FOR YEARS, many bariatric patients remained behind closed doors, often leading sedentary, dependent lives. Today, a diverse range of bariatric products has flung open those doors, giving severely obese adults the opportunity to be more independent and productive than ever before.

Indeed, home medical equipment manufacturers now cater to the bariatric community with everything from beds and wheelchairs to scooters, walkers and bath products. Sales of such items, manufacturers say, now account for 10 to 100 percent of their annual revenue.

Why bariatrics? Most manufacturers surveyed say they entered the market because it made economic sense. About 5 percent of the U.S. population-or nearly 14 million people-is severely obese. And this percentage is expected to increase.

"There's tremendous growth poten-tial in this market," confirms Scott Alexander, product manager for KCI, a bed manufacturer based in San Antonio. "I've been in patients' homes where they haven't left the house for eight years!"

New Products-and Sales LOOKING TO SERVE this underserved population, Wheelchairs of Kansas in Ellis, Kan., has manufactured bariatric products exclusively for the past 11 years, according to Michele Eberle, marketing director. Company founder Lee Frickey entered the market by producing wheelchairs for customers weighing 300 to 1,000 pounds, Eberle says. Soon, however, the company identified a demand for additional types of bariatric equipment and began to expand its product line. Today, the company offers power wheelchairs, walkers, beds and lifts.

Steve Cotter, vice president and director of marketing for Gendron Inc., says his Archbold, Ohio-based company has sold bariatric wheelchairs for more than 20 years, and it has expanded its product line to include bariatric bath products such as commodes and bath transfer benches. "It's a significant niche for our company," he says.

Teftec, a 5-year-old company in Spring Branch, Texas, moved into the bariatric market after first producing a standard-size chair for clients weighing up to 400 pounds. It was a natural progression to use the design and stability features of the company's standard-size chairs in the production of bariatric power chairs, says Tom Finch, president.

And like the company's standard chairs, he notes, the bariatric power chairs operate indoors and outdoors to give users maximum independence. "It's an indoor chair that can be used off-road very well," says Finch, adding that bariatric sales account for 10 to 15 percent of the company's business.

Pride Mobility Products, Exeter, Pa., sells three types of products for the bariatric market: scooters with a 400-pound capacity, power wheelchairs with a 450-pound capacity and lift chairs with a 475-pound capacity. Altogether, says Scott Higley, national sales manager, they account for a "significant" amount of Pride's overall sales.

A Certain Style BREAKING INTO THE bariatric market is attractive, but manufacturers in the niche caution that it involves much more than just making your standard products larger.

As Higley recalls, early versions of bariatric wheelchairs tended to be, well, large and bulky.

Not only were they unappealing in style, but they also had few options, he adds. Standard-size wheelchairs of the time came with a wide selection of options; bariatric clients, however, were limited to chairs with "older design, reinforced-looking frames" that looked like large, awkward medical equipment, he says.

Such is not always the case anymore. According to Finch, his bariatric chairs appear less bulky because the wheels are underneath rather than at the sides of the seat frames. For added comfort, the chairs also offer adjustable foot plates, custom seats and enhanced suspensions.

When companies finally began designing bariatric equipment that had real style, Higley says, it changed the dynamics of the entire market. "That's why I think you're seeing growth (in this market)."

Bariatric equipment designs are most successful, says Higley, when they are both stylish and durable. "People don't want to sacrifice one for the other," he says. "So the challenge is to provide them with both, which we feel we do. We don't ever want to sell something that sacrifices one for the other."

His company, for example, uses a rigid power base frame for its bariatric wheelchairs because a folding frame has too many moving parts-and thus a greater opportunity for failure.

Because durability and strength are so critical, says Cotter, the lighter-weight composite materials used in the wheel construction of mobility equipment for average-size individuals might not be suitable for a 700-pound patient. "There has not been as radical a change in materials in the (bariatric) segment as there has been in lightweight chairs," he says.

Capitalizing on Customization CUSTOMIZATION IS ANOTHER critical issue for manufacturers serving the bariatric market. "All of our equipment is custom-made," reports Eberle, for one. "We have nothing in stock."

Customized products are in great demand, agrees Cotter. Ten years ago, he reports, Gendron manufactured bariatric chairs in three widths that were limited to a couple of weight capacities. Today, it produces a diverse line of bariatric wheelchairs for customers weighing 350 to 700 pounds. Options include a variety of seat-to-floor heights, seat plane angles, seat widths and seat depths.

