Episode Transcript
[00:00:01] Speaker A: Welcome to Obesity a Disease, the official Obesity Medicine association podcast exploring the many facets of the disease of Obesity a Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.
[00:00:29] Speaker B: Hi, everybody. I'd like to welcome you to our next pediatric podcast. Today we have the pleasure of discussing the EPSDT program. And we have, and this is based on a recent publication in Obesity Pillars on the subject. And we're lucky enough to have the lead author and one of the co authors here today to discuss it. My name is Suzanne Kuda. I have a private practice obesity practice in San Antonio, Texas, where I primarily see children, young adults. I do see some adults also.
In addition to hosting podcasts for the oma, I also am the executive editor for the Journal of the OMA Obesity Pillars and had the pleasure of being the editor for the for this particular manuscript. I'm also the lead author for the pediatric obesity algorithm, and I'm really excited to discuss this topic with our guest today.
And our first guest and lead author of this publication is Dr. Vidmar. Can you please introduce yourself?
[00:01:32] Speaker C: Absolutely. Thank you for having me today. So I'm Elena Vidmar. I'm a pediatric endocrinologist and obesity medicine specialist at Children's Hospital Los Angeles in la, where I direct obesity medicine and bariatric surgery. I have the privilege of caring for youth living with obesity in our multidisciplinary clinic, and I also conduct clinical research focused on multimodal approaches to treating obesity, really looking at how we can combine medications and bariatric surgery in this cohort.
[00:02:00] Speaker B: Awesome. And then we have Dr. O'. Hara.
[00:02:03] Speaker D: Like Suzanne, I have been involved in pediatric obesity for a little close to 20 years and practicing in Maine for 30 years and have started an interdisciplinary clinic for pediatric obesity way back in 2009.
And so my focus also has been on telemedicine and leveraging that in order to access patients who are living rurally for the state of Maine, but also thinking about increasing access in general for kids.
I work with Suzanne on the pediatric algorithm as well, and I'm a reviewer for PDF for the Obesity Pillars.
[00:02:37] Speaker B: Okay, so awesome. So today we're going to be discussing the EPSDT program, and the article that this is based on is published in Volume 19 of Obesity Pillars.
The link to the article will be in the footnote.
So I think we're going to start with a description of what EPSDT is. Dr. Vidmar, will you please describe EPSTT for our audience?
[00:03:04] Speaker C: Absolutely. And in full transparency. I don't know that I really knew or understood what this was until probably 18 months ago when I learned that California was going to lose coverage to GLP1s for young people living with obesity. And amazing colleagues like yourselves and others taught me about it.
[00:03:21] Speaker B: So.
[00:03:22] Speaker C: So this. The EPSDT is early and periodic screening, diagnostic and treatment, and it is a comprehensive Medicaid benefit that was established to ensure that young people receive medically necessary healthcare services.
And so I think historically it's been thought of as a benefit that can be used primarily for preventative care, but it actually has a pretty broad utilization that can occur not only for screening and diagnostics, but also for treatments of any chronic condition. And that's how we've been able to harness it for the treatment of pediatric obesity.
[00:04:02] Speaker B: Okay, well, I think that, you know, I have been involved with the Texas form of that, which is called Texas Health Steps, for years, but it's only been recently and that I've been trying to use it to prescribe obesity medication, which is what we're going to concentrate on today, of course.
And I think, you know, you guys have really furthered this process along some by helping educate all of us in out there because the more we use it, you know, the better.
So, Dr. O', Hara, can you please describe why you and the other authors wanted to do this review and how you think this article helps you navigate through the system?
[00:04:51] Speaker D: Yeah, our motivation and reason is pretty straightforward in that it really came out of necessity.
[00:04:56] Speaker A: Right.
[00:04:56] Speaker D: I first learned about EPSDT and my light bulbs went on during one of the main AP chapter board meetings when a representative from Main Care, which is our Medicaid here, started talking about EPSDT and thinking about using it for treatment, where my eyes were like, really?
