1. Sarah Hampl, MD Children’s Mercy Kansas City
MoCAN Status Report Recommendations to the Children’s Services Commission
Sarah Hampl, MD
Children’s Mercy Kansas City

2. Objectives
To provide brief refresher on the problem and rationale and purpose for the Subcommittee on Childhood Obesity
To outline recommendations and progress being made to implement in a coordinated manner.
To provide details on how your support and input can help advance work to address this issue.

3. What’s the Problem? Missouri ADULTS –recently increased to 10th highest obesity rate in nation
Obesity most common health problem for adults and children
ADULTS
32.4 % (2015)
10 out of 51
CHILDREN
2-4 year-old WIC participants
13.0 % (2014)
36 out of 51
10-17 year olds
13.5% (2011)
36/51
Obesity is one of the most common health problems in children and adults. Missouri’s 2015 adult rates jumped from 15th highest to the unenviable ranking of the 10th highest adult obesity rate in the nation according to The State of Obesity: Better Policies for a Healthier America released in September Missouri's adult obesity rate trend line shown below is currently 32.4%, up from 30.2 % in 2014, and 11.3 % in 1990. 
Among high school students, Missouri’s obesity rate of 14.9% ranks the eighth-highest among the 43 states that reported this data. If we don’t impact the high proportion of teenagers who are obese, Missouri’s adult obesity rate will continue to increase, as teens are very likely to carry their obesity into adulthood. Turning the tide on the obesity epidemic and improving children and adolescent’s current and future health is the focus of a group of committed partners. This cross-sector group is implementing critical recommendations made to the Missouri Children’s Services Commission by a Subcommittee composed of experts with broad community input from across the state in 2014.
“While stable rates of adult obesity may signal prevention efforts are starting to yield some results, the rates remain extremely high,” said Jeffrey Levi, PhD, executive director of TFAH. “Even if the nation holds steady at the current rates, Baby Boomers—who are aging into obesity-related illnesses—and the rapidly rising numbers of extremely obese Americans are already translating into a cost crisis for the healthcare system and Medicare.”
Levi added, “In order to decrease obesity and related costs, we must ensure that policies at every level support healthy choices, and we must focus investments on prevention.”
Adult obesity rates in Missouri ( )
The State of Obesity: Better Policies for a Healthier America, September

4. CMH primary care statistics vs. US for overweight/obesity
Age group
National rate*
n=3355
CMH FY 2013
n=15,728
CMH FY 2014
n=17,140
CMH FY 2015
n=17,116
2-5 years
22.8%
27.5%
27.3%
6-11 years
34.2%
39.6%
40.3%
12-19 years
34.5%
44.4%
45.1%
43.0%
CM population has high proportion of Medicaid, Hispanic and Blacks
*Ogden CL et al. JAMA 2014;311:

5. A look at subpopulations of boys and girls by race/ethnicity shows us that we are especially challenged to help find solutions for our Hispanic males and females aged 6 and older. The rates of overweight and obesity are above 50% for Hispanic teen boys. We also see rates above 50% for our AA young women. Also, we can see that rates of overweight and obesity really climb between the ages of 2-5 and 6-11 years old for children in all race/ethnicity categories.

6. 6,000 kids 2 and older per year above a healthy weight range!
This is the bottom line and why we have to act now. The red bars represent children who are in a healthy weight range, while the blue bars represent children who are overweight or obese. In 2014, we saw nearly 6,000 kids ages 2 and older who were above a healthy weight range. This was
36%!

7. Why EBMC Treatment? Background and Rationale
Cost impact of childhood obesity in US is $14 billion/year; in adults is $168 billion/year
Brookings Institute 2012

8. Costs of childhood obesity
Annually, the average total health expenses for a child treated for obesity under Medicaid is $6,370 while the average health costs for all Medicaid insured children is $2,446
This represents a difference of $3,924 in spending
Only 18% of children presenting to Children’s Mercy’s Weight Management Clinics did not have a co-morbidity of their obesity
Marder and Chang, 2005, Thomson Medstat Research Brief

