Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement

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2 Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Alliance Healthcare Initiative. 2. Review of expert committee recommendations and U.S. Preventive Task Force Recommendations 3. Benefit implementation details 4. Resources available for primary care providers and registered dietitians 5. Questions& Answer session 6. Post-course survey

3 Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Alliance Healthcare Initiative. 2. Review of clinical evidence and U.S. Preventive Task Force Recommendations 3. Benefit implementation details 4. Resources available for primary care providers and registered dietitians 5. Questions& Answer session 6. Post-course survey

4 Alliance for a Healthier Generation 2010 There is no single cause and no single solution for childhood obesity. As a result, the Alliance works to positively affect the places that can make a difference in a child s health including homes, schools, doctor s offices and communities. The Alliance is leading the charge against the childhood obesity epidemic by engaging directly with industry leaders, educators, parents, healthcare professionals, and most importantly kids. Founded in 2005 by the American Heart Association and William J. Clinton Foundation, the goal of the Alliance is to reduce the nationwide prevalence of childhood obesity by 2015 and to inspire young people to develop lifelong healthy habits.

5 Childhood Obesity & Healthcare Nearly 1 in 3 children and teens in the United States is already overweight or obese. Overweight children and teens are more likely to develop serious health problems such as high cholesterol, high blood pressure, heart disease and type 2 diabetes. Healthcare professionals are eager to work with families around the prevention, assessment, and treatment of childhood obesity.

6 Alliance Healthcare Initiative Prevention, Assessment & Treatment The Alliance for a Healthier Generation convened national medical associations, leading insurers and employers to offer comprehensive health benefits to children and families for the prevention and treatment of childhood obesity. Insurers and employers offer: at least four follow up appointments with a primary care provider at least four visits with a registered dietitian

7 Building from the Evidence Base Recommendations released in January 2010 from both the US Preventive Services Task Force, the Surgeon General, as well as the 2007 Expert Committee Recommendations for the Prevention, Assessment and Treatment of Obesity spotlight the importance of screening children a for obesity and clinicians referring patients as appropriate to programs to improve their weight status. These recommendations are aligned with the benefits the Alliance Healthcare Initiative offers children and their families. Alliance Healthcare Initiative is the place where these new best practices have real-world application.

8 Ground-breaking Childhood Obesity Benefits Today: 2 million children have access to this new benefit Health insurers and employers offering this benefit include: Aetna Inc. (via select employers) Accenture Blue Cross and Blue Shield of North Carolina Blue Cross Blue Shield of Massachusetts Highmark Inc. Humana PepsiCo WellPoint By 2012: The Alliance aims for 6.2 million children to have access to this benefit option..

9 Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Alliance Healthcare Initiative. 2. Review of the U.S. Preventive Task Force Recommendations and the Expert Recommendations 3. Benefit implementation details 4. Resources available for primary care providers and registered dietitians 5. Questions& Answer session 6. Post-course survey

10 SCREENING FOR OBESITY IN CHILDREN AND ADOLESCENTS: CLINICAL SUMMARY OF USPSTF RECOMMENDATION 2010 Population Recommendation Children and adolescents 6 to 18 y of age Screen children aged 6 y and older for obesity. Offer or refer for intensive counseling and behavioral interventions. Grade: B Grade B Definition: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Suggestions to practice: Offer/provide this service. USPSTF Levels of Certainty Regarding Net Benefit: Moderate American Academy of Pediatrics Commentary on USPSTF Recommendations Evidence for Effective Obesity Treatment: Pediatricians on the Right Track! (Jan 2010): recommends screening and intervention beginning at age two and older For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents please go to

11 SCREENING FOR OBESITY IN CHILDREN AND ADOLESCENTS: CLINICAL SUMMARY OF USPTF RECOMMENDATION 2010 Screening tests BMI is calculated from the weight in kilograms divided by the square of the height in meters. Height and weight, from which BMI is calculated, are routinely measured during health maintenance visits. BMI percentile can be plotted on a chart or obtained from online calculators. Timing of screening Interventions Balance of harms and benefits Relevant recommendations from the USPSTF Overweight = age- and gender-specific BMI at 85th to 94th percentile Obesity = age- and gender-specific BMI at 95th percentile No evidence was found on appropriate screening intervals. Refer patients to comprehensive moderate- to high-intensity programs that include dietary, physical activity, and behavioral counseling components. Moderate- to high-intensity programs were found to yield modest weight changes. Limited evidence suggests that these improvements can be sustained over the year after treatment. Harms of screening were judged to be minimal. Recommendations on other pediatric and behavioral counseling topics can be found at

12 Let s Move! In February of 2010, the AAP joined First Lady Michelle Obama in support of her Let's Move! initiative to end childhood obesity within a generation! As part of the White House Initiative, the AAP pledges to engage in a range of efforts toward 2 primary goals: Body Mass Index (BMI) is calculated for every child at every well-child visit in accordance with AAP recommendations*, and that information is provided to parents about how to help their child achieve a healthy weight; and Prescriptions for healthy active living (good nutrition and physical activity) are provided at every well-child visit, along with information for families about the impact of healthy eating habits and regular physical activity on overall health.^ * BMI measurement begins at the 24 month visit ^ These actions are consistent with existing AAP policy and Bright Futures Guidelines.

