Innovations In Missouri
Medicaid: Considerations for
Childhood and Adult Obesity
Evidence-Based Intervention
Samar Muzaffar, MD MPH
Missouri Department of Social Services
MO HealthNet Division
Medical Director
Objectives
• Overview
– MHD Population
– Overweight/Obesity Rates
• Policy Considerations
• Developing Models
OVERVIEW
Overview
• MHD Population
– Roughly 890,000 MHD participants
– Roughly 440,000 in Managed Care
– Roughly 450,000 in Fee-For-Service
– Roughly 1/3 Adults
– Roughly 2/3 Children
Overview
• MHD principles
– Application of public health, population health
management approach
• Example- Health Home, Managed Care contract
requirements, FFS Case Management Pilot
– Addressing Social Determinants of Health as possible
– Integration of Primary Care and Behavioral Health
– Implementation of informed, evidence-based policy
and updating existing policy to follow the evidence
• Example- Early Elective Delivery, Update to Smoking
Cessation Benefit
– Evaluation of outcomes
Example: Primary Care Health
Home and Target Population
• Disease Breakdown
– 33% Diabetes (national prevalence 8.3%-CDC 2010)
– 30% COPD/Asthma
– 61% Cardiovascular disease (national prevalence 6%CDC 2010)
– 74% BMI>25; 50% BMI> 30 (national obesity
prevalence 36%- CDC 2010)
– 4% Developmental Disability
– 52% Use Tobacco (national prevalence 18-19%- CDC
2011)
LDL Changes in PCHH
Patients with Initially High
Levels
132
HA1c Changes in PCHH
Patients with Initially High
Levels
131.19
10
130
9.89
9.8
128
9.6
126
9.4
124
121.12
122
p<.0001
p<.0001
9.17
9.2
120
9
118
8.8
116
Pre
Pre
Post
Diastolic Blood Pressure Changes
in PCHH Patients with Initially High
Values
Systolic Blood Pressure
Changes in PCHH Patients with
Initially High Values
89
152
150
88
149.75
Post
87.84
87
148
86
146
85
142.94
144
p<.0001
142
83
140
82
138
81
Pre
Post
83.85
84
Pre
Post
p<.0001
Clinical Correlations
• 1% point decrease in HbA1c yields:
o 21% decrease in Diabetes related deaths
o 14% decrease in Heart Attacks
o 37% decrease in micro-vascular complications
• A 10% Cholesterol Reduction yields:
o 30% reduction in Coronary Heart Disease
• A 6 point reduction in Blood Pressure yields:
o 16% reduction in Coronary Heart Disease
o 42% reduction in Stroke
• Hennekens, C. Circulation 1998; 97:1095-1102
Financial Correlations
• Health Home Impacts:
– Reductions in ED utilization
– Reduction in Hospital utilization
– Demonstrated cost savings
Example: Primary Care and Behavioral Health
Integration- Life Expectancy
80
75
70
65
60
55
50
45
40
No Mental Disorder
Any Mental Disorder General Any Mental Disorder Public
Population
Sector
Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year
Bar 1 & 2:
follow up of a nationally representative US survey. Med Care. 2011 June;49(6):599-604
Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality
in a sample of Maryland residents with severe mental illness. Psychiatry Res. 2010 Apr 30;176(2-3):242-5
Example: Primary Care and Behavioral Health
Integration- Per Member Per Month Costs
$1,600
$1,400
$1,200
$1,000
$800
No Mental Disorder
$600
Any Mental Disorder
$400
$200
Melek et al Milliman
Inc, 2013
$0
Private Sector
Medicare
Medicaid
Example: Primary Care and Behavioral Health
Integration- Causes of Excess Mortality
•
•
•
•
•
•
Smoking
Obesity
Inactivity
Polypharmacy
Under Diagnosis of Medical Conditions
Inadequate Treatment of Medical Conditions
Overview
• MHD Obesity Rates
– System Limitations
• MHD uses a claims based system
• BMI not reported to the MHD system unless part of
a claim
Overview
• MHD Obesity Rates
– Data Sources for Modelling
• Adults:
– MHD Primary Care Health Home
» 74% BMI>25
» 50% Obese (national obesity prevalence 36%- CDC 2010)
– CDC National obesity rate 36%
– MO BRFSS rate 30%
• Pediatric, low-income (<130%)
– CDC/NCHS 20.2%
Overview
• Impacts
– Physical
• Increased morbidity and mortality (DM, Heart
Disease, mental health, etc)
Overview
• Impacts
– Financial
• Each Medicaid beneficiary that is obese on average
costs $1,021 more than normal weight
beneficiaries (Finkelstein EA, Trogdon JG, Cohen JW, DietzW. Annual
medical spending attributable to obesity: Payer-and service-specific estimates.
Health Affairs. September/October 2009;28(5):w822-w831. doi:
10.1377/hlthaff.28.5.w822.)
• Pediatric: Missouri will expend $12 billion annually
on obesity-related health care costs by 2030 (CSC
Childhood Obesity Task Force Report, 2014)
POLICY CONSIDERATIONS
Policy Considerations
• Goals
– Follow evidence-based guidelines and standards
• Ex. Early Elective Delivery
– Positively impact morbidity, mortality, quality of life
– Maintain cost-effectiveness; awareness of budget
limitations and potential impacts
Policy Considerations
• Goals
– Develop models for different methods of
implementing a service
• Assess fiscal impact of the conditions
• Assess fiscal impact of proposed interventions
– Cost-neutral or cost-saving? Budget impacts generally
require appropriations authority
– Assess short- and long-term impacts- clinical, fiscal
• Mechanism to evaluate outcomes
– Attain approval or appropriations authority to
implement the policy change
Policy Considerations
• Resources and Reference Points include:
– National Programs (example Medicare)
– Other State Programs
– National guidelines/literature
– National and State bodies of expertise (ex. ACOG for
EED, USPSTF, etc)
– Academics/Research
DEVELOPING MODELS
Developing Models
• Application of Evidence-Based Treatment
Guidelines for Pediatric and Adult Obesity
– United States Preventive Services Task Force
(USPSTF) Recommendations
• Adults: Screen all adults (18 and older); refer to
intensive, multi-component behavioral therapy for BMI
30 or greater
• Pediatric: Screen all children 6 years and older; offer
comprehensive, intensive behavioral intervention
Developing Models
• Steps underway:
– Documentation of burden of disease
– Evaluation of impact of Pediatric Obesity
– Evaluation of impact of Adult Obesity
– Determination of fiscal impact of proposed
intervention
• Short- and long-term evaluation
Developing Models
• Steps Underway:
– Determination of what service is provided
– Determination of codes for the service
– Determination of what provider/specialty type can
provide the service
– Determination of certification requirements
Developing Models
• Possible Next steps:
–
–
–
–
–
Approval or appropriations authority
MHD Systems work
Provider Enrollment systems work
Potential SPA
Potential regulation development
QUESTIONS?