9. Potential Savings for Missouri
Robert Wood Johnson Foundation, 2012

10. Subcommittee Purpose Subcommittee on Childhood Obesity
State of Missouri Children’s Services Commission
Subcommittee Purpose
Review the issue of childhood obesity, the evidence for effective approaches to prevent and treat, Missouri's current approaches, and the gaps in services and resources.
Compile recommendations to create a comprehensive approach that includes access to treatment in Missouri that will fill identified gaps and decrease prevalence of obesity.
Present the report and recommendations to the Missouri Children's Service Commission which will in turn, inform the Governor and General Assembly.
Quick Review as to purpose of original Subcommittee

11. Financial Supporters
The Health Care Foundation of Greater Kansas City and Missouri Foundation for Health provided funds for work of the Subcommittee for Childhood Obesity—report writing, research, meeting facilitation and public forums. ( )
Children’s Mercy and Washington University in St. Louis, University of Missouri- Columbia provided in-kind supports for work of Subcommittee and subsequent proposal writing (2013 through present).
The Health Care Foundation of Greater Kansas City has provided funds for treatment training pilot and start of Commission. ( )
The Missouri Foundation for Health and Health Care Foundation have provided funds for school track. ( )
The University of Missouri-Columbia has provided support for Commission start-up. ( )
Both foundations and select institutions continue to support the efforts

12. Focus Areas for Priority Actions
Align with original recommendations
CHILD CARE: Identify priority implementable changes needed in child care licensing standards, supports considered necessary by the child care community to meet those standards, and a timeline for providing those supports and modifying child care licensing standards. Establish an advisory body to guide this work.
SCHOOLS: Expand Missouri Department of Elementary and Secondary Education’s capacity to support local school districts advances in health and wellness standards. Convene a working group to identify priorities and an action plan to support local school districts’ improvements.
TREATMENT: Expand Medicaid treatment to cover proven family based behavioral treatment and medical nutrition therapy.
COMMUNITY: Establish an advisory body to guide the certification process for licensed providers delivering obesity treatment and compile an action plan to create Centers of Excellence in at least three regions within Missouri to expand prevention and treatment supports for communities.
COMMISSION: Establish a commission to develop a detailed comprehensive action plan, communication strategies, and measures of success necessary to align and fully implement the recommendations to prevent and treat obesity. Assure representation from all sectors.

13. Child care recommendation
Update child care licensing rules to align with the latest evidence on feeding practices, nutrition, physical activity and screen time. Assure training and support services for child care professionals to meet new standards.
Turn over to Jessica

14. Child care recommendation progress
October stakeholder discussion to choose priority actions for updating current childcare regulations
2016 Survey and Analysis
Next Steps
Jessica

15. Ways to be involved- Child Care
Participate in MOCAN’s Child Care Working Group
Assist with efforts to define advocacy priorities and supports needed

16. Schools recommendation
Establish a Student Wellness Program to maintain up- to-date standards for health and physical education curricula. Modify school accreditation by creating and maintaining a health and wellness component. Train and support school staff to implement best practices and school wellness policies related to nutrition, physical activity, physical education, and family engagement.
Still waiting to hear from Janice whether she will be at meeting and can provide update.

17. School Recommendation Progress
Compiled proposal in
Funding awarded
Key actions to be implemented:
New DESE Staff
Advisory Body
Plan
Training and TA for local school districts

18. Ways to be involved-Schools
Participate in MOCAN School Working Group
Apply for advisory group to be established to inform plans
Promote model school wellness policies at local and state level
MOCAN in collaboration with Missouri School Board Association is compiling model school wellness policies and resources.

19. Treatment recommendation
Reimburse licensed professionals with specialized training in family-centered, evidence-based, multi-component weight reduction programs through all Medicaid plans. Reimburse services provided in health care or community settings for children who are overweight of obese.
In other words, improve health equity for the most vulnerable populations, namely, low income children and their families, by increasing the state’s capacity to provide proven treatment services for children who are obese

20. Recent history of obesity coverage
Since Nov 2011, all people with Medicare Part B (medical insurance) who are obese (have a body mass index (BMI) of 30 or more) are covered for obesity treatment
Medicaid has not covered EBMC obesity treatment for children
Private health insurance plans do not cover EBMC treatment for children with obesity

