Samar Muzaffar, MD MPH Missouri Department of Social Services MO HealthNet Division

1. 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

2. Objectives • Overview • MHD Population • Overweight/Obesity Rates • Policy Considerations • Developing Models

3. Overview

4. 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

5. 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

6. 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)

8. Clinical Correlations • 1% point decrease in HbA1c yields: • 21% decrease in Diabetes related deaths • 14% decrease in Heart Attacks • 37% decrease in micro-vascular complications • A 10% Cholesterol Reduction yields: • 30% reduction in Coronary Heart Disease • A 6 point reduction in Blood Pressure yields: • 16% reduction in Coronary Heart Disease • 42% reduction in Stroke • Hennekens, C. Circulation 1998; 97:1095-1102

9. Financial Correlations • Health Home Impacts: • Reductions in ED utilization • Reduction in Hospital utilization • Demonstrated cost savings

10. Example: Primary Care and Behavioral Health Integration- Life Expectancy Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year 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

11. Example: Primary Care and Behavioral Health Integration- Per Member Per Month Costs Melek et al Milliman Inc, 2013

12. 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

13. Overview • MHD Obesity Rates • System Limitations • MHD uses a claims based system • BMI not reported to the MHD system unless part of a claim

14. 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%

15. Overview • Impacts • Physical • Increased morbidity and mortality (DM, Heart Disease, mental health, etc)

16. 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)

17. Policy Considerations

18. 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

19. 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

20. 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

21. Developing Models

22. 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

23. 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

24. 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

25. Developing Models • Possible Next steps: • Approval or appropriations authority • MHD Systems work • Provider Enrollment systems work • Potential SPA • Potential regulation development

26. Questions?