Sammi: Good evening everybody and welcome to this evening’s Tackling Childhood Obesity (Part 2) webinar. Tonight we will be focussing on commercial billing models. Before we make a start, I would just like to make a quick Acknowledgment of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present. Alrighty, moving on then. I will introduce our presenters for this evening. So tonight we are joined by Dr Georgia Rigas and Dr Garry Egger. Georgia is a Fellow of the RACGP and Chair of the RACGP Obesity Management Specific Interest Network. She is also the Senior Bariatric Medical Practitioner in Australia’s first accredited Bariatric Centre of Excellence at St. George Private Hospital in Sydney. Georgia is recognised as a SCOPE certified obesity doctor by the World Obesity Federation and serves on a number of medical advisory committees, both nationally and internationally.
Dr Garry Egger has qualifications in behavioural biology and epidemiology. He has worked in public, corporate and clinical health for over four decades. He is the author of 30 books including five texts, nearly 200 peer reviewed scientific and research articles and numerous popular media articles on health and fitness. In the 1990s, Dr Egger initiated the GutBusters men’s weight loss program, the first of its kind in the world together with Professor John Stevens and Professor John Dixon from the Baker IDI. He began testing the idea of shared medical appointments in Australia primary care centres in 2013 in order to increase efficiencies and outcomes in chronic disease management. Dr Egger received an Australia medal for his services to medical education and health promotion in 2012. He is a Foundation Member of the Australia and New Zealand Obesity Society and the Australasian Society of Lifestyle Medicine. So, thank you Georgia and Garry for joining us tonight.
Alrighty, I will hand over to Georgia now to take us through our learning outcomes for this evening and we will then hand over to Garry to commence our presentation.
Georgia: Thank you, Sammi and thank you everyone for joining us this evening. As Sammi mentioned, this is part 2 of a series of webinars tackling childhood obesity and the preceding one will be made available for you and our last slide will have a link to a number of webinars that might be of future reference for you.
So, I would like to begin with the learning outcomes for this evening. We hope by the end of this online QI and CPD activity, that you should be able to utilise current prevalence data to better understand childhood obesity, to be aware of the associated comorbidities of being above a healthy weight, to assess a child’s weight status and facilitate early intervention and effective management, to utilise appropriate Medicare benefit schedule items, to effectively manage children who are above a healthy weight, including team care arrangements and mental health care plans. And finally, to be aware of commercial models of managing children who are identified as being above a healthy weight in general practice.
Sammi: Alrighty, over to Garry now to take us through the first slide of our presentation for this evening.
Garry: Well, before I do I must say that I am not the expert in childhood obesity. I have spent my life, or the last 30 years of it, working in adult obesity, but I am primarily tonight going to be talking tonight about payment models and different ways of dealing with obesity which can include childhood obesity and the one that I am particularly concerned with at the moment is shared medical appointments and what we now call programmed shared medical appointments. There are different ways of dealing with this of course. We have got routine advice and clinical service delivery. We have got the education and information side of it, and for those who think that education does not work there is a recent paper that just came out yesterday actually to show that with people, even those who have associated genetic problems with obesity that education does work and particularly if it is education based around life experiences. So it is, and that is what we will be talking about mainly tonight. In the childhood settings, of course, you only have limited access in clinical practice, but you would hope that public health is going to operate quite extensively to support you there in working with kids at young ages in childhood. And I must say too, that a lot of my work in the past has been done with working with the cause of the cause in obesity, and when you look at that, you have got to look at society in general, not just the obesity that comes out of particular families or particular individuals. And then that is what we are looking at in the last part, the food and the built environment.
