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

Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Healthier Generation Benefit 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. Question & Answer session 6. Post-course survey

Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Healthier Generation Benefit 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. Question & Answer session 6. Post-course survey

Jenny Bogard, MPH Senior Manager for Healthcare, Alliance for a Healthier Generation A. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. B. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Alliance for a Healthier Generation 2011 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.

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.

Healthier Generation Benefit 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

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 Healthier Generation Benefit offers children and their families. Healthier Generation Benefit is the place where these new best practices have real-world application.

Ground-breaking Childhood Obesity Benefits

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 www.healthiergeneration.org for an array of free tools and resources to help your family lead longer, healthier lives.

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

Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Healthier Generation Benefit 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. Question & Answer session 6. Post-course survey

Dr. Stephen Cook Golisano Children s Hospital, University of Rochester Medical Center A. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. B. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

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 www.preventiveservices.ahrq.gov.

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 www.preventiveservices.ahrq.gov.

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.

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 Healthier Generation Benefit Tools and resources for providers and families

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

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

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

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

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

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

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.

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

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;245-253 Effective interaction with families is the cornerstone of lifestyle change

AAP Resources via website www.aap.org/obesity

AAP Resources Clinical Decision Flip Chart Downloadable Tools

AAP/ ADA/ Alliance Resources

Kari Kren Manager, Evidence-based Practice Manager Research & Strategic Business Development American Dietetic Association A. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. B. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. 30

Healthier Generation Benefit: Call To Action Pediatric Weight Management Evidence-Based Nutrition Practice Recommendations for Registered Dietitians www.adaevidencelibrary.com 31

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 32

Pediatric Weight Management Excerpt from Executive Summary of Recommendations

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, multi-component 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 34

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 35

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 36

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 37

Pediatric Weight Management Algorithms Algorithms are available online: www.adaevidencelibrary.com Pediatric Weight Management Nutrition Care Process Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring and Evaluation Evidence Based Guidelines > Guideline List > Pediatric Weight Management > Algorithms 38

Accessing Pediatric Weight Management Recommendations This Evidence Analysis Library project is free to the public. To access, go to http://www.adaevidencelibrary.com/topic.cfm?cat=2721

Other American Dietetic Association Pediatric Resources ADA Evidence Analysis Library Store http://www.adaevidencelibrary.com/store.cfm Pediatric Weight Management Toolkit Pediatric Weight Management PowerPoint ADA Eatright.org Store Various Pediatric Publications http://www.eatright.org/shop/categories.aspx?id=2 55 ADA Pediatric Nutrition Care Manual http://peds.nutritioncaremanual.org/demo/peds.cfm KIDS eat right - public website at kidseatright.org

www.eatright.org/alliance Link to: ADA Guidelines ADA Positions Care Coordination documents HGB Benefit Details

Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Healthier Generation Benefit. 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. Question & Answer session 6. Post-course survey

Thomas J. Van Gilder, MD, JD, MPH Market Vice President, Wisconsin; Humana Inc. I am an employee and stockholder for Humana Inc.

Healthier Generation Benefit Dr. Thomas Van Gilder, M.D, J.D., M.P.H

Fighting Childhood Obesity Humana formed a relationship with the Alliance for a Healthier Generation in 2009 We share a common goal to raise awareness and help put an end to the obesity epidemic Introduced the Healthier Generation benefit (Childhood obesity benefit) to pilot employer groups in January 2011 2

Eligibility The pilot employer groups are: Members of the Kentucky Employees Health Plan (KEHP) Certain self-insured and small employer groups within the Business Health Care Group of Wisconsin (BHCG) The member inclusion criteria is: Children between the ages of 3 to 18 and Children with a BMI in the 85 th percentile range or higher To determine if your patient is eligible: Check Humana s website at www.humana.com Sign-in to the provider portal and search under the Eligibility Tools tab 3

Healthier Generation Benefit (Obesity Benefit) Benefit Design At least 4 primary care doctor visits for obesity exams (e.g. weight management assessment) At least 4 visits to a Registered Dietitian for nutritional counseling Does not require the existence of a co-morbid condition Does NOT include surgical services for obesity Depending on the plan chosen by the subscriber, there may or may not be co-payment/deductible/coinsurance Support from a nurse or personal coach within a clinical program (Please see your patient s plan benefits for any member cost share (if applicable) and to see whether more than 4 visits are allowed.) 4

