Child Obesity Treatment Services:
Where are Children’s Hospitals
and where can we go?
Stephen Cook, MD, MPH
Associate Professor, Pediatrics
UR Medicine’s Golisano Children’s Hospital
April 2015
Disclosures
Grant funding:
• NYS Dept of Health,
• Greater Rochester Health Foundation
• NIH CBPR project
• CDC Prevention Research Center
Boards: ABOM, AAP IHCW
..…and I used to work at a TJ’s Big Boy
Parents estimation of child’s weight
status vs. measured weight, 2-9yo
Estimation of weight 193 parent/child dyads from
Strong Pediatrics
Tschamler, et al, Clin Peds, 2010;49:470
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Adolescents’ Perceptions of Peers Being
Teased or Bullied: Observed Frequency
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Percentage of teen girls who report frequent
weight teasing
Neumark-Sztainer. J Adolesc Health. 2009;44:206-213.
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Treatment of Obesity in
Children and Adolescents
Stage
Delivery
Behaviors
Stage 1 –
Prevention Plus
Office-based support, with
scheduled follow-up
5 fruits and vegetables
< 2 hrs of screen time
> 1 hr of physical activity
Stage 2 –
Structured Weight
Management
Specially-trained staff in office
with support from referrals
Reduced-calorie eating plan
< 1 hr of screen time
Monitoring
Stage 3 –
Comprehensive
Multidisciplinary
Intervention
Dedicated weight management
program or registered dietician
referral; weekly follow-up for 8-12
weeks
More frequent contact, more
structured monitoring,
goal-setting
Stage 4 –
Tertiary Care
Pediatric weight management
center with multidisciplinary team;
clinical or research protocol
Medication, surgery, meal
replacement, ongoing behavior
change
Adapted from Katzmarzyk
Public: Illinois Medicaid
Chicago: Healthcare and Family Services
Wt Mgmt Visits: > 85th percentile, > 2yrs
Appropriate CPT or UB-04 code
Appr. 5-digit ICD-9 code: 278-00-278-02 AND one V-code: V85.53 or
V85.54
Cover 3 visits over 6mo w/ PCP (Overweight or Obesity as the ONLY
diagnosis)
If co-morbidity, then that is separate.
Step 2 Structured Weight Management:
Primary Care Office With Support
1. Develop plan for balanced macronutrient intake with emphasis on
portion size of high energy dense foods
2. Increase frequency of structured family meals, planning with an RD
3. Reemphasize importance of monitoring logs( age appropriate)
4. Supervised active play 60 minutes /d, community support
5. Weight goal: maintenance or loss of 1#/month (age 2-11) up to 1-2
#/week for obese teens) to achieve 85th percentile BMI
6. Revisit at least monthly with MD, RD, office staff. Reassess in 3-6
months proceed to stage 3 prn
Structured Weight Management
Alliance for a Healthier Generation benefit:
• 4 visits w/ PCP for OW or OB, over 12 mo
• 4 visits w/ RD for OW or OB, over 12 mo
• 99213-214-215 use time-based billing
• Aetna & CD-PHP in New York
• RD codes: 97802 Initial , 97803 Follow-up and 97804
(group)
Severe Obesity (>99th %tile) among US Children &
Teens, or 3.8% or 2.7 million
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Severe Obesity (>99th %tile) among US Children &
Teens, or 3.8% or 2.7 million
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The Affordable Care Act Improves Prevention
and Obesity Coverage
ACA includes several provisions that promote preventive care including obesityrelated services and coverage.
These provisions include an enhanced federal match for states that cover all U.S.
Preventive Services Task Force (USPSTF) grade A and B recommended preventive
services with no cost-sharing. Obesity screening and counseling for children,
adolescents and adults is a USPSTF recommended service.
The law calls for states to design public awareness campaigns to educate Medicaid
enrollees on the availability and coverage of preventive services, including obesity-
related services. To help states, CMS will host calls and webinars regarding
coverage and promotion of preventive services, develop fact sheets that address
Medicaid coverage of preventive services, and share examples of state Medicaid
program efforts to increase awareness of preventive services.
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-ofCare/Reducing-Obesity.html
Treating Overweight & Obesity
Stage 1 – a prevention program managed by a primary care physician
Stage 2 – a structured weight management program managed by a primary care
physician together with a pediatric health care provider, such as a dietitian
Stage 3 – a comprehensive intervention involving a multidisciplinary obesity care
team that can provide structured monitoring, counseling and assessment at
specified intervals and interventions as needed, often at a children’s hospital. **
Stage 4 – tertiary care interventions that can include medication, very low calorie
diets or bariatric surgery
Stage 3: Clinics & Programs
Clinic: multidisciplinary treatment offered without a defined treatment
period or a specified frequency.