So this was during COVID and initially in Maine. We used it when we didn't have a lot of FDA approved medications at the time, but we did use it to improve reimbursement for our interdisciplinary team. So that was my first go at epsdt, which again was cumbersome. And we were the first ones trying it and all of those sorts of things and lots of learning curve, but certainly we had a follow up and I reached out to this person and I said, can I use it for medication?
When we started to get medications FDA approved for children for obesity, and she said, absolutely, you can.
That was our go to.
I did have the luxury of including Dr. Vidmar in one of our appeals, video conferencing. So we're really talking about collaboration and learning and supporting one another. This paper really illustrates some of Those experiences, I think, understand that, as Dr. Vidmar said, EPSD has existed since 1967.
We just really need to leverage that and use that.
I think this paper really shows some practical tips to get started, matter how small. Maine's a small state, and we started small. But every single opportunity gets you closer and illustrates that these children deserve treatment like any other chronic disease. And we're going to ask for it appropriately and provide all the documentation that we need. But it really does leverage itself as an advocacy tool, because if we're not asking for these medications simply because they're denying it, then they don't see a problem.
So the more we continue to push, I think our voices collectively hopefully will have an opportunity to really have impact.
[00:06:55] Speaker B: Yeah, I think that's really true.
And we're, you know, I think starting to make some inroads because we have started to make inroads in treating obesity in general. Right.
I think. And I think that Dr. Vidmar is going to address this. But, you know, it's important to realize that this program supersedes state Medicaid rules, which is really, you know, critical sometimes and can help you. So, you know, although EPSTT has been around for a long time, we just really are in the, I guess, infancy of using it for in obesity medicine.
So could you address that issue, Dr. Vidmar?
[00:07:42] Speaker C: Yes, of course. So I just want to echo what Dr. O' Hara said. I think so much of this comes from necessity and collaboration. So I think a lot of folks think about EPSDT at the start of trying to get reimbursement for obesity care or thinking about coverage for obesity medications. My experience was the reverse. So in California, we had complete access for youth with public insurance for five years. And it was really incredible coming from a safety net hospital. And then our financial situation shifted at the state level, and we got told that in January 1, 2026, all coverage would go.
And so then we suddenly needed something that superseded the state level coverage.
And that is where I was reminded of things I had learned at various conferences from different ones of my collaborators, such as Jamie Moore in Colorado, who's really championed this work as well when it comes to the coverage for obesity medications. But I think just the important thing to remember is sort of how we navigate Medicaid both at the state level and at the federal level, and understanding that one, this benefit ex for all young people who have Medicaid living with a chronic disease that require this medically necessary care.
But two, that the state does not necessarily need to offer it to them, we need to request it and create those pathways. And I think that was a really good learning lesson for us in California because it had to be brought up and advocated for by the clinicians. And then once we did it, the state said, yes, of course we will adhere to this, but they were not the ones bringing it to the table. And so I think that was just a really good reminder to really understand the different resources and then how you can access it at the different levels.
[00:09:33] Speaker B: Yeah, I think, you know, we are still learning how to get this implemented nationwide and hopefully it'll become more widely used and more, you know, standardized across the country because it's, you know, what if you have a patient who you're seeing and they are on Medicaid and they choose to go to college outside of your state.
Right. Or they're traveling and they're away for the summer visiting their, you know, non custodial parent and you know, you need to refill their medications.
You know, just a whole lot of reasons why this shouldn't be by care, shouldn't be dependent on where you live, you know, by geo geographical limitations. And I think the other thing that we should probably at least discuss is why the disease of obesity is. It's so important that we use this mechanism for the disease of obesity. So who wants to take that one?
[00:10:41] Speaker D: Oh my gosh, there's so many reasons.
