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WebinarFebruary16,2017
ImprovingPaymentforObesityCare:StrategiesandAdvocacyRecommendationsfromtheAAP/AHRQObesityTreatment&Reimbursement
Conference
Meetthefaculty
StephenCook,MD,MPH,FAAPAssociateProfessorofPediatrics,Golisano Children’sHospitalatUniversityofRochester,AssociateDirector,AAPInstituteforHealthyChildhoodWeight
MeettheFaculty
Moderator:SandraG.Hassink,MD,FAAPAmericanAcademyofPediatricsPast-PresidentandMedicalDirector,AAPInstituteforHealthyChildhoodWeight
Housekeeping
Beforewebegin,pleasenoteafewhousekeepingdetails:• Pleaseuse*6tomuteyourphone;ifyou’reusingcomputerspeakers,
pleasemutethemtoavoidfeedback.
• Pleasedonotputyourselfonhold,aswewillbeabletohearyourholdmusic.
• Today’swebinarwillberecorded.Thelinktotherecordingwillbeshared~1weekfollowingtoday’sevent.
• Questionswillbeansweredattheendofthewebinar.• Questionsshouldbesubmittedinthechatbox.Noquestionswillbe
takenbyphone.• Allquestionsfromthewebinar,includingthosethatwerenot
answeredduetotimeconstraints,willbeavailableinasummarydocumentthatwillbepostedwiththerecording.
Today’sWebinar
• Explorepotentialpaymentmodelsforfamilybasedbehavioralpediatricobesitytreatment
• Learnadvocacystrategiestosupportimprovedcoverageforcare
• IdentifyresourcesavailablethroughAAPandotherstosupportyouradvocacyworkforimprovedcoverageofcare
MeetthefacultyWelcome
Whoisinourvirtualroomtoday?
MeetthefacultyThankyouforcompletingthepoll!
• Weareallanimportantpartofhelpingchildrenwithobesity
• Weallhaveaplacewithinthevarioussystemsthatinfluenceeffectivetreatment.
• Aftertoday’swebinarwehopeyouwillseeyouplaceinthesevarioussystemsandhowyoucanbecomeachangeagentwithinthesesystems.
• Mission:Toadvancethetranslationofevidence-basedtreatmentforchildhoodobesitybyworkingcollaborativelytowardsthedevelopmentoffeasible,acceptable,effectiveandsustainablecaredeliverymodelssupportingtheUSPSTFrecommendationsandcreationofaunifiedstrategyforpolicychangeregardingreimbursement.
Background– AHRQConference
• ExaminetheUSPreventiveServicesTaskForce(USPSTF)recommendationsforchildhoodobesitytreatment,includingthecurrentdraftUSPSTFrecommendations(anticipatedfinalizationandrelease2017)
• Identifyessentialteammembersforthetreatmentofchildhoodobesity
• Discusstheintegratedcaremodelandcontextfortheclinicalmanagementofobesity
• Reviewanddiscussamodelforeffectivechildhoodobesitytreatment:family-basedbehavioraltherapy
PreviousWebinar– EffectiveTreatment
aap.org/AHRQConf
• Familytreatmentmodeliscritical• Interventionsneedtobecomprehensiveand
behavioral• Treatmentshouldconsistofmorethan25
hoursofcontactwithflexibilitytoadjustintensityofcontactbasedonindividualfamilyneeds
• Comprehensiveandconsistenttrainingforstaffteamsdeliveringobesitytreatment
ConsensusRecommendations
TEAM ROLE WHO CAN FILL IT
Medical management PhysicianNurse PractitionerPhysician Assistant
Behavioral interventionist
Mental Health Specialist (e.g., Psychologist/Social Worker/Master’s Level Counselor)DietitianExercise professionalHealth coaches/educators
Supervision PsychologistPsychiatristSocial WorkerPhysician (specialty other than psychiatry)
Subspecialist access as needed (could be virtual)
Exercise Physiologist Registered Dietitian Medical Subspecialist Mental Health
Coordination InterventionistNavigatorCase worker
ConsensusRegardingTeamRoles
Conclusions
• Accesstopaymentforchildhoodobesityisinconsistentandinsufficient
• Demonstrationprojectsshouldbeconductedbyallpayers(Medicaid&private)
• Providersshouldworkwithstatestodevelopstateandregionalstrategiesforappropriatepaymentmodels&todevelopalternativepaymentstrategies
Wilfley,Staiano,Altman,Lindros,Lima,Hassink,Dietz,Cook,Obesity2017,Jan;25(1):16-29.