Georgia: Thank you Garry. So it obviously begs the question, why is childhood obesity a major concern? And as healthcare professionals who see patients on a daily basis, anyone who has spent time with young patients knows that often children and young people do not come because of their obesity per se, they usually come because of something else and as we can see here on the diagram, the reasons can be many. But psychosocial are definitely the most common and most concerning. We see patients describe bullying at school and in the social environment, social exclusion for example where they describe they are not chosen or they are the last to be chosen in team sports, people not wanting to sit next to them because they smell of urine that they may have accidentally passed because of their size. So, really distressing stories and these are the kinds of stories that I hear when I consult with young people. They do not come because they are worried that they have got a fatty liver or if they have got hypertension. They are worried because they have got no friends, they are getting bullied either personally or on social media et cetera. And so, it is important for us to peel the onion layers so to speak, to dig beyond the surface and try to actually work out how the obesity may be affecting the person. Of concern in particular, are the high rates of depression, the low self-esteem and body image that young people report. We often find that these children tend to do less well at school with a higher incidence of school dropout, and as I mentioned earlier, weight is the most common reason for children being bullied at school and this simply needs to change. It is just unacceptable. To add further salt to the wound, not only do they get a suboptimal education, when they do enter the workplace, they often earn less and are less likely as young adults and later on in life to actually get promotions, and this has been shown in studies. And then obviously there are the physical issues which may be the initial reason for the presentation. It may be the reason why parents bring in a child. For example, recurrent musculoskeletal soft tissue injuries like ankle sprains, may be because of an abnormal blood test that we noticed fatty liver et cetera. But sometimes it can be something subtle and this kind of like reminds me of the story where I had a mum bring in her 12-year-old lovely Indian daughter, and she came in saying I am concerned doctor because I am constantly trying to scrub this black dirt of her neck and arm pits and I have even used steel wool to the point where the kid was bleeding, and I am concerned what should I do? And then when I examined the child, she had a lot of features of metabolic syndrome and she was above a healthy weight, and what the mother was calling a “dirty neck” was actually acanthosis nigricans. And so essentially once I actually explained to the mother and the daughter that this was a symptom and a clinical sign of a health condition, we were better able to engage them in some clinical management. So sometimes it can be something which the parent just thought was “dirt” or something benign, but to us we thought, oh my gosh this is an opportunity for us to intervene.
So before we continue to go any further, I think it is important that we are clear about what we are talking about, and one thing that we definitely do know is that it is inappropriate to use words such as overweight or obese when we are talking about families and children because this is very stigmatising. The language that I am about to discuss has been tested with families and children included and has been found to be acceptable. So, when I show you in the upcoming slides the BMI for age and gender charts, you will note that there is the fifth percentile and below line which is below a healthy weight. There is the fifth to the under the 85th centile, which is deemed a healthy weight. When they are above the 85th centile but shy of the 95th centile, they are considered above a healthy weight. And finally if a child’s anthropometry is at the 95th centile and above, then they are deemed as being well above a healthy weight. Now, it must be made very clear that this is used as a screening tool, and as I say to parents, this is just to help guide us to determine their health risk. We are by no means trying to label the children. Essentially what we want to do is to see how we can improve the health and wellbeing of this young child, adolescent et cetera.
Now, in the United States and in the UK, the prevalence of obesity in young people is actually increasing. However, on a positive note, here in Australia, the prevalence of childhood overweight and obesity has remained relatively stable since 2007. However, the rates are high and are a cause for concern. So much so, that it is a New South Wales Health priority but also obviously a national priority, and as GPs we have a duty of care to help young children and their families with this very important issue. What you may or may not be aware of, is that by around the age of three, 20% of children who are above a healthy weight, sorry, by around the age of three 20% of children are above a heathy weight and therefore this is a critical time at which point we should be able to intervene. The earlier that we intervene, the more likely we will be able to change the weight gain trajectory that these young people often find themselves on.
Now, most GPs should be aware of the BEACH data, BEACH standing for Bettering the Evaluation And Care of Health provided in Australian primary care. So, for every 200 children that present to their family doctor, 60 are above a healthy weight as we can see here in the yellow and 23 are well above a healthy weight as we can see here in the red. So we are definitely seeing these children in our consulting rooms, however our major concern is that only one, yes as you have seen on the screen, only one of these children is offered a weight management intervention. And so obviously as GPs, we are letting the children down and we need to do something about it.