I think when we first started this work, and I will say for me it started in 2001 thinking about how do we take care of these children who are crossing percentiles in an unhealthy way. And I think as you said, Dr. Kuda acknowledging obesity as a chronic disease, that if we include overweight and obesity, it affects almost 27 million children in the United States and 50% of the kids in the US rely on Medicaid. Right.
And so I think what's really important is that we have data now that if we are not treating and we have the AP CPG that just came out in 2023, that there's no more watchful waiting. We're not going to wait till a kiddos 18 to intervene. We don't do that for any other chronic disease. I think the, the language that exists for adults in the Medicaid where they're excluding or carving out obesity care is because they're using inappropriate nomenclature. This is not about weight loss. This is a chronic disease that has significant impact on short and long term health outcomes for our children.
And the costs are going to be greater the longer we delay Care. And it was very explicit in saying, we do not delay care. No more watchful waiting. And so I remember my first appeal when the Medicaid said, no, we don't cover weight loss medications. I said, that's great, because I'm asking for an obesity medication.
Right. So I think that, again, is proving the point of we have data, we have guidelines.
And more recently here in our state of Maine, where they talk about vital care, which is repsdt, they are saying we must approve medications as long as it's not completely experimental. We have medications that are no longer experimental, and our job is to illustrate that to them, because without it, our patients have no access.
And we're that pathway, we're that bridge to them.
[00:12:35] Speaker C: I'll just add to. I think that it's so important to acknowledge that by treating the disease of obesity, you're actually redefining it as the disease for everyone, for the patient, for the state, for clinicians. And I think that has been a very powerful force in the state of California as we've tried to implement epsdt because it obviously is looking at screening, diagnosis, and treatment. So everyone is talking about the treatment because that's actually the product. That's where the money comes in. But at the end of the day, it's directly linked to the state acknowledging pediatric obesity as a complex chronic disease that requires treatment. And I think there's such a power in creating that link, both obviously clinically and with our patients, but also at the state advocacy and coverage level.
[00:13:24] Speaker D: And such a huge hit towards bias and stigma. Right. I think that is so powerful. Every single time you send in a prescription through epsdt, you are knocking on that bias with science and evidence and conviction. Right. It does take a lot of work. I know, Dr. Kuda, you'll ask about that, but I think it's worth it. We work hard for a lot of other prior authorizations with commercial insurers and Medicaid in general. So I think that's a reality for all practicing clinicians, unfortunately.
[00:13:56] Speaker B: Yeah.
So that does bring us to the issue of how if you're not in states where some of these processes have already been ironed out, like, you know, you've done the work in California, just kind of figured out you've done the work in Maine.
Colorado is already. I mean, I know. I know here in my little corner of Texas, but of course, it's a big state. And I. You know, I don't. I don't. I know that even one of my colleagues in Houston, Sarah Barlow, wasn't familiar with the process. And, you know, so we, you know, how do you, if you're a practicing pediatrician or family practitioner, seeing children or a pediatric obesity provider, find out what is going on in your state?
[00:14:48] Speaker D: Dr. O', Hara, I think you know, for me what was the most effective way one, and we had that introduction. Certainly your AP chapter is a tool to leverage and utilize. They know your state Medicaid people very well.
I would say that once we actually started to want to do it, we targeted who the best contact was within Medicaid, and we zoomed with them multiple times.
Granted, ME, we have one very straightforward Medicaid compared to the complexity of California or Texas, for sure. So I acknowledge that. But I think starting with one person and finding a champion there who may not have all the answers, but if they can buy in and support you, I think they're there. They truly did want to help us when we were starting this and trying to make the path as painless as possible and again, learning from others. I wish I'd known that Jamie was already doing this work in Colorado because she was, like, trailblazing years before. And I think Dr. Vidmar was saying earlier, really collaborating with one another and posting those opportunities. I think on Omar, our pediatric community, we are vibrant. We are happy to support one another, ask a question, you know, how to go, make a template, all of those things. I know, Dr. Vidmar, you have created a really fabulous protocol and systemize this very well.
