Creating a Sustainable Obesity Management Program: The Center for Better Health and Nutrition

The Center for Better Health and Nutrition (CBHN) is a comprehensive obesity treatment, management and prevention arm of the Heart Institute within Cincinnati Children’s Hospital Medical Center (CCHMC), drawing upon a multidisciplinary team of experts from cardiology, endocrinology, and general pediatrics. The hospital sees the program as necessary due to the high incidence rate of obesity in the surrounding community. Despite the very evident need for these obesity and community health initiatives, it remains a problem to financially sustain a program that receives low to no reimbursement for services and also commits to numerous mission-based community events. The program continues to expand and support more community initiatives. An in-depth analysis was performed to study direct cost and revenue, income capture, and quality improvement.

Created in 1999, the program has seen volume growth from its beginning, but it was not until fiscal year (FY) 2010, after the program expanded to satellite locations, that the most significant growth was observed. From FY10 through FY11, the program experienced a 30% increase in medical visits and had developed four satellite locations. Driven by the expansion and community outreach efforts, the program has tripled in size, now serving over 2500 visits per year in 14 locations.

CBHN offers a standard clinic that includes medical, exercise, and dietitian providers. In addition to the standard clinics, two other critical programs were created: School Clinics and Community Outreach. School Clinics bring the standard CBHN fully staffed program into the school environment immediately after classes are completed. These clinics are available to all attending students and their siblings, and are provided to the patient families at no cost. CBHN currently maintains school clinics at five inner-city locations, helping deliver and develop medical, activity, and nutrition interventions. Community Outreach has generated 35,000 touches in FY15 at 211 events such as health fairs, walks, races, street festivals, and farmers’ markets. This effort coincides with the hospital’s strategic initiatives to improve child health in the community.

Relevance

Over the past 30 years, obesity rates have more than tripled in the United States. Although rates seem to have stabilized over the past five years, about one-third of American children are still overweight or obese. In Cincinnati, overweight and obesity rates remained stable at 34% from 2010 to 2014. This static situation suggests that obesity continues to be a widespread problem despite attempts to combat the issue. Overweight is defined as weight from the 85th percentile to the 95th percentile BMI for age; obesity is defined as at or above the 95th percentile BMI. Most obese children become obese adults, putting them at increased risk for diabetes, cardiovascular disease, and early death.

Program Design

Each patient seen at CBHN meets separately with a medical provider, registered dietitian, and exercise provider as part of the multidisciplinary team. At each visit, a nurse performs a height and weight check before leading the patient to a room to meet with the other providers. Visits normally last one to two hours, and patients are asked to come back to be seen one month after their initial CBHN visit, and then every three months thereafter. The program addresses obese children’s medical needs and offers a family-centered behavioral lifestyle intervention along with exercise classes.

Beyond these main specialties, five additional services are crucial to the success of the overall program: nursing, psychology, social work, community outreach, and administration. Of the CBHN’s 31 total staff positions, 12 are paid directly from the CBHN budget (Tables 1 and 2). Salaries are the largest expense for the program.

As of FY16, clinics are scheduled at 14 different locations, up to 75 miles away (Figure 1). The program offers half-day (four-hour) clinics and staffs approximately 70 clinics per month. The volume projections for FY16 are over 2900 medical visits, of which 34% will be new visits (Figure 2).

Clinic Flow

Each clinic is a multispecialty service that bills a professional fee and a facility fee. The patient first checks in at the registration desk. A nurse or medical assistant retrieves the patient from the waiting room and escorts him or her back to the clinic area and performs anthropometric measurements (i.e., height and weight). The nurse then places the patient in an exam room. A medical provider is always first to enter the room and evaluate the patient. Depending on clinic flow, a dietitian or exercise staff member sees the patient next, and then, the last provider (dietitian or exercise staff) meets with the patient. At the end of the appointment, a nurse enters the room and delivers the After Visit Summary. After that, the patient can proceed to the check-out desk to schedule the next appointment (Figure 3).

Analysis

Even though volume is high, the program has struggled with a bottom-line deficit. Factors contributing to this shortfall include the following:

• Dietitian visits usually are nonreimbursable.

• “Obesity” is not a diagnosis that is well covered by insurance.

• The population served is often under-resourced. Many of the program’s services are not covered by insurance, and therefore default to self-pay. Because many of the patients are unable to afford this expense, the bill becomes a write-off.

• Community outreach and school clinics are mission-based practices, created with the idea of positively affecting the community with no expectation of generating revenue.

• The program requires a highly skilled workforce, resulting in higher salaries.

The program is projected to have a $730,000 deficit for the year on a direct cost and revenue basis that includes clinic, community, and academic missions. However, when considering the total financial impact derived from the additional medical services associated with this population for related conditions, the program has demonstrated a low level of profitability.

Revenue Capture

Outpatient testing for new patients within 90 days of an initial CBHN visit is considered downstream revenue. This revenue is included when calculating the true profitability of the program. It is expected that CBHN visits will produce $936,009 in downstream revenue for FY16 (Table 3).

