Pennsylvania: Designing Services to Treat Overweight and Obese Medical Assistance Children

1. Pennsylvania: Designing Services to Treat Overweight and Obese Medical Assistance Children Holly Alexander RN, BSN Pennsylvania Department of Public Welfare Director, Office of Clinical Quality Improvement Email: HALEXANDER@state.pa.us

2. 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

3. 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

4. ACCESS Plus and Voluntary Managed Care (where available) Mandatory Managed Care - HealthChoices Program Service Areas ERIE SUSQUEHANNA WARREN McKEAN BRADFORD TIOGA POTTER CRAWFORD WAYNE WYOMING FOREST SULLIVAN ELK CAMERON LACKAWANNA VENANGO PIKE MERCER LYCOMING JEFFERSON CLINTON LUZERNE CLARION MONROE LAWRENCE COLUMBIA MONTOUR CLEARFIELD UNION BUTLER CARBON CENTRE ARMSTRONG SNYDER NORTHUMBERLAND NORTHAMPTON BEAVER SCHUYLKILL INDIANA MIFFLIN LEHIGH CAMBRIA BLAIR JUNIATA PERRY ALLEGHENY BERKS DAUPHIN BUCKS LEBANON WESTMORELAND HUNTINGDON MONTGOMERY WASHINGTON CUMBERLAND LANCASTER BEDFORD PHILADELPHIA CHESTER FRANKLIN YORK FULTON DELAWARE FAYETTE ADAMS GREENE SOMERSET

5. 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

6. 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)

7. 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

8. 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%

9. Designing the Service Package • Rationale • Types of service • Return on Investment (ROI) modeling • Review for legislative changes, CMS approvals, regulatory or contract changes

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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?