Analysis Shows Existing Medicaid Benefit Codes Cover Childhood Obesity-Related Health Care Treatment
From 2004 to 2005, researchers at George Washington University (GWU) School of Public Health and Health Services analyzed whether health insurance-especially Medicaid-could cover preventive health services for children at risk for obesity.
From 2005 to 2006, researchers at the GWU Center for Health Services Research and Policy looked at whether insurers' coverage and payment practices, especially those of state Medicaid programs, supported recommended clinical practice.
Over the course of both studies, researchers reported three key findings:
- Medicaid, under its Early & Periodic Screening & Diagnostic Treatment (EPSDT) benefit, can cover comprehensive, obesity-related pediatric health care services. No new legislation or guidance is needed. (ID# 052240)
- Every service needed to provide quality childhood obesity prevention services according to clinical guidelines in use as of 2005 has an existing code for provider reimbursement. No new codes are needed. (ID# 053842)
- Most state Medicaid manuals do not provide clear or adequate information about coverage levels and appropriate reimbursement codes for specific elements of care. Providers, therefore, remain uncertain about which services they can provide and if they can be reimbursed. (ID# 053842)
The Robert Wood Johnson Foundation (RWJF) supported the GWU School of Public Health and Health Services with a $44,668 solicited grant (ID# 052240) from December 2004 through July 2005 and the GWU Center for Health Services Research and Policy with a $90,341 unsolicited grant (ID# 053842) from November 2005 through October 2006.
The prevalence of obesity among children has been increasing at a rapid rate. According to Preventing Childhood Obesity: Health in the Balance, a 2004 report from the Institute of Medicine (IOM), childhood obesity in the United States has doubled in the past three decades for children ages 2 to 5 and adolescents ages 12 to 19 and tripled for children ages 6 to 12. Obese children are at risk for short- and long-term health, emotional and social consequences.
The IOM report recommended that pediatric practice include obesity-related preventive health interventions as part of routine medical care. However, health care providers often report that without reimbursement, it is difficult to incorporate appropriate obesity screening, counseling and referral services within routine care.
A critical milestone occurred in 2004, when Medicare reclassified obesity from a behavior to a medical condition. This ruling established an opportunity to reassess how all third-party payers-including Medicaid, the largest insurer of children-cover and finance preventive interventions aimed at reducing childhood obesity.
But both public and private health insurance issues and options can be difficult to comprehend. Policy-makers, public health agencies and health care providers lacked clear and accessible guidance about which health insurance resources were available and how to use them to finance services to prevent and treat childhood obesity.
RWJF is committed to tackling one of today's most pressing threats to the health of children and families-childhood obesity. The goal is to reverse the childhood obesity epidemic by 2015. Projects and programs funded by RWJF work mainly in schools and communities, where the goal is to improve access to affordable, healthy foods and to opportunities for physical activity.
RWJF places special emphasis on reaching children at greatest risk: African-American, Hispanic, Native American and Asian/Pacific Islander children living in low-income communities.
RWJF has a four-pronged approach to halting the increase in childhood obesity:
- Building the evidence regarding what works to promote healthy eating and to increase physical activity among children.
- Testing innovative approaches in order to spread promising models.
- Educating leaders and investing in advocacy strategies.
- Working on ways to help health care providers screen and counsel to prevent and to manage childhood obesity.
The overall goal of the two studies was to investigate which health insurance resources were available to cover services related to childhood obesity. The studies also looked at whether insurers' coverage and payment practices supported recommended clinical practice, especially with respect to state Medicaid programs.
The First Grant: Methodology
Under grant ID# 052240, researchers at the GWU School of Public Health and Health Services:
- Reviewed the prevalence and health implications of obesity risk in children.
- Ascertained the existence of clinical consensus on broad guidelines for preventive health interventions for children who are obese or at risk of obesity.
- Assessed the implications of the 2004 change in Medicare language on the availability of private and public health insurance coverage for services to children at risk for obesity.
The researchers determined that all recommended childhood obesity prevention services for children and adolescents to age 21 can be covered under Medicaid's Early & Periodic Screening & Diagnostic Treatment (EPSDT) benefit. This finding led to the second grant.
The Second Grant: Methodology
Under grant ID# 053842, researchers at the GWU Center for Health Services Research and Policy conducted an in-depth study of Medicaid services, which are administered by the states. They:
- Examined several clinical guidelines for childhood obesity preventive health interventions, including those of the American Academy of Pediatrics, and selected four sets as representative samples.
- Compared the sample guidelines to state Medicaid statutes to learn the extent to which state programs used the EPSDT benefit to address and finance pediatric obesity-related services.
- Compared the guidelines to standard national medical reimbursement codes to see whether codes were available for all recommended services.
- Reviewed state Medicaid manuals to see whether they clearly explained the coverage offered as well as the reimbursement codes for providers to use.
