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Recent developments are paving the way for more pediatricians to counsel their patients on obesity prevention and treatment. Perhaps most notably, a few insurers like Blue Cross and Blue Shield of North Carolina (BCBSNC) and Highmark Inc. have begun offering reimbursement for obesity assessment, prevention, and management services.
Meanwhile, in Pennsylvania, advocates are pushing reimbursement for weight assessments and weight management programs serving Medicaid-eligible children. In addition, the obesity counseling movement just received a boost from the American Medical Association (AMA), in the form of "how-to" obesity prevention guidelines, released June 8.
The AMA's recommendations address dietary intake, physical activity, and eating behaviors (see sidebar and "FYI"). The recommendations are meant to be shared with all pediatric patients and their families and leave little doubt about what messages primary care providers should impart. But unless pediatricians get reimbursed for obesity counseling, the messages may not reach patients.
REIMBURSEMENT NEED
Historically, insurance policies have precluded coding for obesity counseling.
"It's a real problem," says Jonathan Klein, MD, MPH, professor of adolescent medicine at University of Rochester Medical Center in New York. "Pediatricians in general feel their patients aren't covered for nutritional services or community-based interventions."
On behalf of the American Academy of Pediatrics, Klein recently surveyed pediatricians on their obesity counseling practices. Of the 1,600 respondents, 56% said they don't get reimbursed for counseling on obesity, according to the survey results, which Klein presented at the Pediatric Academic Societies' Annual Meeting in Toronto in May. Far fewer—14%—said they felt they could actually code for obesity.
These results aren't surprising to those in the field. "Many pediatricians will code for abnormal weight gain, a rash on the back of the neck, hypertension, abnormal glucose or liver function tests. We look for some comorbidity, and that's what we use," says Robert Schwartz, MD, a pediatric endocrinologist at Brenner Children's Hospital of Wake Forest University Baptist Medical Center in Winston-Salem, N.C.
INSURANCE COVERAGE SHIFTING?
But glimmers of change in reimbursement policies allow some physicians to avoid using these loopholes.
"In North Carolina, there has been progress," Schwartz notes.
In 2005, BCBSNC implemented a benefit that would cover up to four office visits a year specifically for physicians to assess weight and provide treatment counseling on weight loss (DOC News, March 2005, page 8).
"We consider this a standard benefit across the board. It's offered to all groups," says Betsy LaForge, MPH, director of program development for BCBSNC's Healthcare Division.
Providers whose patients are covered by BCBSNC no longer have to "hide" obesity counseling under a different code. "The diagnostic code is obesity. That's unique," LaForge says. "We believe we were the first insurance company to do this."
BCBSNC also has begun to include registered dietitians in its network of providers. All members can receive up to six nutrition visits per year as part of the standard benefits package.
Pittsburgh-based insurer Highmark also has begun to reimburse pediatricians for obesity counseling.
"We have a generation of children whose life expectancy may actually decline because of the obesity epidemic," says Virginia Calega, MD, vice president and medical director of medical management and policy for Highmark. "In order to take care of our members, we felt like we needed to do something."
In January 2006, Highmark implemented a reimbursement policy for obesity counseling. All pediatric patients with a body mass index (BMI) in the 95th percentile are covered for two additional visits and for one laboratory visit that includes a lipid profile and tests of glycated hemoglobin (A1C), aspartate aminotransferase, alanine aminotransferase, and fasting glucose. Patients with a BMI in the 85th percentile are eligible for one additional follow-up visit.
When pediatricians code for these visits and lab work, they use the specific diagnosis of obesity. "The visits can be used for preventive counseling or nutritional counseling," Calega says.
According to Highmark officials, members are taking advantage of the expanded coverage. "These extra visits have gone up by about 23%," Calega says. "We're seeing that people are utilizing it. We'd like them to utilize it more."
| Highlights From AMA's Pediatric Obesity Prevention
Recommendations Dietary Intake
Physical Activity
Eating Behavior
|
STATES HAVE A STAKE IN WEIGHT MANAGEMENT
Insurers aren't alone in the push for better coverage of obesity counseling. The state of Pennsylvania is hoping to implement a program that will provide coverage of weight assessments and formalized weight-management programs for Medicaid-eligible children with a BMI at or above the 85th percentile for sex and age.
"The benefit would allow these children to have an assessment of their weight status, followed up by periodic assessments and a treatment program," explains William Krieger, PhD, of the Office of Clinical Quality Improvement in the state's Office of Medical Assistance Programs.
The counseling and treatment program would be administered in one of two ways: Either a certified registered nurse practitioner or nurse on staff at the patient's primary care office would work directly with the patient or the patient would seek out a formal weight-management program.
"The issue is capacity. Not all primary care practitioners have the resources to dedicate to formal weight-management programs," Krieger says. "We want to put the benefit out there, hoping it will build capacity."
If its budget is approved, this statewide program will launch in August 2007 and will cover Medicaid-eligible children and young adults ages 2–20.
Although the examples of coverage for counseling on obesity prevention and treatment are few and far between, their existence is provoking others to consider how they too might facilitate physicians' role in reversing the childhood obesity epidemic.
"Through our efforts, we have initiated a conversation that many
others are having," Calega says. 
Footnotes
AMA's recommendations for managing overweight and obese children were recently published with co-funding from the Department of Health and Human Services' Health Resources and Services Administration and Centers for Disease Control and Prevention. Access the recommendations online at www.ama-assn.org/ama1/pub/upload/mm/433/ped_obesity_recs.pdf.
To view growth charts for tracking age- and gender-appropriate BMI, visit www.cdc.gov/growthcharts.
Prevention of Pediatric Overweight and Obesity, a 2003 policy statement by the Committee on Nutrition at the American Academy of Pediatrics, can be accessed online at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424. A statement of reaffirmation for this policy was published February 1, 2007.
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