[00:16:09] Speaker C: And I just want to echo, too, I think, you know, working too, with, like, patient groups, you know, at Children's Hospital Los Angeles, we work a lot with the Children's Health Coalition, and they had an amazing advocate that really helped us along this process, getting connected to the right Medicaid aids, which, again, was really helpful just because California is a big state. There was a lot of moving parts. And then again, just to echo that, I can't tell you how helpful it was to have colleagues and collaborators that had already done this. You can imagine it was a really daunting task when we were told at my institution 900 kids were going to lose coverage. And that felt really overwhelming to even think about what to do next. And so to be able to just. Just call someone or email them and say, what can we do?
Was phenomenal. And also really sort of the origin of why we wanted to write up this manuscript so that we sort of had materialized all of our thoughts that had come through all of those phone calls and emails and texts.
[00:17:07] Speaker D: And I'll say in the paper, it was meant to be very practical. Right. So there are some really step by step tips. There's some really helpful tables of what our examples were. Doesn't mean that's going to be applicable to every state. I think, you know, it might be a little bit nuanced in New York versus Texas, but I think if you start at the very beginning and go to those key resources, you'll navigate to the right place, reach out to any of us obviously. But I think that's a really important part of the process for sure is looking and hopefully people will find the paper helpful to be brave enough to just start.
[00:17:44] Speaker B: Yeah, I think one of the things places to start is to like you all mentioned, contact anybody you know at Medicaid in your state, at the, you know, at the, at the leadership level in your state, which is, which can be challenging to do to find somebody, but you know, you can start at least. This is, this is the way I have started in Texas is you, I initially put in prescription and of course it gets denied.
And then you put in, then you fill out the form that, the Texas Health steps form and that gets denied. And hopefully along the road of these denials you get paperwork that says you can challenge this by such and such date by calling such and such number. Right.
And then you have to call the number and you have to set up a peer to peer and you may not get to talk to the right person for the first three or four times until you work your way into whoever can help you. Because I know that at least in, in Texas they have a, there's a sheet that they go by which gives them how they handle these. And right there on the sheet it says if you're under 18, deny.
I mean that's, that's their, that's what. They automatically are going to deny it.
So you don't. So what. At the end of the day, what we have to do is write a prescription, get a denial, appeal the denial and then write a letter of medical necessity after you figure out where the, you have to do that. So I've been able to get it approved after going through all those steps. But it is, it is a lot of steps.
It's, it's challenging.
Yeah, absolutely. And it's not approved for every patient. It's individualized.
So, you know, I've had some luck and some, I've had some continued denials.
It doesn't seem to be based on need.
It seems to be based on whoever reviewed it.
[00:19:57] Speaker C: Yeah, we found that as well. I think there is Some variability which makes it challenging.
[00:20:02] Speaker D: And I think that anytime we go through these steps and we were doing this with private insurance, that's what I mean. That's an ever evolving landscape right now for adults and for any covered children by their parents or guardians, insurance. Right. They're, they're removing them, they're carving them out. It really forces us to advocate not only on an individual and state level, but at the national level. Right. How long have we been looking at TROA, since 2013. Right. To standardize some of this, which hopefully can make these things go more smoothly. But I think to your point, Dr. Kuda, even as daunting and challenging as it is, that is the path that we have.
[00:20:44] Speaker B: We don't have a choice.
[00:20:45] Speaker D: Yeah, we have no choice because without it, they have no access. And even in states that are covering, the 13 states, to our knowledge that are covering, many of them have caps and criteria that are not based in science. And could our EPSDT be used to counter some of those? That would be an opportunity to leverage It Again, like Dr. Vidmar said, it's an opportunity to educate all of those people in policy making seats. Right. And at least we bring our voice to that table every single time. And hopefully it gets a little bit easier and a little bit of peer pressure to say California, Colorado, Maine. What are you doing in XYZ State that are not, that are not following this because it is very explicit in the outline of or the spirit of epsdt. I think as we write in our paper is really to provide treatment that is evidence based, period.
