Pennsylvania: Designing Services to Treat Overweight and Obese Medical Assistance

Children

David K. Kelley MD, MPA Chief Medical Officer

Pennsylvania Department of Public Welfare Office of Medical Assistance Programs

c-dakelley@state.pa.us

Objectives

Review the environment for change in Pennsylvania (PA)

Outline steps utilized to prepare PA Medical Assistance’s (MA) service package to treat children who are overweight or obese

Understand the pricing model of the obesity service package that includes budgetary impact and ROI

Understand the service package design

Discuss educational efforts for providers and consumers

Pennsylvania Medical Assistance

Covers 1.8 million consumers (14% of Commonwealth population)

Mandatory Managed Care Program – HealthChoices – covering 1.1 million consumers – 650,000 children

Enhanced Primary Care Case Management Program – ACCESS Plus – covering 300,000 consumers – 188,000 children

Program Service Areas ERIE

CRAWFORD

WARREN

FOREST

McKEANPOTTER

CAMERONELKVENANGO

MERCER

BEDFORD

BLAIR

SOMERSET

CAMBRIAINDIANA

JEFFERSONCLINTON

LYCOMING

SULLIVAN

TIOGA BRADFORDWAYNE

WYOMING

PIKE

LUZERNEMONROE

SCHUYLKILL

CARBON

LEHIGH

COLUMBIA

BUCKS

BERKS

CHESTER

LANCASTER

MONTGOMERY

YORK

LEBANON PERRY

CUMBERLAND

DAUPHINJUNIATAMIF

FLIN

UNION

SNYDER

CENTRE

ADAMS

FRANKLINFULTON

HUNTINGDON

CLEARFIELD

CLARION

LACKAWANNA

MONTOUR

NORTHUMBERLAND

PHILADELPHIA

DELAWARE

SUSQUEHANNA

LAWRENCE

BUTLER

ARMSTRONG

FAYETTE

WESTMORELAND

ALLEGHENY

BEAVER

WASHINGTON

GREENE

NORTHAMPTON

ACCESS Plus and Voluntary Managed Care (where available)

Mandatory Managed Care - HealthChoices

Work Occurring in PA on Obesity

Departments of Health and Education – BMI in schools

Pennsylvania Advocates for Nutrition and Activity (PANA) – Keystone Healthy Zone School Programs

Department of Agriculture – Promoting PA Fruits and Vegetables

PA Medical Society – Physician Survey

Obesity Workgroup

Formed stakeholder workgroup in 2004 – Multi-agency, consumers, providers

Developed an action plan

Initially met monthly - decreased to annually

CDC Award

Heinz Grant - HEALTH for Families Project (Healthy Eating and Activity for Lifetime Habits)

Tools for Providers and Consumers

Tool Kits for Providers

• General Information

• Clinical guidelines, research and education

• Treatments, management, prevention

• Patient education and consumer information

Consumer Brochures

www.pamedsoc.org/obesity

Annual BMI Performance Measure

In 2007 36% measured were overweight or obese 15% overweight and 21% obese

85% had height and weight measured

BMI calculation 2005 to 2007 increased from 21% to 41%

Designing the Service Package

Rationale

Types of service

Return on Investment (ROI) modeling

Review for legislative changes, CMS approvals, regulatory or contract changes

ROI Methodology

33% of children are overweight or obese Assumed 1% treated – 3,000 children

Average cost of treatment - $974.42/year

41% of the 3,000 children – about 1,200 will achieve a BMI less than 85%

Over 10 years 1.67 ROI

Childhood Nutrition and Weight Management Services

Require an initial assessment (96150) Each 15 minutes face-to-face with patient $20.38 Limited to three initial assessments/365 days Minimum 30 minutes – maximum 45 minutes

Re-assessment (96151) Each 15 minutes face-to-face with patient $20.38 Limited to four re-assessments/365 days Minimum 30 minutes – maximum 60 minutes

Use of Appropriate Diagnosis Coding 278.00-278.02 along with V-code V85.52-V85.54

Childhood Nutrition and Weight Management Services

Counseling Codes 96152 - face-to-face individual counseling $19.16 96153 - face-to-face counseling two or more $5.39 96154 - face-to-face family counseling, patient present

$19.16

Maximum twenty-four 15 minute units for all codes combined per 365 days

RN can bill in addition to physicians, CRNPs and clinics

Childhood Nutrition and Weight Management Services

Nutritional Counseling Code (S9470)

Only billable by registered dietician – able to enroll as individual provider

Maximum 12 visits/365 days – flat rate of $26.46 per visit

Allow community as place of service for visit to grocery store with consumer

Educational Efforts

PA Medical Society

• Obesity Summits – CME

• Counter Details – CME

• Provider Tool Kits

• Website links to assessment tools and intervention methodology

ACCESS Plus

• Provider rep education

• Gathering direct provider feedback

• Provide referral sites

Educational Efforts

Pennsylvania Chapter of the American Academy of

Pediatrics • “Let’s Talk” on childhood obesity

• Website links to bulletin

• Posting information on billing Consumers

• EPSDT (Early Periodic Screening, Diagnosis and Treatment) letter includes information on services

• Working with consumers on best distribution methods

• Approach to improve awareness of services

Challenges/Barriers

Additional educational efforts

Need for additional MCO reimbursement

Cannot begin counseling services without having had an assessment

Do we need consumer and/or provider incentives? What type?