Using the Benefit How to use the benefit: No enrollment or precertification is required to use the benefit Parents simply take their child (age 3-18) to the primary care doctor or a Registered Dietitian The PCP will determine if the child meets the BMI inclusion criteria for this benefit The PCP will measure the BMI percentile of the child (Use the CDC Website to help you determine.) The PCP office can help the patient to find a Registered Dietitian The PCP and the Registered Dietitian will collaborate to create the child s obesity treatment plan 5

Finding a Dietitian (For KEHP Members) To refer a child to a Dietitian, you can use Humana.com and click on the Find A Doctor tab Select an option to search by and then select the appropriate network When arriving at the step to Search for a Provider Type, select Other Health Care Providers in the first drop-down. Under the Specialty drop-down choose Dietitian If you have trouble finding a Dietitian using Humana.com, you may call Humana s customer service number on the back of the member ID card 6

Finding a Dietitian Additional Sources Many dietitians are located within health systems/hospitals Your Provider Relations executive can provide you with a list of dietitians currently in the KEHP or BHCG- HPN network Humana s Customer Service line or Personal Nurse coaches (Wisconsin only) can also assist in finding a dietitian

Finding a PCP or Pediatrician To refer a child to a PCP or Pediatrician, you can use Humana.com and click on the Find A Doctor tab Select an option to search by and then select the appropriate network When arriving at the step to Search for a Provider Type, select Primary Care and Family Medicine in the first drop-down. Under the Specialty drop-down choose the appropriate doctor If you have trouble finding a doctor using Humana.com, you may call Humana s customer service number on the back of the member ID card 7

How do I submit the claim? You will need to put the appropriate ICD-9 code in the primary position on the claim Common obesity codes include: V85.53, v85.54, 278.00, 278.01, 278.02 For regular obesity exams, use the CPT code most appropriate for the patient you are seeing For nutritional counseling visits, the following is a list of CPT codes that are utilized and associated with obesity. Please use the most appropriate CPT codes for your patient and the clinical services you provide. CPT Code Description 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 Medical nutrition therapy; reassessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 Medical nutrition therapy; group (two or more individuals), each 30 minutes G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen, individual, face-to-face with the patient, each 15 minutes G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen, group (two or more individuals), each 30 minutes S9470 Nutritional counseling, dietitian visit 8

Clinical Program Humana s Healthy Generations Personal Nurse (PN) program Available to BHCG qualifying members Providers are asked to provide the personal nurse with the treatment care plan of action so he/she can support the providers care plan PN s provide ongoing patient/family support and education on healthy lifestyles and obesity treatment /prevention. PN s make outbound calls to eligible members based on claims to introduce the program benefits. PN s also take inbound referrals into the program from members and providers If you feel a patient qualifies for this program, please refer them by calling 1-866-424-2479 9

How is the Benefit Being Communicated? Humana has created several member, provider, and employer communications The materials below are distributed to the provider or member in 2010 or 2011. (Distribution dates and methods vary among the KEHP and BHCG employer groups.) Provider Communications Member Communications Employer Communications 4Q For Your Practice Article Member Open Enrollment Employer Newsletter Article (11/2010) Materials Targeted letters (1/2011) Flyers at Fairs Employer Letters Detailed targeted letters Targeted E-mails (3Q11) Webinar/CME Courses (TBA) Break room Flyers / Posters Detailed information on how to use the benefit Information posted on employer s benefit intranet 10

Data Analytics Humana will be completing internal analysis using claims and clinical data to determine the success of the benefit and the behavior change of members In addition, through collaboration with the Alliance, Emory University will be completing an external analysis with de-identified data Humana will also be providing feedback to our employer groups on the success of the program 11

Resources Available to Primary Care Providers and Registered Dietitians Humana www.humana.com American Academy of Pediatrics www.aap.org/obesity American Dietetic Association www.eatright.org/alliance Alliance for a Healthier Generation www.healthiergeneration.org/healthcare

Local Resources Available to Primary Care Providers and Registered Dietitians KY Chapter-American Academy of Pediatrics Mary Yourk maryyourk@kyaap.org - www.kyaap.org KY American Dietetic Association Danita Kelley sanita.kelley@wku.edu - www.kyeatright.org WI Chapter American Academy of Pediatrics Kia LaBracke klabracke@aap.net - www.wisaap.org WI American Dietetic Association Lynn Edwards WDA@centurytel.net - www.eatrightwisc.org

Questions and Answers 10 minutes Thank you for submitting questions throughout this presentation. Please continue to submit questions using the Questions function. Additional questions can be submitted via email to: healthcare@healthiergeneration.org Any questions that remain at the end of this session will be posted at: www.healthiergeneration.org/cme

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