Now, the information that is on this slide comes from a poll that was undertaken by the Royal Children’s Hospital in Melbourne in 2016. And the survey showed that parents do want health care professionals to raise the issue of weight to the family. They feel that this needs to be done obviously in a very sensitive and non-judgemental manner and we need to use appropriate language as we said before. Things like “above a healthy weight”. We are worried about the child’s health and development and how well they are. We also want to make sure that in the ensuing consultations, that when we are talking about a child’s wellbeing, that when we do talk about goals, that these are realistic, and at the outset, maintaining weight is often enough. And the emphasis always has to be, we are trying to improve the child’s health, make sure that they are adequately developing, but also we want to equip them and empower them and support them so that they can adopt healthy lifestyle habits that they will then continue with them in adulthood.
Now as some of you might be aware, in my past life when I was in the UK, my specific interest was women and children’s health, and I brought that across when I came back to Australia and I have translated that into the multigenerational effects of obesity. And this still is an issue that is close to my heart. So, I am not going to labour the point, and for those of you who wish to learn more our last slide for tonight does refer to some links for a previous webinar where we did talk about this further, and the reason I wanted to mention it, was we are talking about children who are already above a healthy weight tonight, but often they might be one of many children that the family may have and so what I wanted to firstly bring to your attention was that if a woman puts on an excessive amount of weight during her pregnancy, obviously that foetus is undergoing epigenetic metabolic translational genetic imprinting and so, what is happening in utero will influence that child, and therefore that child will have a higher rate of childhood obesity and also diabetes later on in life. And so we have an opportunity as GPs, the opportunity because we are very well placed, to actually make sure that if we have identified a woman who has had previous gestational diabetes or already has a child with obesity or I should rephrase that, already has a child who is above a healthy weight, then when she comes back to discuss potential future family planning, we are really well placed to try to help maximise her health and optimise her health before she conceives, and also monitor her quite closely so that we can try to change the genetic imprinting for subsequent children. But anyway, for those who are interested to find out more there will be a link later on tonight.
So moving right along, this is an opportunity for me to have a sip of my tea while I let you have a read of this polling question. So, once you have identified a young person as being above a healthy weight, do you – and please vote – document in the medical notes, however opt not to really say or do anything specifically about it, or do you opt to ask the parent or the carer or the child if they are worried about their weight, or C, do you advise them to eat less and exercise more with or without a handout to reinforce what you discussed. D, do you refer them to a dietician or E, do you do something else and if so please specify. And whilst everyone is just having a look, I might actually just invite my fellow speaker, Garry, what do you think? I appreciate that you are not a, you know, clinician, a GP yourself. Sorry, you are a clinician but not a GP yourself, sorry I take that back. How do you think people are going to answer? What do you think?
Garry: Well, I would just correct that. I am actually not a clinician Georgia, I am more in public health. I was a clinician at one stage but I do not do that anymore. I would go along with the majority of the people being polled there at the moment and I think it is something that needs to be brought up, but brought up very sensitively with patients. Unfortunately parents do not normally accept that their child has got a weight problem and the first part of it is making that clear without offending the parent or the child.
Georgia: Correct. And you raise a very valid point Garry, because essentially there is that concern, am I going to offend the parent? Does it reflect poorly on them and their parenting skills? And that is why if we focus on, as we are going to do in the upcoming examples, focussing on their health and the well-being of the child, rather than sitting there and pushing some labels, then I think we will be able to enlist the support of the family. So, interestingly 41% of the audience voted B and that is a good thing. Ask permission, you know, are you worried about the child’s weight and see what comes of that. If they say no, what would you recommend, Garry? In your clinical practice back in the day when you were seeing patients. I know you did not see children particularly, you were seeing the other age end of the spectrum, but do you think they should accept no we do not want to talk about it? Or what would you recommend clinicians do?
Garry: It is a really difficult one and I am sure most of the doctors listening will know that, because just about every doctor that I know has had somebody walk out on them when this subject is broached, particularly about a child. So it does have to be broached, but it does have to be broached extremely sensitively, and maybe looked at in terms of would you like to do something, would you like me to help you do something about reducing weight, or indeed improving the health of the child?
