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Insurance reimbursement for the treatment of obesity in children
A M Tershakovec1, M H Watson, W J Wenner
1Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Insights
Third-party payer reimbursement for pediatric weight management programs is low, averaging 11%. This financial challenge impacts program viability for treating childhood obesity.
Area of Science:
- Pediatric Endocrinology
- Public Health
- Healthcare Economics
Background:
- Childhood obesity prevalence is rising in the US.
- Third-party payer reimbursement for pediatric weight management is often limited.
- Effective interventions are crucial for addressing this public health issue.
Purpose of the Study:
- To analyze third-party payer reimbursement rates for a pediatric weight management program.
- To investigate associations between child characteristics, insurance type, and reimbursement.
- To assess financial viability of such programs.
Main Methods:
- Cross-sectional survey conducted at a tertiary care pediatric medical center.
- Evaluation of reimbursement rates for initial evaluation and management services.
- Analysis of patient demographics and insurance policy types for children aged 2+.
Main Results:
- Median reimbursement rate was 11%, with wide variation (0%–100%).
- Reimbursement rates significantly differed based on insurance policy type.
- No significant differences in reimbursement based on child's sex, race, or degree of obesity.
Conclusions:
- Low reimbursement rates jeopardize the financial sustainability of pediatric weight management programs.
- External funding or substantial out-of-pocket payments are necessary for program viability.
- Addressing reimbursement barriers is essential for effective childhood obesity treatment.
Objective:
Although the prevalence of obesity among children in the United States is rapidly increasing, third party payer reimbursement for evaluation and management may be limited. The purpose of this analysis is to evaluate third party payer reimbursement rates for a pediatric weight management program for obese children and associations among child characteristics (eg, degree of obesity), insurance policy type, and reimbursement rates.
Study Design:
Cross-sectional survey in a tertiary care pediatric medical center. Reimbursement rate of charges for initial evaluation and management and patient characteristics were evaluated for children 2 years or older enrolled in the Children's Hospital Weight Management Program.
Results:
From October 17, 1995, to December 23, 1997, 191 children were evaluated in the Children's Hospital Weight Management Program. The children were on average 10.1 0.3 years old, with a mean body mass index z-score of 4.9 0.2; 46% were black, and 65% were female. The median reimbursement rate was 11% and varied widely (0% to 100%). Reimbursement rates differed significantly among policy types. Reimbursement rates did not differ between boys and girls or white and black children, nor were reimbursement rates associated with the degree of obesity.
Conclusions:
Despite the need for weight management services for obese children, these low reimbursement rates preclude the long-term financial viability of such programs without external support or a significant proportion of patients who can pay "out-of-pocket."