21. Treatment recommendation progress
Nutrition
Physical Activity
Behavior Change
26+ hours of contact
Mo HealthNet Division-State Medicaid Agency is compiling regulations to expand coverage to include multi- component treatments:
Family-based Behavioral Treatment (FBT) and
Medical Nutrition Therapy (MNT)
Moderate-to-high intensity= ≥26 hours of contact
Multi-component= Nutrition, physical activity, behavior change
For ≥6 months
For children ages 6 and older with BMI≥95th percentile
Includes parents/caregivers

22. MO HealthNet actions
Compiled treatment parameters for intensive behavioral therapy for children and adults with obesity in primary care and other settings based on the evidence and experiences from other states
Defined eligible providers for
intensive behavioral therapy (licensed psychologists, licensed professional counselors, licensed clinical social workers)
medical nutrition therapy (licensed registered dietitians)
Projected total annual costs based on participation estimates for Missouri children and adults
Reached out to CSC subcommittee members to discuss and inform their approaches

23. MO HealthNet Actions
Prepared an amendment to their state plan to include expanded coverage for obesity treatment and submit to the Centers for Medicare and Medicaid Services (CMS) for approval
Updating state rules and regulations
Working on operational details (e.g., billing codes, pre- authorization processes, credentialing)
Treatment coverage may be available by end of 2017

24. Treatment progress continued
Children’s Mercy received funding from the Health Care Foundation of Greater Kansas City
Increase readiness to provide treatment
Medical care providers ready to assess, diagnose and refer for EBMC treatment
Dietitians ready to perform assessment and provide treatment recommendations
Behavioral health providers ready to provide individual and family- based treatment
Must be certified to meet MCD requirements that adequate training has occurred
Currently no national or state certification process to assure that licensed behavioral health providers have the training to deliver EBMC treatment
In anticipation that coverage will be available, we want to make sure we have systems elements in place:

25. Treatment Progress, continued
Establish a certification process for Missouri’s licensed providers to deliver EBMC treatment
Washington University is taking lead with input from Children’s Mercy and others on adaptation of course curriculum they have already developed and used
Will develop certification process for those that complete training
Will establish health care advisory group to guide pilot and establish plan for statewide replication.
Will evaluate and modify after 18 month trial

26. Ways to be involved-Treatment
Participate in Health Care Advisory Group
Help recruit medical providers, eligible FBT providers and dietitian for trainings – focus on those providers in settings serving clients eligible for Medicaid
Participate in training if you are an eligible provider and interested.

27. Oversight commission recommendation
Establish a commission to oversee implementation of the subcommittee’s recommendations, study effectiveness of prevention strategies, and provide an ongoing forum for education and future actions.
Between DHSS, MOCAN, state healthcare provider groups, other state stakeholders, would decide what the best infrastructure would be.

28. Oversight Commission Progress
Funds received to start Commission on Children’s Health and Wellness
Mission:
implement the Children Services Commission (CSC) recommendations by
building on existing efforts,
leveraging new resources, and
strengthening and aligning state services and policy
in order to improve children’s health, initially with focus on prevention and treatment of obesity in Missouri.
University of Missouri Extension will
Create Steering Committee to guide formation
Build on MoCAN structure
Convene group later in 2017
Operate as an ad hoc group to assure alignment of efforts, and then evaluate whether should continue after 2018

29. Ways to be involved Oversight Commission
Provide input on best approach and core functions (planning, evaluation, advocacy, and acquire funding to implement plans)
Contact Donna Mehrle if interested in participating further

30. Centers of Excellence Recommendation
Establish Centers of Excellence across Missouri to assure regional, coordinated access to treatment; provide evidence-based weight management services; train health care providers, school staff and others about screening, treatment, referral coordination and prevention strategies; and support research to improve approaches.

31. Centers of Excellence recommendation progress
Select Universities are currently providing functions envisioned for Centers
Train and certify providers to expand capacity to treat within communities
Train community partners in evidence-based prevention strategies
Build partnerships
Provide treatment and consultation for most difficult cases
Support research and disseminate new findings
Evaluate efforts
Commission will craft plan to formalize Centers of Excellence by .

32. Milestone Timeline
Overview of the work completed and planned is depicted on this timeline.