And we have that data.
[00:21:45] Speaker B: Yeah. I think the burden is on us because it forces us to prove medical necessity.
I mean, that's, that's the key. And I do think that before we leave this particular discussion, if you are in a state that, for example, we have multiple Medicaid providers in Texas, I know they, they must have the same in, in California.
I'm contracted with like six of them, but I'm not contracted with all of them. I'm, you know, those are the, the main ones. But in order to get to the person you need to talk to, you have to talk to a person in each of those plans. You, you can. There's no one person who oversees all these managed plans. At least in Texas. I've got to talk to the manager or the person who's in charge of this at Community first, at Superior, at Aetna, Medicaid, etc, you know, so, yeah, that's what you have to do right now. Now we're Going to move on to adulthood. Always an issue with Medicaid in general.
But let's discuss it in this context.
Right.
[00:22:54] Speaker D: I think that's the part that is ethically challenging for any of us who deal with Medicaid, particularly when we've been using epsdt, because it does stipulate that it ends when the child, young adult, turns 21. And many of us, particularly you, Dr. Kuda, who are seeing young adults and adults, but even in general pediatrics, many of us are seeing kids into their mid-20s.
This is going to impact those patients.
We lose coverage. And so I think our paper talks a little bit about planning ahead. We do that in general for transition of care, looking for other alternatives of which it might be trying to switch to a medication that is cheaper, out of pocket, all those sorts of things. It is not.
I don't have the answer to that other than continued advocacy, although I will say it does also can happen in the reverse where we may have kids who are covered under EPSCT or a state that Medicaid is covering directly and then they move to a private insurance that denies as well. And now we're taking away that medication as well. So I think it asks a larger question that is not simply answered as a limitation of EPSCT, but also any insurance coverage. And it really does widen the gap of disparity for those who cannot afford out of pocket cost. For these medications that are life saving. I'm going to put them at the same level because it is life trans transformative and life saving for a lot of these kids.
[00:24:20] Speaker C: Yeah. So I think, you know, in California again we've sort of had this coverage to no coverage and now back to coverage. So we're trying to sort of understand what that looks like.
I think that we've been really trying to be thoughtful about sort of indication for obesity related complications and how we can use use as our FDA indication is expanding and our toolkit is expanding. How can we really be sure that we are getting all of those diagnoses and really transitioning coverage as we are able. That certainly doesn't apply to all of our patients, but we know that many of our patients living with severe obesity also have obstructive sleep apnea masled other things that might give them qualification. And so that's been one of our sort of transition plans that we've been trying to work with.
It has been interesting in California. And I think this goes back to Dr. Kuda's questions about like how the federal benefits interact with the state benefits. Is that there is some variability in how the states execute their plans. And so we have had some of our patients where actually we have gotten coverage past 21, even though that's not what should be allowed. And so I also think that comes back to sort of the workforce question, which is we only have so much bandwidth, but how do you create programs and practices where you can do the most likely to get covered, but then maybe it's worthwhile to have a plan where you're still requesting. And so for sort of the outliers of both young kids and our kids over 21, we've sort of created a pathway where we try to assess for their other comorbidities that might be covered, as well as just putting in an additional request because we've had some coverage that way.
[00:26:01] Speaker D: And that's sort of how, when we first started doing obesity care way back 25 years ago, we had to rely on other comorbidities for any sort of treatment. Right.
So going back to other indications is still something we have to think about doing creatively.
[00:26:16] Speaker B: Yeah. And, you know, it's interesting that we've had this experience. I've had the experience where I've tried to get GLP1s for very severely affected patients, and when they turned 18, they got it.
You know, I mean, it's, it's crazy.
On the Texas health stuff, on the EPSTT program.