"It is no longer one-size-fits-all," Cotter says. "Even though these are production products for us, every single one is different."

This wide variety in available products does put pressure on the distribution side of the business. Because most products are customized, providers cannot keep them in stock. And it's particularly tough for rural-based "mom and pop" providers to carry bariatric equipment because they don't have the population base to support the market.

For the most part, Eberle says, providers order each product when requested by the client.

The ABCs of Bariatrics FOR MANUFACTURERS, PART and parcel of being in the bariatric market is offering education-not only about the products but also about how they should be used and who should use them.

Gendron, for example, offers training and advice in helping HME providers select the appropriate products for their customers. It also hosts presentations, workshops and other educationalforums for health care professionals. The company makes a concerted effort to develop relationships with physical and occupational therapists, notes Cotter. "That awareness drives the demand, which in turn drives the higher degree of customization," he says.

Because its products are highly customized, Eberle says, Wheelchairs of Kansas has a special customer service department to train and educate providers in selecting just the right model for each customer.

By focusing on just three product lines, the Pride sales team has become product specialists instead of generalists, according to Higley. That way, he says, his staff can train dealers how to select proper seating and positioning and handle other special requirements for their bariatric customers.

Alexander of KCI says his company works with providers-and directs its attention to caregivers, who encounter special challenges caring for severely obese patients. Risk management is a concern for these caregivers, Alexander says, and they need equipment that not only provides a comfortable environment for the patient but also ensures the safety of the nursing staff and others who must work with the equipment.

For example, he says, many bariatric patients were forced in the past to sleep on mattresses on the floor because regular bed frames wouldn't accommodate their weight. Today, however, his company manufactures beds that can support up to 1,000 pounds.

One of the troublesome issues with larger beds, Alexander continues, is fitting them through narrow door openings. But he says KCI solved the problem by creating a two-piece, modular-design unit that can be assembled in the home.

The Reimbursement Challenge FOR MANUFACTURERS, PROVIDERS and patients alike, reimbursement for bariatric products of all sorts is yet another difficult issue.

Martin Szmal, general manager of reimbursement services for Pride, says his department works closely with providers to ensure smooth billing. Medicare provides adequate coverage for the cost of manual and power wheelchairs for bariatric clients, he says, but reimburses for bariatric scooters only at the same rate as for those designed for normal-weight patients. On average, however, bariatric scooters cost about 20 percent more than average-size scooters.

Before July 1998, says KCI's Alexander, bariatric equipment didn't have a clear Medicare "B" reimbursement code. Today, he says, Medicare reimburses for bariatric equipment at a fairer rate-but providers still face a low return on their investments.

"It's not a cut-and-dried industry," Alexander says. "There are a lot of things working for us and a lot of things working against us."

The good news, according to Cotter, is that reimbursement hasn't "tightened up" for bariatric equipment as much as it has for other types of home medical equipment. Still, he agrees that one of the industry's greatest challenges ahead is to produce products with new and improved features that also keep the unit cost low enough for reimbursement.

Forecasting the Future WHAT DOES THE future hold for the bariatric market?

Alexander declines to give specific figures but says the number of bariatric beds produced by KCI has "soared" in recent years. And while the company is strictly a bed manufacturer, Alexander doesn't rule out expansion of the product line.

At Wheelchairs of Kansas, says Eberle, "I see us getting busier and busier." She says she also sees more competitors in this market segment today than 10 years ago to match the increase in the number of bariatric patients.

Cotter reports that Gendron bariatric power wheelchairs have experienced significant sales growth the past few years. He also says he expects his company to continue to add new bariatric products to its lineup.

To judge by the optimism of the manufacturing base, the outlook for the market is rosy. As more products become available for bariatric patients, more people will take them out on city streets and in outdoor recreational settings-and so help increase product awareness and demand.

While ahead of the curve in product development, the United States isn't the only target market for bariatric products.

* Pride Mobility Products, Exeter, Pa., is selling its products throughout the world.

* Gendron Inc., Archbold, Ohio, has limited distribution of its products in parts of Europe, Canada, Latin America and Asia.

* Wheelchairs of Kansas, Ellis, Kan., sells its products in Puerto Rico and Canada.

* Teftec, Spring Branch, Texas, plans to expand its sales overseas, especially with its off-road chairs in areas where sidewalks of centuries-old cities have not been upgraded to accommodate wheelchairs.

* KCI, San Antonio, sells bariatric products in Canada and plans to expand into the European market. -L.W.