Barlow S E Pediatrics 2007;120:S164-S192©2007 by American Academy of Pediatrics
UniversalAssessmentofObesityRiskandStepstoPreventionandTreatment
Barlow S E Pediatrics 2007;120:S164-S192©2007 by American Academy of Pediatrics
UniversalAssessmentofObesityRiskandStepstoPreventionandTreatment
PossibleVisitSchedule- FFS
Evidence-basedChildhoodObesityTreatment:ImprovingAccessandSystemsofCareChicago,IllinoisJuly9th-10th,2015
Whyisthisimportantforme?
• PCP – youneedtoknowwhatyourhospital,healthsystem,ACOwillsupport.Canyourefertocommunity,tertiarycare,orhavehealthcoachinyouroffice.
• HospitalDirector/Lead– youwanttoknowhowtodeliverFee-for-Servicebutalsobundledcare&/oralternativepaymentsw/Community-basedOrganization
• RDorMSWorMHC– wherecanIprovidethiscare/bepartofateam,eitherFFSorbundled
ReimbursementModels&ConsiderationsforChildhoodObesity
AHRQPre-ConferenceSurvey
3PrimaryBarrierstoImplementationofEvidence-basedChildhoodObesityTreatment*
77%Lackofinsurance/coverage
74%Coststoimplementtheintervention
66%Lackofadequatetrainingforproviders
EvolutionofDelivery&Payment
Miller,HealthAffairs,2009.
FiveFactorsDrivingTotalHealthCareCosts
1. Prevalence ofhealthconditionsinthepopulation2. Numberofepisodesofcarerequiredpercondition3. Numberandtypeofhealthcareservicesaperson
receivesineachepisode4. Numberandtypeofprocesses,devices,anddrugs
involvedineachservice5. Thepriceforeachofthoseindividualprocesses,
devices,anddrugs
Obesity Volume 24, Issue 5, p 1116-1123, APR 2016
PrevalenceofobesityandsevereobesityinUSchildren,1999-2014
6.3% = Class II: >120% of Obesity
2.4% = Class III: >140% of Obesity
TreatmentofObesityinChildrenandAdolescents
Stage Delivery BehaviorsStage 1–
PreventionPlusOffice-basedsupport,with
scheduledfollow-up5 fruitsandvegetables<2hrsofscreentime
>1hrofphysicalactivity
Stage2 –StructuredWeightManagement
Specially-trainedstaffinofficewithsupportfromreferrals(RD)
Reduced-calorieeatingplan< 1hrofscreentime
Monitoring
Stage3 –ComprehensiveMultidisciplinaryIntervention
Dedicatedweightmanagementprogramorregistereddietician
referral;weeklyfollow-up for8-12weeks
Morefrequentcontact,moref1/3rdstructuredmonitoring,
goal-setting
Stage4 –TertiaryCare
Pediatricweightmanagementcenterwithmultidisciplinaryteam;
clinicalorresearchprotocol
Medication,surgery,mealreplacement,ongoing behavior
change
Adapted from Barlow 2007
Evidence-basedChildhoodObesityTreatment:ImprovingAccessandSystemsofCareChicago,IllinoisJuly9th-10th,2015
About15%of2-19yr olds
TreatmentofObesityinChildrenandAdolescents
TreatmentofObesityinChildrenandAdolescents
Stage Delivery BehaviorsStage 1–
PreventionPlusOffice-basedsupport,with
scheduledfollow-up5 fruitsandvegetables<2hrsofscreentime
>1hrofphysicalactivity
Stage2 –StructuredWeightManagement
Specially-trainedstaffinofficewithsupportfromreferrals(RD)
Reduced-calorieeatingplan< 1hrofscreentime
Monitoring
Stage3 –ComprehensiveMultidisciplinaryIntervention
Dedicatedweightmanagementprogramorregistereddietician
referral;weeklyfollow-up for8-12weeks
Morefrequentcontact,moref1/3rdstructuredmonitoring,
goal-setting
Stage4 –TertiaryCare
Pediatricweightmanagementcenterwithmultidisciplinaryteam;
clinicalorresearchprotocol
Medication,surgery,mealreplacement,ongoing behavior
change
Adapted from Barlow 2007
About7.5%of2-19yr olds
If1/4th w/Obcome/followup~4%
If1/4th continue,then~1%(>6yr)
If1/4th continue,then~0.2%
Evidence-basedChildhoodObesityTreatment:ImprovingAccessandSystemsofCareChicago,IllinoisJuly9th-10th,2015
About15%of2-19yr olds
