Commentary: Examination of Health and Behavioral Code Reimbursement From Private Payers in the Context of Clinical Multidisciplinary Pediatric Obesity Treatment

In response to the epidemic of childhood obesity, the University of Michigan Health System developed the Pediatric Comprehensive Weight Management Center (PCWMC). Due to a large demand for obesity services across the economic spectrum, but particularly for low-income adolescents, our health system determined that clinical multidisciplinary weight management services should be accessible to all potential patients without regard to their ability to pay. Subsequently, the PCWMC obtained approval to use the charity care screening exception which allows care to be provided using a sliding scale (starting at zero for low income patients). The charity care screening exception is an institutional policy for patients who do not have insurance and who have an inability to pay for healthcare as determined primarily by the United States federal poverty level guidelines. As such, patients in the program are screened by financial counsellors prior to entry to determine the amount they will be responsible for based on the sliding scale, over and above their insurance copays and deductibles. For example, patients may qualify for 100% adjustment of charges if their household income does not exceed 250% of the federal poverty level guidelines, and 55% adjustment if their household income is between 250% and 400% of the guidelines. Following financial screening, all patients are scheduled for a comprehensive multidisciplinary initial assessment in the PCWMC. The multidisciplinary team includes a medical director (i.e., pediatrician), pediatric psychologist, exercise physiologist, dietitian, and social worker. Following a feedback session to review results obtained from the initial assessment, a decision is then made about joining a 6-month behavioral family-based weight management program. The adolescent program (Michigan Pediatric Outpatient Weight Evaluation and Reduction; MPOWER), described elsewhere (Woolford, Sallinen, Clark, & Freed, 2011), first started accepting patients in April 2007. Briefly, patients currently attend weekly 2-hr sessions for six months. One hour always includes group exercise for adolescents, led by an exercise physiologist. The second hour of the program includes a rotating schedule of group visits, with the monthly family nutrition group led by the dietitian, the parent behavioral group led by the psychologist, and the youth behavioral group led by the social worker. Families also participate in two 45-min individual sessions per month where they meet with two of the following providers: psychologist, exercise physiologist, dietitian, and social worker. In 2008, the PCWMC expanded its services by implementing the MPOWER JR program for patients 7 to 11 years old. This program is also six months in duration with weekly 2-hr sessions. The program is held at the local YMCA, which allows for parents to also exercise during the first hour with their children. The second hour of the session rotates between groups (i.e., separate for parents and children) and individual sessions. A comprehensive assessment of patients’ progress (including repeat laboratory tests, psychological measures, exercise testing, and determination of body composition) is performed by the team at three and six months to provide feedback for families and to inform treatment decisions. When the PCWMC was first created, it was decided that health and behavior codes would be the most appropriate way to bill for behavioral health services provided by