[00:26:38] Speaker D: Right, right. And we think about some of these medications like Sema and liraglutide, they have indications and FDA approval for children with diabetes. And it's the same medication that we were asking for for obesity. Right. So it's, it's not like it's a whole new weird, questionable class of medication that we're completely unfamiliar with, and they're covering it for patients with diabetes. And so it begs the question if we, those of us who are clinicians, when we're in the room with a patient, if your child had diabetes, you would get this medication, but your child has obesity, therefore it's denied. No one wants to have that conversation.
None of us want to be able to say we have an FDA approved medication that we know can be very effective and change your child's health outcomes. It's there, but we can't get it to you. Any step. Epsat, all of the above are steps to access to care.
And whatever it is, whether it's leveraging comorbidities, our goal is to treat early. Right. So some of those guidelines, I know we had a colleague who was posting on one of our OMA community post that A particular state was having significantly high BMI criteria for any coverage of medication. I mean, that's. That's not AAP guidelines.
[00:27:52] Speaker B: Right.
[00:27:53] Speaker D: We're saying we should treat when we see the disease.
And so if we do that, then we can prevent all of the things that we're now using to try to get coverage. So, I mean, it feels, you know, in a strange way, counterintuitive to really preventive care.
[00:28:08] Speaker C: Right.
[00:28:10] Speaker B: Yeah. And, okay, I think we have talked about, like, how we would fight to get coverage for our patients, you know, in the various.
In our clinical practices.
Now let's discuss a little bit about how we. If you're so inclined, you can participate at the advocacy level, either at the state level or, you know, nationally.
[00:28:35] Speaker D: Yeah.
[00:28:35] Speaker B: Dr. Vidmar, do you want to take that?
[00:28:37] Speaker C: I think that's a great question. So I think certainly advocacy happens at multiple levels. One of the thing I just want to share is I am not an advocate by nature. I don't have training or background, and I actually have never done this before. And so I'll be honest, sometimes I listen to talks and I hear podcasts, and I think that these are people who really know how to do this, but anyone can actually do this. And I think this last six months has really taught me this and really taught me that, like, the appeal and success of one patient has such huge benefits on all of our patients. And so I think there is sort of a thoughtfulness around how you advocate, which we've sort of talked about, which is trying to find the right people, and that can be hard.
However, almost always someone knows who that person is, whether it's at your institution or through a collaborator, because we all have these contracts. We all have things that we have to interface with Medicaid. And so I think one of the things about advocacy is making sure you're doing it to the right people that actually hold the power to make changes and to actually implement things.
Another thing I think we've learned in California is to make sure that what you're doing is efficient and effective. So, for example, we were writing, like, 15 page letters because it made us feel really good. And we felt like we were shouting at the paper and at people and getting really excited. And then once we finally got to the right person, we realized that, like, they just were looking for six words, and if we had those six words, it was gonna go through. Right. And so we were just advocating in the wrong way to the wrong people. And so really making sure your efforts are worth what it is that you're doing is going to make everyone happier and make you more successful as you're kind of getting to tables that are going to have the greatest impact.
[00:30:20] Speaker B: Yeah, I, I really, you know, I've seen letters, appeal letters that have been posted on the community and all that. And I think that if you can keep your appeal letter to a paragraph, then you have a much better shot at having someone look at it. If you.
[00:30:38] Speaker C: Absolutely.
[00:30:39] Speaker B: If, if it's three pages long or four. No, but he's looking at it. It. No. So, you know.
[00:30:46] Speaker D: Right. Yeah.
[00:30:47] Speaker B: Say complications, medical necessity, you know, likely to progress, to fill in the blank, you know.
[00:30:56] Speaker D: Right.
[00:30:57] Speaker C: Yes.
[00:30:57] Speaker D: Very succinct. And I think that's one of the things that I love about this paper we have that outlined, like, who, what, where, when, what do you need to put in? What are the comorbidities that you want to list? What were the previous attempts? How has this disease progressed without treatment?