TreatmentofObesityinChildrenandAdolescents
FourFactorsthatDrivePaymentDecisions
1. Challengeinbundlingpayment2. Negotiatingthepaymentamount3. Assuringqualityhealthcarefor
patients4. Aligningincentivesthrough
multiplepayers
AdaptedfromExhibit2,Miller,HealthAffairs,2009
Fee-For-Service Episode-Of-CarePayment
ConditionAdjustedCapitation
TraditionalCapitation
Discouragesunnecessary servicesin
anepisode?No Yes Yes Yes
Paysforallnecessaryservicesinanepisode? No Yes Yes Yes
Encouragescoordinationof
multipleproviders?No Yes Yes Yes
Facilitatescomparisonofcostsofdifferent
providers?No Yes Yes Yes
Encouragesprovidinghigh-qualityservices? No
Yes,ifqualitymeasuresaretiedto
payment
Yes,ifqualitymeasuresaretied
topaymentYes/Maybe
Avoidspenaltyfortakingsicker patients? Yes
Yes, ifpaymentisadjustedforseverity Yes No
Discouragesunnecessary episodes? No No Yes Yes
RiskontheProvidervs.RiskonthePayer
Fee-For-Service EpisodeofCarePayment
ConditionAdjustedCapitation
TraditionalCapitation
ApplicationtoChildhoodObesity
Treatment
Currentnationaldatashows
servicesnotbeingcovered.FFS
presentsahighlevelofriskto
insurersfromhighvolume&over-utilization.
Limitstreatmentduringadefined
episode,andnotinchroniccaremodel.
Mightbeapplicable incasesofadolescentbariatricsurgery.
Encouragescoordinationandinnovationincare
delivery.Incentivizeshigh-
qualityandefficiency.
Putsahardcaponreimbursement.Leadstolemon
droppingandcherrypicking.Placesahigh
levelofriskonproviders.
WhereisRisk? 100%Payer 100%Provider
RiskontheProvidervs.RiskonthePayer
PaymentreformBundledpaymentsforacutecareepisodes(Hipreplacement)Value-basedpayment(PayforQualityP4Q)Patient-centeredmedicalhome(HealthHome)AccountableCareOrganizations(AdultvsChildFocus)Acceptsperformanceriskforqualityandcost
Medicaid(Medicare)CommercialPlanLargeEmployerGroups
PaymentReform
JointReplacementasBundledEpisode
OverviewofPayers&TheirPriorities
• WhoisLicensed&ScopeofPractice• Commercial&LargeEmployergroupplans
– Tideischangingtoprovidecoverageforweightmanagementtochildrenandfamilies
– EMPLOYERS:Wantmoreproductiveworkforce
• AccountableCareOrganizations(ACOs)– Initialfocusonpatientsinpoverty,andthesocio-economic
barrierstheyface, andonhighcostservices,admissions/EDvisits– Focusonsystemsofcare&caremanagementforpatientswith
complex,chronicconditions
• Medicaid/MedicaidManagedCare– State-by-statepriorities
CommercialPayers:Comments
• Approximately50%ofchildrennationwidearecoveredbyemployer-sponsoredhealthinsurance
• Allbasicservicesincludingwell-childvisitsandroutinevaccinationsarecoveredundertheseplans
• CriticalPointstoMakeaboutChildObesityIntervention– Notjustweightloss,alsogeneralhealthcareandprevention– Obesityprogramsarepreventive treatmentsthatpreventthe
onsetofothermedicalissues– Paymentshouldbebundled forthewholetreatment– Consistent,uniformproductthatproducessimilaroutcomes
ACOComments
• Adult-focusedvsChild-focused(PediatricHospitals)• Accountablecaremeansresponsibleforthehealthand
outcomesofdefinedpopulationofpatientswithsomerisk– Variesbasedonhowthepopulationisdefined,e.g.,allservicesrelated
toahipreplacementorfullfinancialriskforaprimarycarepopulation– Focusisonsystemsofcare– Largelyincentivizedbyinitiallyfocusingonthebiggestdriversofpoor
andexpensivehealthoutcomes• Obesitydoesn’tdriveadmissionsorincreasedmedicalcostsinshortterm,majorityofcostsasadults&inadifferentsystem
– Investmentsinthispopulationneedsupportfromothersources(e.g.,employers,government)andanemphasisonthelong-termpayoffforthegovernmentthatwouldresultfromcare
