries per week (10-15 rejections), you should negotiate to receive 2-5 new patients per week.

Billing or Contracting
Each surgery is billed out for approximately $25,000 - depending on geographic area, and contractual arrangements with private insurance or CMS.  Exercise therapy / wellness counseling should be written in as part of the contract.  Coding for such programs may fall under CPT coding segments as those listed below.  Therapists should remember that contracting for services is a long term treatment plan - so charges (listed below), should
be set and reviewed accordingly:

• 97110 - Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility
• 97112 - Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception
• 97150 -  Therapeutic procedure(s), group (2 or more individuals)
• 97530 -  Therapeutic activities, direct (1 on 1) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Financial Amounts
Most billing under the current CPT coding system is for acute services.  Billing for 97110 or 97530 may take place for 3-8 visits, depending on the  diagnosed condition. Therefore, rates may vary (depending on geographic area) from $35-80 per session.  Rates should be built into the contract for total bariatric services.  If exercise were to take place three times per week for six months (at a rate of $40 per session), rates would average $720.00 for that exercise timeframe.  It is estimated that a year-long exercise program would cost on average $1,500-2,500 per patient.  It is an extremely reasonable addition to a total program based on the benefits accrued.  

Outcomes / Disease Management
These benefits would certainly mean proper outcomes for exercise services.  Outside of maintaining or losing additional weight, outcomes for such a program would include the following:

• Body fat measures - the use of skinfolds, BIA, or air displacement methods that would give a simple and repeatable measure of fat to lean ratios
• Fitness measures - improvements in aerobic and strength throughout the program based on the type of prescription
• Range of motion - concomitant improvements in joint range of motion
• Reduction in basic physiology measures - blood pressure, resting heart rate, pulmonary measures, fasting blood glucose
• Quality of Life measures - issues of self esteem, depression, improvement in activities for daily living, and other related surveys should be performed throughout the program

The demand for outcomes has spurred a new industry in the health and fitness world - with Orion Outcomes software leading the charge in the medical outcome environment - with programs for cardiac rehab, weight management, and cancer wellness as part of their offerings.  Whatever program is used - it is imperative that programs develop outcomes strategies from the first day of exercise. 

Follow Up
Do patients in commercial weight loss programs keep the weight off?  They do if you believe the commercials.  However, the data is clear that most who attempt long term weight loss do not succeed.  Therefore - another important aspect of bariatric programs are long term follow up of patients (every six months). This would ensure that patients who tend to backslide can be brought into the supervised aspect of the program if needed.

Cost Savings
There are many studies that have shown tremendous cost savings for employee based health programs.  In the area of bariatrics, the cost-benefit of such an invasive procedure is weighed against long term complications arising from being morbidly obese over time.  We are assuming that the application of cost savings from other clinical programs may be applied to the obesity issue.  The long term effects of regular exercise on reductions in co-morbidies may also make such program appealing to health care providers.  

We can hope that health plans, anxious to save money on what they consider to be one of the greatest health challenges of this decade - will see the benefits of adding exercise therapy to the surgical and counseling services already afforded weight loss patients who are in need of dramatic lifestyle changes that are needed to help their ailing health, but what may be considered the ailing health of our nation as a whole.
 

Selected Readings

Avenell, A., Broom, J., Brown, T.J., Poobalan, A., et al.  (2004). Systematic review of the long term effects and economic consequences of treatment for obesity and implications for health improvement.  Health and Technology Assessments Journal.  8:21:1-194.

Franks, P.W., Ekelund, U., Brage, S., et al. (2004).  Does the association of habitual physical activity with the metabolic syndrome differ by level of cardiorespiratory fitness?  Diabetes Care.  27:5:1187-93.

Kennedy, R.L., Chokkalingham, K., and Srinivasan, R. (2004).  Obesity in the elderly:  Who should we be treating, and why, and how?  Current Opinions in Clinical Nutrition and Metabolic Care.  7:1:3-9.

Gibb, B. (2004). Food minus exercise = fat.  The Lancet.  363:9416:1246.

Janssen, I., Katzmarzyk, P.T., Ross, R., Leon, A.S., Skinner, J.S., et al. (2004).   Fitness alters the associations of BMI and waist circumference with total and abdominal fat.  Obesity Research.  12:3:525-37.