Georgia: Yes, that is exactly right. And if they say look no I am not interested right now, I probably would add and just say, look is it alright if down the track I raise it again with you, or would you like, I just want to let you know that the door is always open so if at any point you or your child is worried about their weight and how it is impacting on their health, you know I am always here for you to come back and we can discuss things further. So just having that door open so that they can initiate discussion down the track. Okay, fantastic. And then in the second poll it was refreshing to see that 93% voted yes. And this is considered best practice as per the RACGP red book. We are – I will not say obliged, it is best practice, when we identify an individual who is above a healthy weight, that we record it in their notes. Ideally as we are going to see in the next slide, do more than that, but we have to put in recall to make sure that we bring them in at least three to six months later for a review. We do not want to just forget them and then see them again five or ten years later and they are still on a weight gain trajectory.
So moving right along. I know it is beyond the scope of this webinar, but it is a very good resource and I think it would be remiss of us if we did not refer back to it, even though we did bring it up at our initial part 1 of this two part series webinar. The Healthy Kids for Professionals website has a lot of good resources for clinicians, but also for family members, particularly for health professionals it is very good because it helps us to bring up the issue of weight and the associated health concerns in a sensitive, non-stigmatising way and there are some video vignettes showing how to have that type of conversation and in the context of different cultural groups who may have different beliefs about weight and how it is perceived in their culture. It also gives advice on how to set up a plan with a patient to explore and address any issues, any barriers et cetera, and also any barriers how to overcome them. It is also quite good, there are a lot of resources there that you can actually give to patients and their families, and what I particularly like about the website is that it is very user friendly, easy to navigate, especially for people like myself who are not particularly IT savvy and essentially we have got to get back to the first principles and remember that this is a chronic health condition. It is not a urinary tract infection that you treat and bang, it is gone. It is going to be something that we are going to be chipping away at over a course of a series of consultations. And this website in particular has been very helpful in helping us create realistic chunking of tasks. So we can break it up into small, obtainable bite sized tasks that we can in a series of consultations start to tackle. And so in my mind, but also in the patients mind, they feel that they are experiencing a series of little wins as opposed to trying to move a mountain, you are just trying to climb the mountain but you do not have to go straight up, you can go the scenic route and manage to get there safely.
Now to get to the actual crux of tonight, because we really want to explore the commercially viable options of you know, commercial billing et cetera, I would like to begin with the most common one that we are mostly aware of, and I do not mean to be patronising to my colleagues who have been in general practice for many years, but you know it is important that we start from basics. So, GP management plans as you will see on the screen are for patients who have got a chronic or terminal medical condition and who would benefit from a structured care approach. Patients who have a chronic or terminal condition would benefit from a multidisciplinary team approach and so it is very clear that patients who are experiencing, who are above a healthy weight or well above a healthy weight, and are experiencing the psychosocial issues or physical issues, would benefit from a multidisciplinary team approach which would include a dietician, a psychologist, perhaps an exercise physiologist because often these kids are trying to do the exercise that their lighter and fitter counterparts are doing, but they do not have the exercise capacity and tolerance for it or they may not be doing as well as they should do and therefore are more prone to soft tissue musculoskeletal injuries. And so, getting involved in programs like Go4Fun and other similar ones that are involved in other states might be the way to go forward. We also know that the team care arrangements make the provisions for us to be able to use the integrated or Allied Health care team members. However, it has to be said and it goes without saying, that GPs should review the MBS online requirements before billing against any of these items. And as we all know, it is our responsibility, i.e. the responsibility of the individual GP to ensure that they bill against the correct item numbers. But just to recap, the GP management plan item numbers are 721 and 732. The team care arrangements are 723 and 732. And then another option as we are going to illustrate shortly in our case examples, are mental health care plans and the items numbers which I am sure that you are aware of, essentially the mental health care plans can be utilised for patients who have a mental health disorder that has been diagnosed by a doctor.