Right. Or when it's taken away, this is what happens. Right. Obesity persists, worsens, escalates. Now we have this comorbidity along with it being very bulleted and very direct is probably, like you said, the most effective and efficient way to advocate as well. So, yeah. 100. We don't want them to feel like, oh, my gosh, I'm reading this tomb. Right. The first time I sent it, I think it was 63 pages. And I'm like, that's not going to help anybody.
You know, here's the article. They're not going to read it. But if you can summarize and highlight and say, according to this AAP guideline, according to this clinical trial, one sentence and then list the specifics about your patient, that's going to be your best shot.
Yeah.
[00:31:55] Speaker B: Okay. I think the only thing I wanted to add, personal experience, case I've had recently.
So I had a case of a child who gained over 100 pounds between the age of 11 and 13 after being placed on atypical antipsychotics, which he needed. He did need to be treated. He had significant behavioral health problems. He benefited from the atypical antipsychotics and, and needed to stay on them to continue, you know, his treatment.
However, now his weight is, you know, a huge problem.
So I did go through the process of the, you know, getting a denial, appealing it, talking to the person at his medicated plan, getting it approved. So it gets approved. Yay.
You know, and I start him on Wegovy or semaglutide. Sorry.
Yes, semaglutide. And he is Doing well.
So it comes time for him, and he stays on the starter dose for about two months while we're working through all this process. Right.
And then we see him, okay, he's ready to move up to 0.5 the next dose. Right. Well, we put that into the pharmacy and it gets denied.
[00:33:27] Speaker D: Yeah. So.
[00:33:29] Speaker B: Because it's like, if they have it plugged into their computer system, so it's not even like a human is involved, it is automatically denied.
So we had to call back the insurance plan, the Medicaid insurance plan, and they were like, oh, yeah, that's a mistake. And they actually called the pharmacist and said, dispense the medication, you know, but you could expect to have continued these continued things because, you know, these things are not done by people. A lot of times they just have a protocol built into the computer.
And so you. You have to just be aware of that. And, you know, the next time we need to go up on a dose, I'm going to try to preempt it.
[00:34:17] Speaker C: Yes.
[00:34:17] Speaker D: Yeah, I think that's what we found too, in our first go around, was planning ahead and really checking in with the family, you know, two weeks in and say, how are you doing? Do we anticipate going to the next dose? Do we think we need to stay at this dose for longer for side effect, or what reason?
And again, Maine is a smaller state, so I sympathize with the larger states that have complicated Medicaid systems. But we had. I mean, we would be proactive and we would anticipate that and then talk to the pharmacy and say, hey, this kiddo should be getting this dose, but it's a lot of steps. And then again, you know, how do you make those efficiencies in a protocol when you don't have that human contact is really going to take practice and time to utilize this more effectively. Just like it's new to a lot of all of us who are been practicing pediatrics for a long time, it's likely new for some of these Medicaid who have not been asked to leverage this pathway either. And so how do we support one another there?
[00:35:13] Speaker C: And I would just say too, you know, trying to traverse a large state on this, we've actually had to really go back to Medicaid over and over and over again. So, for example, in California, they were requiring a prior authorization for every single dose. So I had heard stories that this was an error. So I went to them and I said, this is an error. They said, no, in California, when we activate epsdt, we, you need a prior off each dose. And so we had to do a lot of back and forth. I had to go to four different appeal meetings. And then finally they approved it to be something that came in a batch for the whole titration dose that might occur for that individual child's experience. But that was a really good lesson of just, you certainly can do it one off. But for us, just at the volume that we were dealing with, that was something we actually couldn't handle. So then we had to invest the time to kind of move up and really understand if this was something on the state level that they would change.
[00:36:07] Speaker D: Right, right. Okay.
[00:36:08] Speaker B: So honest.