Types of testing include:

• Laboratory studies;

• Electrocardiography;

• MRI;

• CT scanning;

• Echocardiography; and

• Ultrasound.

Interventions

E/M Coding

When an E/M coding review was performed as a quality improvement effort, documentation deficiencies were uncovered that, when corrected, led to significant revenue from direct reimbursement (Table 4).

Nurse Practitioner Role

By hiring nurse practitioners (NPs) for the medical role, instead of additional physicians, the program saves significantly on salary costs and still is able to provide specialized attention to the patients and their families. At first glance, this position may seem less effective due to lower productivity (25th percentile), a decreased clinical FTE (0.7), and reduced reimbursement rate (85% of MD reimbursement). However, the current NP handles much of the charting, calls patient families directly for lab results and other services, and spends time reviewing and researching patient charts. Despite the discounted reimbursement rate, this expanded focus on the patient, along with salary savings and high volumes, make this practice a cost-effective investment. NP positions cost approximately $80,000 less than physician positions. Overall, the NP role saves on program expenses while still providing a high-quality standard of care and meeting the needs of our patients.

Financial Analysis: School Clinics

Although the school clinics are a free service and can be considered as contributing to the overall deficit of the program, they actually account for only a small portion of program expenses when compared with billed clinics (Table 5). These three-hour clinics follow the program’s standard clinic practice, where the patient sees a medical provider, dietitian, and exercise provider separately. In this case, clinics are held in the school nurse’s office, art room, or other larger areas within the school.

Clinics are open to all attending students and their siblings. School nurses and health aides identify candidates for the program and offer family referral to the CBHN, where a visit is scheduled. A parent or guardian is required to attend the visit with the child. Because this is a mission-based venture, serving an underprivileged and at-risk population, visits are not billed and are therefore free to the patient families. The CBHN Clinic presence in the schools has fostered a strong collaborative relationship that has led to several other initiatives, including fruit and vegetable taste-test programs, in-school and after-school physical exercise sessions, and cafeteria interventions to improve food selection.

When downstream revenue, E/M coding, and the NP role are taken into account, the financial snapshot of the program becomes more positive, moving from a $736,844 deficit to a $199,165 profit (Table 6).

Summary

The CBHN is a mission-based program that operates at a low level of profitability inclusive of downstream revenue, proper E/M coding, and the NP role. Many services are nonreimbursable, and families often are not able to self-pay, contributing to the overall deficit on a direct cost basis.

However, being able to fully understand and quantify downstream revenue has moved the program from a loss leader to a level of low profitability. Additional revenue was acquired resulting from the coding audit, and improvements in documentation have impacted coding and billing and more accurately reflect how and at what level patients are being treated. Costs were addressed with the NP role, which is critical for economical service expansion due to its lowered cost profile and concentrated focus on the patient.

Although quality improvement efforts have been applied, and extended revenue has been captured, ways remain in which the program can improve and proactively position itself in its best financial standing. These include monitoring dietitian and exercise reimbursements, analyzing the school clinics, and identifying additional revenue.

As healthcare laws change, the program is beginning to encounter requirements for preauthorizations for exercise visits. Some preauthorizations are, in fact, being denied due to timeliness and medical necessity factors. Becoming proactive in implementing a process to more efficiently handle these preauthorizations should allow the program to recognize this changing landscape more quickly and better adapt to the requirements of the insurance companies, helping to ensure better reimbursement.

It will be important to continue to proactively recognize and advocate for the appropriate reimbursement for new technology.

Furthermore, dietitian visits usually are accepted as a noncovered service, because most of them are nonreimbursable through insurance. It will continue to be important to advocate for these visits and work with Medicaid to approve these visits as a covered service.

The mission-based school clinics provide an excellent resource to an underserved population. Although they do not contribute significantly to the bottom line and are a small percentage of overall loss, as the program grows there will be a need to find balance between serving as much of the underserved community as possible while still meeting financial benchmarks.

To help sustain the program in the future, it will be important to continue to proactively recognize and advocate for the appropriate reimbursement for new technology. For example, equipment such as the InBody and MedGem testing devices, which can be billed as a service, should be documented and billed accordingly.

Overall, the CBHN is a profitable program when costs are kept lean and all relevant revenue is considered. The program provides necessary care to its patients and their families and is recognized as a sustainable resource. With volumes increasing at substantial rates, it will be important to continue to monitor and improve upon the program financials in order to balance the mission-based practice with rising healthcare costs and nonreimbursable services.

Recommended Readings

Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311:806-814.

Siegel R, Hudgens M, Simmons K, Denno D, Bell I, Shelly J, Kotagal U. Small prizes increase healthful food selection in a school cafeteria [abstract]. Appetite. 2015;89:305.

Siegel RM, Anneken A, Duffy C, Simmons K, Hudgens M, Lockhart MK, Shelly J. Emoticon use increases plain milk and vegetable purchase in a school cafeteria without adversely affecting total milk purchase. Clin Ther. 2015;37:1938-1943.

Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, Taveras EM. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120 :S254-288.