Jeanne Jones, a nurse at Orange Coast Memorial Medical Center, gingerly felt her way down the steps because she couldn't see her feet beneath her broad belly. She waddled to the hospital lobby and pressed her plump frame into a chair. When she got up, she had to squeeze herself out.
As she made her way toward the hospital pharmacy, she spied a nurse she had worked with for years. She was about to say hello when the nurse looked away.
She didn't recognize Jones, who helps manage the Fountain Valley hospital's weight loss surgery program, because Jones made the rounds in an actor's fat suit. Jones had rented the 35-pound disguise to get a sense of the physical obstacles her obese patients encountered at the hospital.
Feeling all but invisible when she was ignored, Jones confronted her colleague, saying, " 'Hey, don't you know who I am?' She said, 'Oh, my god. I didn't pay attention to you because you are so fat,' " Jones recalled. "I was so shocked."
That's when Jones retooled the weight-related sensitivity training at the hospital. There are no longer any "fat" people at Orange Coast. Overweight patients and visitors now are referred to as people "of size."
In the hospital trade, big people have become big business.
Orange Coast performed 467 weight loss operations last year, up from 19 in 1997, the year it began with one surgeon. Since then, the hospital has added three surgeons to keep up with demand. Patients have flown in from as far away as Alaska, Japan and Germany for surgery.
Across the country, stomach stapling and other weight loss surgeries, with their promise of a trim physique, have grown nearly tenfold in a dozen years. More than 140,000 patients underwent the procedures in the U.S. last year -- at an average cost of $25,000 -- generating revenue of more than $3.5 billion.
For many of the nation's hospitals, one-third of which are losing money, weight loss surgery is a welcome source of revenue. The surgeries help balance the costs of emergency rooms, providing care for the uninsured and other cash drains.
Some hospitals chase weight loss patients the same way casinos compete for high rollers.
Fourteen years after a federal advisory committee cautiously endorsed the risky surgery, the field is getting crowded, particularly in California, where about 10% of the weight loss operations are performed. At last count, the American Society for Bariatric Surgery said, at least 1,445 surgeons were performing the procedures at more than 450 hospitals across the country.
"It's a gold rush in medicine," said Roland Sturm, a senior economist at Rand Corp., a Santa Monica think tank. "No hospital or doctor wants to be left behind."
Because the procedures are elective, a hospital can wait to verify insurance coverage, cash a patient's personal check or help a patient line up financing before scheduling the operation. That makes it a tempting field for hospitals that are swamped by unpaid bills.
But some insurers are concerned that the rapid proliferation of weight loss surgery is jeopardizing patient safety.
"Many hospitals are setting up what we call their 'neon sign,' " said Dr. Michael-Anne Browne, a regional medical director for Blue Shield in Southern California. "A lot of hospitals are trying to get into the game, and that concerns us."
In California, HMO patients have a good chance of getting their surgery approved because their plans are required by law to cover any treatment a doctor deems necessary. However, preferred provider organizations have more latitude.
Outside of California, some insurers that were deluged by claims for weight loss surgery have stopped covering the procedures altogether. Other plans are delaying operations by requiring patients to enroll in medically supervised weight loss programs for six months to a year. Some plans pay for these diet programs; others don't.
"It's not like getting your appendix taken out," said Dr. Sam Ho, medical director at PacifiCare Health Systems Inc., a Cypress-based insurer. "This is a very, very complicated procedure. There are lots of risks: blood clots, stroke [and] abscesses."
Hospitals with inadequate pre- and postoperative diet and counseling programs and inexperienced surgeons can put patients at risk of complications and even death, insurers say. They point to studies showing that surgeons who have performed fewer than 50 operations have more patient complications and higher death rates.
A recent analysis by Rand Corp. of 150 weight loss studies found that one in five patients had complications, and most of them were minor. As for the serious complications -- such as intestinal leaks, blood clots and bowel obstructions -- they often require subsequent operations and prolonged hospitalization.
Reported death rates for weight loss surgeries range from 0.5% to nearly 3%, said Dr. Melinda Maggard, a UCLA surgeon on the Rand research team. A common cause of death in weight loss cases is infection stemming from bowel leaks, Maggard said.