Program: multidisciplinary treatment following a curriculum and
delivered over a specified duration of time with a specified number of
visits.
Stage 3 / POWER
As Stage 3 multidisciplinary care providers, children’s hospitals are
primarily managing care for children who are obese (>95 percentile for
BMI) or severely obese (>99 percentile for BMI). Data from a 2010
Children’s Hospital Association retrospective review of the 13 participating
children’s hospital weight management programs in the Pediatric Obesity
Weight Evaluation Registry (POWER) shows:
• 61.4 percent of patients were severely obese and 35 percent were obese
at presentation
• More than 90 percent of patients two to five years old were severely
obese at presentation
• Nearly 75 percent of patients presented with a comorbidity
“In God we trust; all others must
bring data.”
W. Edwards Deming
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Growth of Stage 3 Services
Stage 3: Clinics & Programs
Stage 3: Wait Time
Stage 3: Home Base
69% felt they had a champion for obesity treatment from hospital’s
executive or medical leadership
Stage 3: Multi-specialty Services Offered
Staffing for Stage 3 Services
Comprehensive weight management services typically include four key roles
• 97 percent of teams have a dietitian
• 86 percent of teams have one or more physician
• 75 percent of teams have a mental health professional
• 67 percent of teams have a physical activity specialist
Frequency of Funding Source for Staff
Stage 3: Data Collected on Parent
Stage 3: Data Collected on Outcomes
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Plans Beyond The Just The Clinic
•
61 percent of respondents report obesity has been identified as an area of
concern on their hospital’s most recent community health needs
assessment. Only 4 percent of respondents indicate it was not identified as
an issue, the remaining 35 percent did not know either way. (N = 122)
•
54 percent of respondents cite obesity as a topic addressed in their
institution’s strategic plan. 12 percent said specifically that it is not in their
strategic plan, while 33 percent did not know.
(N = 82)
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3yr old WCC w/ pt Not Mykid
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Pt NW, first seen at 3yrs and noted to be obese
PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?
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Pt MN
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One city’s communities of solution
Note: Political boundaries, shown in
solid lines, often bear little relation
to a community’s problem-sheds or
its medical trade area.
Reproduced and adapted with permission from: Folsom M. Health
is a Community Affair: Report of the National Commission on
Community Health Service. Cambridge, MA: Harvard University
Press; 1967:3, Fig 1.
Annals Family Medicine, May/June 2012
Vol. 10 no. 3 p 250-260
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The Expanded Care Model
• Build healthy
public policies
• Create supportive
environments
• Strengthen
community
action
Activated
Community
Community
Health System
• Information
• SelfSystems
Management
• Delivery System
Support/Develop Design/Reorient • Decision
Support
personal skills
health services
Informed,
Activated
Patient
Productive
Interactions &
Relationships
Prepared
Proactive
Practice
Team
Population Health Outcomes /
Functional & Clinical Outcomes
Prepared
Proactive
Community
Partners
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Who are we really treating?
Those with Overweight and above?? 25-30%
Those with Obesity only?? 12-22%
OW or OB and a parent w/ OW or OB?  2/3 of youth w/ OW or OB
Or
Those with Severe Obesity (>99th percentile or > 120% of Obesity)
• 3-4 % of youth in your region.
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Treatment of Obesity in
Children and Adolescents
Stage
Delivery
Behaviors
Stage 1 –
Prevention Plus
Office-based support, with
scheduled follow-up
5 fruits and vegetables
of
< About
2 hrs of 30-35%
screen time
yr oldsactivity
> 1 2-18
hr of physical
Stage 2 –
Structured Weight
Management
Specially-trained staff in office
with support from referrals
Reduced-calorie
eating plan
If 1/3rd come
/
< 1 hr of screen time
follow up= 10%
Monitoring
Stage 3 –
Comprehensive
Multidisciplinary
Intervention
Dedicated weight management
program or registered dietician
referral; weekly follow-up for 8-12
weeks
More frequent contact, more f
If 1/3rd continue,
1/3rdstructured
monitoring,
then
~3%
goal-setting
Stage 4 –
Tertiary Care
Pediatric weight management
center with multidisciplinary team;
clinical or research protocol
Medication,
meal
If 1/3rdsurgery,
continue,
replacement, ongoing behavior
then ~1%
change
Adapted from Katzmarzyk
Questions??
@DrSteveCook
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