MedicaidComments
• “Whenyouhaveseen1Medicaidplan,youhavestillonlyseen1Medicaidplan”
• Medicaidbroadlypaysfortreatmentservicesforchildrenwithobesity(“CMShastotelluswhatcodes”)
• CriticalPointstoMakeaboutChildObesityIntervention– Approachchange/implementationatastatelevel– Treatmentapproachneedstobeflexible– Rolesneededmustbeconsideredandadvocatedforwhennecessaryto
ensurepaymentforprovidersotherthanphysicians– Beneficialtotargettreatmenttochildrenwhoare>95th orhigher
• Theydon’tcareaboutparent/adults
“Financiallyrewardprovidersandplansthatdeliverhighvaluecarethroughemphasizingprevention,coordination,andoptimalpatientoutcomesincludinginterventionsthataddressunderlyingsocialdeterminantsofhealth”
NYDOH,April2015
NewYorkStateDepartmentofHealth:APathTowardValue-basedPayment
NYSMedicaidRedesignTeamDeliverySystemReformIncentivePayment(DSRIP)
Buffalo
RochesterSyracuse
Albany
Value-baseRoadmap– movingawayfromFee-For-ServicetowardValue-basedPayment
• Roadmap– movingawayfromFee-For-ServicetowardValue-basedPayment
PopulationHealthfocusonoverallOutcomesandtotal CostsofCare
Sub-populationfocusonOutcomesandCostswithinsub-population/episodeofCare
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm
FeeforService+PerMemberpermonth
HealthHomeorPMPM
BundlePayment
HowanIntegratedDeliverySystemMayFunction:adaptedfromtheDSRIPProgramvision
• Roadmap– movingawayfromFee-For-ServicetowardValue-basedPayment
Commercial / Exchange
From left to right, value shifts from being about volume to a different risk and reward structure
Medicaid
Medicare
Shared Savings
Bundled Payments
Capitation Full RiskShared Risk Health PlanP4P
Direct to Employers
Fee-for-Service
Current Arrangements
Future Arrangements
UpstateNYMedicalCenter&ACOValue-BasedCareRoadmap
OtherKeyPartners/Models
• Hospitals/HealthSystemswilltakeleadonrisk• YMCAhasnationalmodelforDPP
– DevelopingmodelforkidsbasedonMEND– Couldbesub-contractforbundleorbillpayerdirectly
• On-lineorweb-basedbyEmployers(KURBO)• AllianceforHealthierGenerationBenefit
– BluesandLargeEmployer– VeryBroadroleoutinLouisiana
Outcomes/Measure/Metrics
DeliverySystemReformIncentivePayment:MappingStatePrograms
http://www.chcs.org/driving-health-care-innovation-through-dsrip/
WhatareMetrics/OutcomestoMeasure?
• Avoidweight-onlymetrics• Haveappropriateweightchange(5-10%),notcure• Focusonpatientrelatedoutcomes• Focus/addparentparent-related• Processmeasuresarealsoimportant• Advocateformeasuresthatcouldbeusedinpayfor
performanceoraccountablecarearrangements– Tiedollarstoimprovementinshort-termoutcomes(e.g.,decreaseinthe
percentofthepediatricpopulationwithaBMIabovethe85th percentile)– Measurelong-termsavingsforpediatricpatientswhowereorare
engagedineffectiveweightmanagement(e.g.,preventionofmedicalcomorbiditiesandassociatedfinancialsavings)
HowtobeaChampionforObesityTreatment
RoleofHealthcareProvidersNeedtoengage:• parentsandpatientsinadvocatingforbetteraccessto
andreimbursementforchildhoodobesitytreatment.• ObesityActionCoalitionhttp://www.obesityaction.org/
• hospitalleadership likeDirector,Dept Chair,C-suite• healthcaresystemstoassembleneededservices&
advocateforpayment• stateorganizationstoadvocatefor(publicandprivate)
payment.(ie,AAP,HospitalAssoc.)Together(patients/families,healthcaresystems,&providers)needtoworktogethertoencouragefullcoverageforeffectiveobesitytreatment Wilfley,Staiano,Altman,Lindros,Lima,Hassink,Dietz,Cook,
Obesity2017,Jan;25(1):16-29.
Wilfley,Staiano,Altman,Lindros,Lima,Hassink,Dietz,Cook,Obesity2017,Jan;25(1):16-29.