The First Grant
Researchers at George Washington University (GWU) School of Public Health and Health Services who conducted the first study (ID# 052250) reported these findings in Reducing Obesity Risks During Childhood: The Role of Public and Private Health Insurance:
- Excess weight is associated with risks to child health and development.
- Research suggests that preventing obesity may be more effective than treating it after onset.
- Guidelines exist to assist providers in screening and treating obese and at-risk children. There is general agreement on the content of these guidelines (nutrition, exercise and education).
- Medicaid's existing statutes encompass coverage of all recommended guidelines for child obesity risk reduction under its EPSDT benefit. There is no need for legislative change or new federal guidance in the way the statute is written.
- Few state Medicaid programs specifically describe the childhood obesity services that they support. Reasons for this may include resource allocation decisions from the state on what it will reimburse and time lags between the 2004 change in Medicare language and changes to state Medicaid manuals.
- Few private insurers cover comprehensive childhood obesity prevention services, although certain services such as body mass measurement, an index of obesity, may be covered. An exception is Kaiser Permanente's health plan, which launched a weight-management initiative for children and adult members.
The Second Grant
Researchers at GWU Center for Health Services Research and Policy who conducted the second study (ID# 053842) reported these findings in Strategies for Improving Access to Comprehensive Obesity Prevention and Treatment Services for Medicaid-Enrolled Children:
- Existing guidelines for childhood obesity prevention and treatment fall entirely within the classes and categories of the EPSDT benefit that cover nutritional assessment and health interventions to "ameliorate" physical and mental conditions in children.
- Reimbursement codes are available to bill for all recommended childhood obesity prevention services.
- State Medicaid provider manuals tend to be limited to a brief overview of EPSDT services without specific reference to coverage of obesity prevention and treatment services. Providers, therefore, remain uncertain about which services they can provide and if they can be reimbursed.
- Medicaid managed care contracts generally do not include obesity prevention and treatment strategies in their performance measurement requirements.
- Some states have taken steps to use EPSDT coverage standards to encourage best practices among pediatric health professionals and providers. Two states (Nebraska and Arizona) have developed specific approaches to using EPSDT to improve obesity-related pediatric practice.
See the Bibliography for details on the reports.
The researchers' report on the first study, Reducing Obesity Risks During Childhood: The Role of Public and Private Health Insurance (ID# 052240) concluded with a discussion of how to engage public and private insurers in finding ways to increase their investments in preventive health services for children at risk of obesity.
On the federal level, they suggested that the Centers for Medicare & Medicaid Services (CMS):
- Disseminate information about the importance of childhood obesity risk to state Medicaid programs.
- Augment existing CMS guidelines on EPSDT with special guidance on using managed care, integrated service delivery and disease-management techniques to develop comprehensive prevention programs for children at risk of obesity.
For the private sector, the researchers suggested stimulating coverage of comprehensive obesity risk prevention for children in private health insurance and employee health benefit plans through financial incentives and performance measures. For example, national organizations could benchmark childhood obesity prevention performance measures that purchasers could use to evaluate health insurance plans. Other suggestions included:
- Ensuring that providers apply best practices under the EPSDT benefit and disseminate specific obesity prevention and treatment guidelines.
- Clarifying proper coding and payment procedures for obesity prevention and treatment services.
- Encouraging providers to take a comprehensive approach, bundling obesity prevention and treatment services into a single package following a disease-management model.
AFTER THE GRANT
The researchers submitted an abstract for presentation at the summer 2007 conference of Academy Health. They planned to submit a manuscript for publication in a peer-reviewed journal.
The project ended after the second grant.
GRANT DETAILS & CONTACT INFORMATION
Study of State Medicaid Resources for Childhood Obesity Prevention
The George Washington University School of Public Health and Health Services (Washington, DC)
- Developing a Guide to Using Health Insurance Resources for Childhood Obesity Prevention and Treatment
Amount: $ 44,668
Dates: December 2004 to July 2005
The George Washington University Center for Health Services Research and Policy (Washington, DC)
- Study of State Medicaid Payment Practices Related to Preventing Obesity
Amount: $ 90,341
Dates: November 2005 to October 2006
Sara Wilensky, J.P., M.P.P.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Rosenbaum S, Wilensky S, Cox M and Wright DB. Reducing Obesity Risks During Childhood: The Role of Public and Private Health Insurance. Washington: George Washington University Center for Health Services Research and Policy, 2005. Available online.
Wilensky S, Whittington R and Rosenbaum S. Strategies for Improving Access to Comprehensive Obesity Prevention and Treatment Services for Medicaid-Enrolled Children. Washington: George Washington University School of Public Health and Health Services, 2006. Available online.
Presentations and Testimony
Sara Wilensky, "Strategies for Improving Access to Comprehensive Obesity Prevention and Treatment Services for Medicaid-Enrolled Children" (Draft Findings), at the National Initiative for Children's Healthcare Quality, 2006 Childhood Obesity Invitational Summit & National Congress, September 20, 2006, Washington.
Report prepared by: Nina Berlin
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Jeane Ann Grisso