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
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?
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