So let us have a look and see what other options there might be. Over to you, Garry.
Garry: Well, shared medical appointments are something that are not very well known here in Australia, although they have taken off overseas, and ironically we have helped the English start these. They are now operative in about 500 medical centres in the UK and it is just the source of BMJ article coming up I think in the next week. Now, I will describe a little bit more what they are as we go along. But a shared medical appointment, the definition is that it is an individual medical consultation carried out sequentially in a group of patients with similar concerns who are all listening and contributing. So, you have got a doctor, you have got a facilitator there who is generally the practice nurse or an exercise physiologist or a dietician who runs the show, and the doctor does consulting with each individual patient just as he or she would do in an individual consultation, it is just that eight or ten other people are there listening and contributing to the consultation under the guidance of the facilitator. Now, one of the reasons for this and the rationale for it is that it takes about and there has been a paper published in the US just recently or sorry in the last couple of years to show that it takes about 23 individual appointments of about 15-30 minutes to get an average of 3 kg to 7 kg or an average of 5 kg weight loss in individuals. So it is very difficult working with individuals over the long term, whereas if you can work with a group, you get peer support from other people in the group and also it cuts down on the time that the doctor is involved. I will talk a bit more about shared medical appointments and the billing for them in a little while, but I think it is probably better to – Georgia are you going to talk about the Health Care Homes model or do you want me to do that?
Georgia: I am happy for you to. Would you like to?
Garry: Yes, well Health Care Homes make the shared medical appointments much more easy to carry out, because it is a bulk billing. Sorry, it is a capitation model and therefore if you keep patients out of the surgery by running group sessions where people are happy to become more involved in self-management, then it is to your advantage based on the capitation model. The MBS item number model does not work very well with this process, because the item numbers that are used, the main one being an item 23, is under dispute with the MBS as to whether you are able to use it in a group situation. Although we do have information now from the MBS that this can be used provided two or more patients are seen - sorry are not seen simultaneously, but are seen consecutively. I am trying to see my notes here under the other details. So they may be seen consecutively, but not simultaneously. And shared medical appointments never were meant to see patients simultaneously, it is just that there other patients there that can contribute to the consultation, people who have had the same experience. And so the prime advantage is getting peer support for the patient and the patient’s carer, in this case if it is a child. These are now spreading around Australia, but we have an application in to the MBS review for a special item number to deal with shared medical appointments. So if you are not in the Health Care Homes trial PHNs of which there are only ten at the moment in Australia, then it becomes a little more difficult to operate under the current MBS system. Now, just to finish up there, the proof of concept was carried out by us in the, and I say us when I am talking about the Australasian Society of Lifestyle Medicine, in the south east of New South Wales PHN, and we have run a program now which was paid for by the PHN. So it was paid for under a Health Care Homes model, but it was most successful, not so much, we were not looking at outcomes because this was only carried out over about six months. To get successful outcomes in weightless, you really have to be going for about 12 months. But it was certainly successful in terms of patient and provider satisfaction. In fact 99% to 100% of patients were satisfied with the model. About 94% of them would prefer to have this type of consultation rather than an individual consultation with the doctor when it came to weight loss. Bear in mind that these are adults, these are not necessarily children, but it does give an indication of the popularity of this type of model. And 100% of the providers were happy with the model because it is much easier to do that it is to do an individual consultation, and of course you cut down the cost. We actually did some work on the cost and it showed that it is about 50% of the cost of individual consultations. But if you actually select your patients wisely because about a third of the patients that we had admitted to having psychological issues which stopped them from losing as much weight as they could have, and if you are able to do something with those and then work in a shared medical appointment arrangement with the others, then you decrease the cost to about 20% of the standard cost. So this is something to look to and if anybody is interested in looking into this further they can go to the Australasian Society of Lifestyle Medicine website, which is Lifestylemedicine.org.au. Lifestylemedicine all one word, .org.au, and look up shared medical appointments under that. I will hand back to Georgia to talk about the practice nurse incentives and co-payments then before we get off this slide.
