Guest Columns

The true cost of obesity to SNFs

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Joy Stephenson-Laws, Law Offices of Stephenson, Acquisto & Colman, Inc.
Joy Stephenson-Laws, Law Offices of Stephenson, Acquisto & Colman, Inc.

Obesity continues to pose significant problems for the United States. The U.S. Centers for Disease Control and Prevention reports that more than one-third of adults and children are now considered obese. Often forgotten, or overlooked, in these statistics are the number of older adults, and their caregivers, who are impacted by this epidemic. 

It is now estimated that more than 40% of obese adults are between the ages of 65 and 74 and that almost 30% are over 75.  On average, more than 35% of adults over 60 are obese.

At some point in their lives, many of these older obese adults will need rehabilitative, short-term or long-term care. It has been reported that at least a quarter of patients entering skilled nursing facilities are either moderately or severely obese. Given that obese adults are almost twice as likely to be admitted to a nursing home and that the incidence of obesity continues to be an issue, the number of obese adults needing skilled nursing care is likely to continue to increase as well.

The cost to SNFs

In addition to the logistical challenges of providing needed medical care for these patients, there are significant costs of their care that can greatly impact the profitability and economic viability of SNFs.  For example, many obese adults are admitted with a variety of co-morbidities such as diabetes, chronic cardiovascular disease, gallbladder disease, sleep disturbances or mobility issues, all of which require additional equipment, supplies and staff.  

These include mechanical lifts, which can cost upwards of $10,000, or extra-wide beds, which can increase capital expense by $5,000 per bed. Total costs for all the equipment required to adequately care for obese patients can readily approach $50,000 per facility. These additional costs cannot be readily passed through to patients nor are they typically reimbursed by Medicaid, which covers more than 60 percent of all SNF patients and residents.

In addition, facilities may also need to make structural changes, which can add another $25,000 to the cost of being able to care for obese adults.

Like their hospital and other healthcare provider counterparts, SNFs also must be prepared for the ongoing increased health risks posed by a patient's obesity once they are admitted to a facility. These include increased risk of cardiovascular events such as stroke or the future need for crutches or wheelchairs as their mobility decreases.  

Obesity also impacts staff levels and costs due to the labor-intensive nature of caring for obese patients. In addition to requiring additional staff to perform otherwise routine tasks such as assisting a patient to use the rest-room, turning a patient in bed or bathing, lifting and moving obese patients also present safety and workers compensation issues. Given the staff at many SNFs may be overweight themselves, this creates a perfect storm for staff injuries. 

While not specific to SNFs, the National Council of Compensation estimates the average cost per healthcare work injury to be over $8,000. This clearly is not an insignificant hit to the bottom line.

What facilities can do now

Unlike hospital emergency rooms, rehabilitative, short-term and long-term skilled nursing facilities do not have to serve patients. Because of this, many refuse to admit patients who are above a certain weight or Body Mass Index (BMI). This approach clearly helps protect the bottom line over the short-term but it carries its own risks and drawbacks, which could be even more costly in the long run. These include the risk of potential antidiscrimination lawsuits under the Americans with Disability Act or incurring community and public opinion wrath for literally leaving sick, elderly obese persons with nowhere to go for care. Neither is an attractive option.

Deciding to help obese patients lose weight is not always an option either, since significant weight loss in elderly patients could end up creating more health problems then it solve. Despite their size, they may lose muscle mass instead of fat which can leave them frail and at risk for fractures and mobility challenges. However, should a patient decide to lose weight under their doctor´s care, there are established medical protocols for doing so and these should be followed to the letter.

But what about patients who are overweight or mildly obese and whose conditions are just starting to create additional operational and financial costs? Or those who are not overweight but are clearly starting to gain weight that could quickly accumulate. Are there steps SNFs can take to minimize the chance these patients will become even more overweight?  

The answer is, of course, “yes.”

While federal regulations state that nursing homes must provide “each resident with a nourishing, palatable, and well-balanced diet that meets dietary requirements and any special dietary needs” under the guidance of a registered dietician, facilities have a lot of flexibility on how this regulation is met. While some have moved into innovative, flexible menus that rival commercial restaurants, many continue to offer selections heavy in grains and carbohydrates.

Reducing food Budgets is counterproductive

One financial argument for continuing to offer these grain-based diets is that the alternative of offering healthier foods is just too expensive for all but the most high-end facilities. On the surface, this makes sense:  Reduce food costs, hold or increase food revenues and profit will increase. From a purely mathematical perspective, this is true.

But from a larger perspective, these same administrators may unwittingly be increasing their institution's risk of increased patient care costs as their patients continue to gain weight.  Assuming staff are choosing their meals from the same menu, injuries and sick leave times can also increase, further eroding profitability. In other words, the cost savings and revenue realized by not shifting to healthier food operations may actually be reducing their institution's overall profitability.

There are many things facilities can start doing to achieve the dual goals of protecting their bottom lines while enhancing patient and community health. Many have already taken steps to shift to healthier menus for patients, staff and visitors recognizing that diet can make a big difference in overall health, outcome of treatments and patient quality-of-life.

This “lead by example” approach includes a wide variety of activities such as:

  • Offering more plant-based diet choices, such as quinoa and brown rice, in patient menus
  • Adding organic foods to their offering and using antibiotic-free meat
  • Reducing the amount of non-healthy, calorie-dense food in dining rooms and cafeteria menus
  • Supporting local farmers to provide fresh produce for patient, visitors and employee meals
  • Nutrition testing to identify nutrient deficiencies which may be preventing health progress. For example simply testing for vitamin C may shed light on why a patient's wounds may not be healing quickly.

Another key activity is developing and providing useful community education and making sure people have the tools they need to make healthier food choices. For example, people should not only know what they need to eat. They also need to be able to objectively assess their health status on a regular basis throughout their lives to identify whether what they are eating is actually working for their bodies. This way they can make dietary or lifestyle changes to address individual barriers to their health. 

This approach will also encourage visitors to bring healthier foods when visiting their friends and relatives in the facility instead of “sneaking in” a cheeseburger, fries and milkshake.  

Joy Stephenson-Laws is founding and managing partner of Stephenson, Acquisto and Colman, a leader in healthcare reimbursement law. 


Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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