13 Call to Action Forces are lining up to create a wave of support for you and the children and families you treat the time is now! Momentum of Let s Move Evidence via the USPSTF recommendations More supporting policy environment focused on improving built environments, increasing access to healthy foods and physical activity, etc Nationwide media campaign starting Alliance Healthcare Initiative Tools and resources for providers and families

14 Clinical Care Recommendations Stages of the Expert Committee Recommendations Prevention Prevention Plus Structured Weight Management Comprehensive Multidisciplinary Intervention Tertiary Care Intervention

15 Prevention BMI 5%-84% - Diet Promote breastfeeding Diet and physical activity: 5 Five or more servings of fruits and vegetables per day 2 Two or fewer hours of screen time per day, and no television in the room where the child sleeps 1 One hour or more of daily physical activity 0 No sugar-sweetened beverages

16 Prevention BMI 5%-84% - Diet Portions Age appropriate Parent s provide child decides Structure Breakfast Family dinners, no TV Limit fast food Balance Food groups Limit refined sugar

17 Prevention Plus BMI >85% Build on Prevention Eating behaviors: Family meals should happen at least 5-6 times per week Allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviors Parents provide child decides

18 Prevention Plus -Physical Activity/Inactivity Advise 60 minutes of at least moderate physical activity per day and 20 minutes vigorous activity 3x/week Refer to community activity programs Encourage development of family activities Consider pedometer use Decrease level of sedentary behavior Limit screen time <2 hrs/day No TV/computer in bedroom

19 Structured Weight Management Stage 2 Weight maintenance that Decreasing BMI as age and height increases; Weight loss should not exceed 1 lb/month in children aged 2-11 years, Or an average of 2 lb/wk in older overweight/obese children and adolescents. If no improvement in BMI/weight after 3-6 months, patient should be advanced to Stage 3

20 Communication Positive discussion of what healthy lifestyle changes families can make (evidence base) Allow for personal family choices Have families set specific achievable goals and follow up with these on revisits Be aware of cultural norms, significance of meals and eating for family/community, beliefs about special foods, and feelings about body size.

21 When to partner Dietitians Mental Health Professionals Physical Therapists, Occupational Therapists, Physical Activity Trainers, etc Others

22 Partnership with Families Any efforts to address obesity in children need to be made in partnership with their family. Families have a critical role in influencing a child s health Cohen RY et al Health Educ Q 1989;16; Effective interaction with families is the cornerstone of lifestyle change

23 Alliance Healthcare Initiative: Call To Action Pediatric Weight Management Evidence-Based Nutrition Practice Recommendations for Registered Dietitians 23

24 What is Evidence-based Dietetics Practice? Evidence-Based Dietetics Practice is the use of systematically reviewed scientific evidence in making food and nutrition practice decisions by integrating best available evidence with professional expertise and client values to improve outcomes. ADA Scope of Dietetics Practice Framework: Approved by ADA House of Delegates 24

25 Pediatric Weight Management Excerpt from Executive Summary of Recommendations

26 Multi-component Program Interventions to reduce pediatric obesity should be multicomponent and include diet, physical activity, nutrition counseling and parent or caregiver participation. A large body of strong research indicates that clinically supervised, multicomponent weight-management programs are more successful than single component programs for short-term and longer-term (more than one year) improvement in child and adolescent obesity. Strong Imperative 26

27 Nutrition Prescription A nutrition prescription should be formulated as part of the dietary intervention in a multi-component pediatric weightmanagement program. The exact specification of nutrients and energy is often translated into a specific eating plan. Nutrition interventions are selected based on the nutrition prescription. Research shows that when an individualized nutrition prescription is included, improvements in weight status in children and adolescents are consistent. When an individualized nutrition prescription is not included, results are less consistent. Strong Imperative 27

28 Nutrition Counseling Nutrition counseling, delivered by an RD (which is inclusive of goal-setting, self-monitoring, stimulus control, problemsolving, contingency management, cognitive restructuring, use of incentives and rewards and social supports), should be a part of the behavior therapy component of a multicomponent pediatric weight-management program. Consensus Imperative 28

29 Coordination of Care The dietitian should collaborate with members of the healthcare team (as available) in planning and implementing behavior, physical activity and adjunct therapy strategies. Effective multi-component pediatric weight management interventions benefit from the diverse expertise of different health-care professionals. Consensus Imperative 29