[00:36:09] Speaker D: And say that one of the major limitations again is this is a little bit of as daunting as it is right now when we go outside of those guidelines, certainly trying to leverage it for kids who are under 12 or anything that's considered off label for us in the state of Maine, that has continued to be a challenge when we know for pediatrics we've had to use off label indications for lots of disease processes, including the kid with the atypical medications that you maybe talked about, Dr. Kuda. Right. That's been a long standing practice, pediatrics. And yet for us that continues to be a significant barrier.
Whereas perhaps with commercial insurance we might have a better time with the peer to peer review. So I think again, this is an opportunity and I think this paper lends itself well to a future paper to really look at the data that we can collect in terms of outcomes. I know in the state of Maine, this on their own, as we start to do this, they're like, we want to really look at the data. We want to follow these kids out. We want to see the improvement, improvements in their, in their laboratory, in their trajectory, their obesity itself.
So I think, you know, it's really lit a fire over there too. So that, you know, can we publish on this and share this information over time?
How many type 2 diabetes did we avert or mastled or just improvement in the disease of obesity, which is worthy unto itself whether a patient has a comorbidity or not.
So all of the above is an opportunity, I think. Think.
Yeah.
[00:37:35] Speaker B: Before we wrap this up, I did want to draw a comparison between two other programs that are out there because I think they, it can get a little confusing. So first of all, the one that's easy to kind of take off the table is called the Bridge program. And this is a program just for people on Medicare. And so it, although there are potentially a Few patients, pediatric patients on Medicare, I think it's very rare to see those. So I don't think that there will be much confusion between the Bridge program and EPT epsdt.
But the other program is called Balance. And Balance is a program that is the states have a choice on implementing it or not implementing it. And I am not sure how many states have implemented it and how many have not. I live in a state that has chosen not to implement it. So, you know, my personal experience with this program is limited, although I do. Although I do know that when it was discussed at the state level here, it was only going to be implemented for 18 and above and this. But if it is implemented in your state, then you may be able to use it it.
But you would have to investigate it. It is not as reliable a tool as, as the EP sdt. Even, even with all the, you know, warts that are on the EP SDT program, it's a little bit more reliable right now than Balance.
And again, if you wanted to find out what's going on in your state, you're going to have to contact somebody at the state level about that.
But for now, I think that the EP SDT program would be a better place to put your energy.
[00:39:36] Speaker D: Absolutely. If you're taking care of children on Medicaid, particularly in a state that doesn't cover or even one that is. Who has. Who might have outdated protocols, caps, can you leverage epsct because it is available state, every state has to utilize it as a separate funding source.
And Warts and all. It moves us forward for sure. And ultimately bringing access to any child that we can is a step forward for sure.
[00:40:05] Speaker B: Yeah, I think, you know, we take every little kernel of opportunity to provide additional care for our patients and we try to grow it from, you know, to germinate it into a little seedling and then grow it into a tree. Right. And I think that's where we're at with this. Hopefully we're a little bit past the seedling point, but we're still, you know, trying to nurture it along.
And we hope that as a result of this educational podcast and if you get a chance to read the paper, you're going to have, as val mentioned, as Dr. O' Hara mentioned, a step by step kind of guide on how to do this. So we certainly hope that you are able to, you know, go to start, start going down this road.
I'd like to really thank both of our participants today, Dr. Vidmar and Dr. O', Hara, for bringing their expertise.
[00:41:14] Speaker D: Thank you so much.
Yeah. Thank you so much.
[00:41:19] Speaker A: Thank you for listening to this episode of Obesity A Disease. For more information about obesity medicine, podcasts and other valuable resources from the clinical leaders in obesity Medicine, please visit www. Obesitymedicine.org podcasts. If you enjoyed this episode and want to listen regularly, head over to itunes where you can subscribe, rate and leave us a much appreciated review.
The views expressed in this episode are those of the host and guest and do not necessarily represent the opinions, beliefs or policies of the Obesity Medicine association or its members. Please join us again for our next episode of Obesity a Disease.