KeyAdvocacyPoints
AdvocacyatStateLevel
PediatricCouncilsThereare39ChapterPediatricCouncils:PediatricCouncilsare:• Aforumforchapterstomeetwithpayerstodiscussissues
impactingaccess,quality,cost,coverageandpayment• Ameanstoaddresspayerpolicies,coveredservicesand
administrativepracticesaffectingpediatricservices• Acollaborativeefforttodiscussideasforresolvingissues
betweenpediatriciansandpayers• Itisnotameanstodiscussornegotiatefees,payment,orany
collectiveactionbypediatricians
AnaloguegroupsfromAcad Nutr DietandAmer PsychAssoc andState-levelHosp Assoc.
PediatricCouncils
• Alabama:ALCHIP• Illinois:BCBS• Minnesota:Obesitycommunitytreatmentservices
• Ohio:Children’sHospitalAssociationofOhio• Missouri:Medicaid&WashU
StateExamples
MHD’sPediatricObesityTreatmentPackageElements
• Eligibility:childrenages≥5y.o.withobesitycoveredbyMOMHD(FFSandmanagedcare)
• Mechanismofbilling:throughamedicaldiagnosis
• Approvedtreatmentproviders:thosewhoarecurrentlyapprovedtobillHBA&Icodes– Licensedpsychologists– Licensedprofessionalcounselors– Licensedclinicalsocialworkers
• LicensedregistereddietitiansforMNTcodesonly
• Treatmentdurationandhours:26hoursofbehavioraltreatmentwith1.5hoursofMNTover6months– Additional3hoursoftreatmentinthefollowing6months
• Total29sessionsofbehavioraltreatmentover12months
MissouriHealthDepartment’sPediatricObesityTreatmentPackageElements
Treatment Sessionlength Numberofsessions ReimbursementRateIndividualassessmentwithBehavioralProvider
30minutes 6 $40persession
FamilymeetingwithBehavioralProvider
60minutes 3 $80persession
GroupmeetingwithBehavioralProvider
60minutes 20 $32perpatient(minimum2patients/familiesforagroup)
IndividualassessmentwithRD(MNT)
30minutes 3 Unknownatthistime;expectedtobe$40/session
Total 27.5Hours 32sessions $750TotalReimbursement
Value-BaseRoadmap– MovingAwayfromFee-For-ServicetowardValue-BasedPayment
• Roadmap– movingawayfromFee-For-ServicetowardValue-basedPayment
PopulationHealthfocusonoverallOutcomesandtotal CostsofCare
Sub-populationfocusonOutcomesandCostswithinsub-population/episodeofCare
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm
BipartisanPolicyCenter.ApreventionprescriptionforimprovinghealthandhealthcareinAmerica.2015
ElementsofaSustainableFundingMechanism
• Paymentforvalueratherthanvolume• Mechanismsforsharingrisksandsavings/benefits
withreinvestment• Optionstocorrectthewrongpocketproblem• Braidedfundingfromdifferentsources• Establishmechanismforfundingcontinuityand
certainty
Summary
• Treatmentoptions(>25hrFBT)sameBUTdifferentreasonsWHYtheywillpay
• Start(Pay)forFFS,thenmovetoVBP– Pre-ACA:FFS100%,needsgrantsandphilanthropy– Post-ACA:FFS30-40%,contracts&bundles40-50%
• Don’tmakeweightonlyormainmetric• PayersreducingRISK,providerstakingonRISK• NeedtolooktowherebothhealthcareDELIVERY and
PAYMENT aregoing• Advocacymight willbehand-to-handcombat,stateby
state
Conclusions
• Accesstopaymentforchildhoodobesityisinconsistentandinsufficient
• Demonstrationprojectsshouldbeconductedbyallpayers(Medicaid&private)
• Providersshouldworkwithstatestodevelopstateandregionalstrategiesforappropriatepaymentmodels&todevelopalternativepaymentstrategies
Wilfley,Staiano,Altman,Lindros,Lima,Hassink,Dietz,Cook,Obesity2017,Jan;25(1):16-29.
ConferenceGrantR13HS02281601:“Evidence-basedchildhoodobesitytreatment:Improvingaccessandsystemsofcare”fromtheAgencyfor
HealthcareResearchandQuality.
• VersionofRecordonline:7DEC2016|DOI:10.1002/oby.21712
VersionofRecordonline:7DEC2016|DOI:10.1002/oby.21712
Thankyou!
Questions