30 Pediatric Weight Management Algorithms Algorithms are available online: Pediatric Weight Management Nutrition Care Process Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring and Evaluation Evidence Based Guidelines > Guideline List > Pediatric Weight Management > Algorithms 30

31 Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Alliance Healthcare Initiative. 2. Review of clinical evidence and U.S. Preventive Task Force Recommendations 3. Benefit implementation details 4. Resources available for primary care providers and registered dietitians 5. Questions& Answer session 6. Post-course survey

32 Alliance for a Healthier Generation Benefit Implementation Details

33 WHO IS ELIGIBLE? Children age 3-18 with BMI 85 th percentile All Anthem lines of business No referral required Appropriate documentation per CPT and ICD-9 guidelines 33

34 How Do We Bill? Diagnosis codes for physician and registered dietitian services V85.53 Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age V85.54 Body Mass Index, pediatric, greater than or equal to 95th percentile for age All services are subject to member copayments and coinsurance per the member s benefits for physician and dietitian services 34

35 How Do We Bill Physician Services Physician services billed using regular Evaluation and Management Codes Use diagnosis codes provided Subject to the appropriate fee schedule for the line of business 35

36 How Do We Bill Dietitian Services Nutritional counseling services Must be billed under the supervising physician s NPI Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Covered up to 16 units though there is a four unit per day restriction 36

37 Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Alliance Healthcare Initiative. 2. Review of clinical evidence and U.S. Preventive Task Force Recommendations 3. Benefit implementation details 4. Resources available for primary care providers and registered dietitians 5. Questions& Answer session 6. Post-course survey

38 Connecting With a Provider For RDs: How to find a Primary Care Provider If RDs do not have an existing relationship with a Primary Care Provider (PCP) in their area, please contact the local chapter of the American Academy of Pediatrics: or the local chapter of the American Academy of Family Physicians to identify practitioners in the community.

39 Connecting With a Provider For PCPs: How to Find a Registered Dietitian For physicians who do not have an existing relationship with a local registered dietitian (RD), the following resources can be used to locate an RD: 1. The American Dietetic Association (ADA) Find a Registered Dietitian Network at Use the online Find a Registered Dietitian (RD) network to identify RDs by geographic locations and areas of expertise such as pediatric nutrition or weight management. 2. Hospital outpatient nutrition departments If an RD is not listed in the ADA Find a Registered Dietitian directory for a particular location, contact local hospital outpatient nutrition departments for information on outpatient weight management nutrition services provided by hospital-based RDs. Some health insurance plans have produced online provider directories; check the plan s website for more information on how to find an RD healthcare provider.

40 Resources Available to Primary Care Providers and Registered Dietitians Anthem Blue Cross and Blue Shield in Virginia American Academy of Pediatrics American Dietetic Association - Alliance for a Healthier Generation

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42 AAP Resources via website

43 AAP Resources Books Clinical Decision Flip Chart Downloadable Tools

44 AAP/ ADA/ Alliance Resources

45 Accessing Pediatric Weight Management Guidelines This Evidence Analysis Library project is free to the public. To access, go to

46 Other American Dietetic Association Pediatric Resources ADA Evidence Analysis Library Store Pediatric Weight Management Toolkit-coming soon Pediatric Weight Management PowerPoint ADA Eatright.org Store Various Pediatric Publications 55 ADA Pediatric Nutrition Care Manual

47 Link to: ADA Guidelines ADA Positions Care Coordination documents AHI Benefit Details

48 HealthierGeneration.org: A destination site for parents and families Healthy Families: Healthy Kids. Parents and guardians are key decision-makers when it comes to the nutrition, physical activity and health needs of their kids. The Alliance for a Healthier Generation provides practical information to help parents create a healthy home for their families. Visit for an array of free tools and resources to help your family lead longer, healthier lives.

49 Educating Parents Resources include both web content featuring simple ideas and solutions for parents as well as videos and brochures for participating insurers and employers to feature on their internet/intranets to help drive utilization. Undergo rigorous scientific review by the American Heart Association to ensure accurate information and best-practice advice Resources for parents can be viewed and downloaded at HealthierGeneration.org

50 Be Well: Messages from Moms on Living Healthier Lives Developed by the Michael and Susan Dell Foundation and the Alliance for a Healthier Generation, this book showcases moms who are working to establish life-long, healthy habits for their kids with the hope that their stories will inspire other parents to help their children eat healthier and get more physical activity. The book is available in print and digital forms (English and Spanish translations). Bulk orders are available free of charge courtesy of the Michael and Susan Dell Foundation.

51 Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Alliance Healthcare Initiative. 2. Review of clinical evidence and U.S. Preventive Task Force Recommendations 3. Benefit implementation details 4. Resources available for primary care providers and registered dietitians 5. Questions& Answer session 6. Post-course survey

52 Questions Thank you for submitting questions throughout this presentation. Please continue to submit questions using the Chat function. Any questions that remain at the end of this session will be posted at: