improving payment for obesity care - ihcw payment... · treatment of obesity in children and...

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,

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• Pleasedonotputyourselfonhold,aswewillbeabletohearyourholdmusic.

• Today’swebinarwillberecorded.Thelinktotherecordingwillbeshared~1weekfollowingtoday’sevent.

• Questionswillbeansweredattheendofthewebinar.• Questionsshouldbesubmittedinthechatbox.Noquestionswillbe

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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

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

http://onlinelibrary.wiley.com/doi/10.1002/oby.v24.5/issuetoc

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


About15%of2-19yr olds



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%


About15%of2-19yr olds


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


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.


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


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


ConferenceGrantR13HS02281601:“Evidence-basedchildhoodobesitytreatment:Improvingaccessandsystemsofcare”fromtheAgencyfor

HealthcareResearchandQuality.

• VersionofRecordonline:7DEC2016|DOI:10.1002/oby.21712

VersionofRecordonline:7DEC2016|DOI:10.1002/oby.21712

Thankyou!

Questions

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