Alliance 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.
Building from the Evidence Base Alliance Healthier Generation Benefit is the place where these new best practices have real-world application.
Evaluation of Healthier Generation Benefit Progress Kimberly J. Rask, MD, PhD Julie A. Gazmararian, PhD, MPH Susan Kohler, RN, MPH Jonathan Hawley Rollins School of Public Health Emory University April 2013
Overview Third party evaluation of both implementation and outcomes Best practices and lessons learned from key informant interviews Monitoring use of the Benefit through claims data Recommendations to increase use of obesity prevention and treatment services 10
Implementing a new health benefit Administrative Barriers to Offering the Health Coverage: Few barriers noted For several this is expansion of an existing Benefit Coverage Offered: Most restrict the coverage to children with BMI greater than or equal to the 85 th percentile for age Co-pay requirements vary by group and/or plan and apply to each visit Enrollment Process for Families: Most signatories have no formal enrollment and/or pre-certification process Marketing: Focus of marketing efforts varies with insurers reaching out to providers and Employers reaching out to employees 11
Use of the Benefit Challenges to Identifying Obese Children from Administrative Claims Data: Use of BMI specific ICD-9 codes is rare Use of CPT or HCPCS codes for nutrition counseling are rare Increase in the number of obese children having at least one preventive medicine visit and/or at least one dietitian visit Remains difficult to identify paid claims processed specifically for obesity-related services 12
Percentage of Covered Children with an Overweight or Obesity Diagnosis Small but consistent increase in the number of covered children that are identified as overweight or obese. Overall percentage increased from 1.5% to 1.9%. This signatory allows providers to use the broadest range of available diagnosis codes.
Number of Overweight /Obese Children with at least One Preventive Visit Most children diagnosed as overweight or obese have at least one preventive medicine visit with a PCP. Overall percentage with a preventive medicine visit increased from 65% to 71%. This signatory dropped co-pays for use of the benefit. Signatory reviewing data to better understand why so low.
Recommendations going forward Build upon the current successes… 1.Continue educational initiatives and outreach to encourage accurate documentation of BMI status. Promote use of overweight and obese diagnosis and procedure codes to allow better identification of eligible children and more reliable monitoring of preventive and treatment services. 2.Evaluate pilot strategies to increase use of obesity services and monitor utilization to identify best practices. 3.Continue collaborative efforts with professional organizations to offer and disseminate resources for health care providers and families. 15
Pediatric Weight Management Algorithms Algorithms are available online: www.andevidencelibrary.com www.andevidencelibrary.com Pediatric Weight Management Nutrition Care Process Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring and Evaluation Evidence Based GuidelinesEvidence Based Guidelines > Guideline List > Pediatric Weight Management > AlgorithmsGuideline ListAlgorithms 17
This Evidence Analysis Library® project is free to the public. To access, go to http://www.andevidencelibrary.com/topic.cfm?cat=2721http://www.andevidencelibrary.com/topic.cfm?cat=2721 Accessing Pediatric Weight Management Recommendations
Other Academy of Nutrition and Dietetics Pediatric Resources Academy Evidence Analysis Library® Store http://www.andevidencelibrary.com/store.cfm Pediatric Weight Management Toolkit Pediatric Weight Management PowerPoint Academy Eatright.org Store Various Pediatric Publications – http://www.eatright.org/Shop/Categories.aspx?id=2 55 http://www.eatright.org/Shop/Categories.aspx?id=2 55 Academy Pediatric Nutrition Care Manual http://peds.nutritioncaremanual.org/demo/peds.cfm KIDS Eat Right - public website at kidseatright.orgkidseatright.org
www.eatright.org/alliance Link to: Academy Guidelines Academy Positions Care Coordination documents HGB Benefit Details
Primary Care Providers: 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: The Virginia Dietetic Association’s “Find an RD”: http://www.eatrightvirginia.org/page/find-an-rd
Local Perspective: RDs 22 Coordinate with the Academy to: Market initial provider webinar Communicate benefit information to RDs Encourage VDA members to partner with PCPs to provide the HGB Increase utilization of RD services via potential benefit redesign
Obesity Related Resources PREVENTION. TREATMENT. RESULTS. Weight of the State, April 2013
Pediatric e-Practice: Optimizing Your Obesity Care INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT 24 www.pep.aap.org
INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT 25 Sample Room: Exam Room
Healthy Active Living for Families INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT27 www.healthychildren.org/growinghealthy
HALF Implementation Guide INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT28 Evidence Parent Feedback Opportunities for Care Conversation Starters Related Parent Resources www.aap.org/HALFIG
HALF Implementation Guide INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT29
HALF APP INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT30 COMING SUMMER 2013!
