The goal of the Alliance is to eliminate childhood obesity and to inspire young people to develop lifelong healthy habits.

Alliance Programs

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.

Healthier Generation Benefit: Supporting Organizations

Healthier Generation Benefit Signatories

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

AAP/ Academy/ Alliance Resources

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 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 Accessing Pediatric Weight Management Recommendations

Other Academy of Nutrition and Dietetics Pediatric Resources Academy Evidence Analysis Library® Store Pediatric Weight Management Toolkit Pediatric Weight Management PowerPoint Academy Eatright.org Store Various Pediatric Publications – Academy Pediatric Nutrition Care Manual KIDS Eat Right - public website at kidseatright.orgkidseatright.org

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”:

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

INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT 25 Sample Room: Exam Room

26 Sample of resources accessible via PeP

Healthy Active Living for Families INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT27

HALF Implementation Guide INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT28 Evidence Parent Feedback Opportunities for Care Conversation Starters Related Parent Resources

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

Opportunities for Involvement Join the AAP Section on Obesity Connect with the Virginia AAP Chapter Virginia Chapter AAP 2201 W Broad Street Ste 205 Richmond, VA 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 – Medical Nutrition Therapy (MNT); initial assessment & intervention, individual, face-to-face with the patient, each 15 minutes 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: 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: (>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: Current Wt: (>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.

 Practice: coding, referrals. marketing  Patient: education, stigma, behavior changes  Financial: copays, high deductible All Anthem is not the same Out-of-state plans

 Staff education  Communication!  Working with Anthem / Medicaid guidelines to craft appropriate follow- up plans  Individualization of guidelines, recommendations  NCQA PCMH certification