Other sample resources: INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT31
INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT32 www.aap.org/obesity
Opportunities for Involvement Join the AAP Section on Obesity email: firstname.lastname@example.org@aap.org Connect with the Virginia AAP Chapter http://www.virginiapediatrics.org Virginia Chapter AAP 2201 W Broad Street Ste 205 Richmond, VA 23220-2022 http://www.virginiapediatrics.org INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT33
Weight of the State Alliance for a Healthier Generation Rhonda Keith, M.S. COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
Anthem’s Role 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. Anthem covers benefit for… at least four follow up appointments with a primary care provider at least four visits with a registered dietitian COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
Program History Pilot officially launched May 15, 2010 Rolled out in conjunction with the Virginia Weight of the State Conference No system changes were needed Focused on promotion and use of benefits Early interest by pediatric practices was high COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY36
Who is eligible? 550,000 eligible children in VA 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 COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY37
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 COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY38
How do we bill? Physicians Physician services billed using regular Evaluation and Management Codes Use diagnosis codes provided Subject to the appropriate fee schedule for the line of business Nutritional Counseling Services Must be billed under the supervising physician’s NPI 97802 – Medical Nutrition Therapy (MNT); initial assessment & intervention, individual, face-to-face with the patient, each 15 minutes 97803 - MNT; re-assessment & intervention, individual, face-to- face with the patient, each 15 minutes Covered up to 16 units – four unit per day restriction COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY39
Measures of Success Use of Benefit We had a 6% increase in the number of preventive visits with a PCP in those children with an obesity diagnosis This compares one year prior to implementation to one year after Participation 38 Pediatric practices utilizing benefit Physician Champions! Physician – Registered Dietitian Relationship COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY40
Partnerships Alliance for a Healthier Generation – American Heart Association – William J. Clinton Foundation Virginia Chapter of the American Academy of Pediatrics The Virginia Department of Health COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY41
What’s Next? Expansion of Program CA Pilot - began April 2012 WI Pilot - start date TBD VA Pilot – increase participating practices Evaluation Anthem will begin research to… Review three years of EMR data Evaluate changes in BMI for participants COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY42
Contact Rhonda D. Keith Community Collaboration Manager Patient Centered Care Programs Anthem Blue Cross Blue Shield Tel: 804.212.6952 Email: email@example.com@anthem.com COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY43
John E. Moore, MD Brooke Mercedes, RD, CSSD Botetourt Pediatrics Carilion Clinic Children’s Hospital
Located in southwest Virginia Roanoke metro region: approx 300,000 Primarily suburban / rural Practice catchment area of 5 counties Some patients are driving hours to this location!
Hospital-owned general outpatient pediatrics 2.5 FTE satellite office, Main office 5.5 FTE with 1 NP Approx 6000 patients 20% Medicaid / MCO 50% Anthem
Step 1: Recognize a Problem More and more children in my practice were obese Step 2: Find a Solution I realized I was in over my head!!! I looked for help
AAP national Virginia Chapter Great toolkit!
In 2011, Anthem rolled out nutrition counseling pilot One of the first times commercial insurance, governmental agencies, hospitals, and private practice were on same page Coverage for in-house nutritional service
Changes office needed to make prior to scheduling patients Find a qualified nutritionist! Work out referral process Iron out coding, billing Anthem would not cover “obesity” Had to code as “Elevated BMI”
Presents with obesity and probable Type II diabetes. Pt seen for education of carb counting and healthy eating Potential barriers: understanding of carbs and how to count them, concern of commitment- appeared overwhelmed
NUTRITION EVALUATION Wt: 127.14 (>95 %ile) Ht: 59.5in (90 %ile) BMI: 25.4 (>95 %ile) Pt is a 10yo male being seen for BMI >95%ile as well as new onset Diabetes which he is jointly followed by Peds Endo for. Reviewed knowledge of CHO counting with pt. His base knowledge was very minimal. Reviewed basics of CHO counting and provided family with handouts for guidance. Helped family to develop meal plan that fits pts current needs. Provided recommendation of 60g at meals and 20-30g at snacks. Recs/Goals 1) CHO intake- meals: ~60g/ea and snacks: 20-30g/ea 2) fiber goal 15g/day 3) eat every 3-4hrs- counting CHOs and monitoring Glu levels as prescribed 4) focus on adequate activity level 5) Prot goal is >15g/meal
Provided hands on examples Provided family with “cheat sheets” and discussed each one. Developed a plan with the pt and mom. On going communication with pt and mom.
Previous Wt: 127.1 Current Wt: 124.0 (>95 %ile) Wt Change: down 3 lbs Pt is doing well with changes. He is understanding what a carb is and where it is found. Discussed different ways to put meals together and what he could eat with freedom. Pt is able to verbalize some of the different carb amounts in food. Very pleased with progress and wt loss. Will send not to school to allow mid morning snack.