Georgia: Thank you. Thanks Garry. So, you might be aware the Commonwealth Government introduced the program called Practice Nurse Incentive Program to provide an incentive to eligible general practitioners who want to try to offset some of the cost of employing a practice nurse, and this may be for a registered nurse or an enrolled nurse, or an Aboriginal health worker. So that definitely is an option, especially very useful for obesity management, but also for other chronic health care conditions. Many GP practices already do utilise this for things such as type 2 diabetes, COPD et cetera, but it is definitely a model that one should consider. Another option that could be noted is co-payments, but I do acknowledge that this is not for everyone and nor for every practice, as GPs would have to consider the prevalence of population groups in our area and see whether a co-payment might be beneficial or not. If it would be acceptable or not, because we do not want to deter patients. We want to be able to offer them good quality care rather than cost-prohibitive care. But GPs should consider whether it is appropriate for their patients and the demographics. Furthermore, something not everyone is aware of, some of the health care, health insurance providers do have healthy lifestyle packages or incentives for their clients. For example, HIF offers claims on gym membership, yoga, Pilates, weight management, an exercise physiologist. Another company, Medibank Private offers Flybuys points by linking their wireless Fitbit for every 10,000 steps that they take. So they are incentivising people to participate in an active, healthier lifestyle. So these incentives can be used for patients to make lifestyle changes and take care of their health overall. So, it is important to try and sometimes think outside the square, and feel free to reach out if you would like to find out more about these.
Moving right along. I would actually like to introduce you to our first case study for tonight. Michael is a five-year-old young boy who presented with his mother. This is a follow up visit after being discharged from his third presentation for an acute exacerbation of asthma at the local ED department earlier this year. He was a term baby, normal vaginal delivery, reasonable birth weight, probably above a healthy weight at the 85th centile. He has had asthma with the usual triggers, but despite multiple presentations to ED, has not had any hospital admissions per se. I think his medications are fairly straight forward and common of how we would treat young people with asthma. Now what you might not be aware of, is that there is accumulating evidence of an association between being above a healthy weight and asthma in children. Also, youth who develop asthma are more likely, and have obesity or are above a healthy weight, are more likely to present in Emergency Departments and also these are the young people who will more likely develop obesity in adulthood and therefore their asthma is more likely to get worse and there will be impaired quality of life and increased morbidity and mortality. So something that is quite important.
I did mention earlier that I would be showing you the BMI for age and gender percentile charts. This is what we were talking about and for more in depth information on what they are and how they are utilised, I do refer you to the previous webinar. But we will be using the one that is on the screen just to illustrate Michael’s case. So as you can see here on the left, there are a series of black dots that appear to be in the green, so essentially when Michael was two, three and four years of age, because we are looking at the X-axis, his weight was within a healthy range, but by the age of five it went into the yellow because and that is called above a healthy range, and now that he is six and has come for his review, we can see that he is in the pinkish-red, which we call well above a healthy weight.
Now I would like to just pause for a tick and ask the audience a question. How do you suggest that we approach Michaels’ routine review for his asthma and incorporate the fact that we have identified that he is above a healthy weight. How would you link the two in a clinical consultation? Feel free to just in free speech just write a few thoughts and I will give you a minute to do that. Whilst you are doing that, and thank you for participating, this leads to a question or discussion that I had with one of my colleagues only a few weeks ago, you know, should we be doing measurements of height and weight in children routinely at every visit, or only opportunistically. Garry, what do you think?
Garry: Again, I am coming from a non-clinical background, so, and I think that one of the issues that there has been controversy over the years, has been as to whether people are over-weighing themselves and over-measuring themselves, particularly with adults and the general agreement now is that it should be used for motivational purposes but not necessarily for, at the rate at which it is overused so that is causes anxiety or concern. So if you have got consultations that are not widely spaced, then you certainly would not do it. But if the consultations are every two or three months, then obviously they are going to be measures that should be used importantly and looked at on an ongoing basis.
Georgia: I totally agree, and that ties in nicely with the feedback that we have got from the group here. It is in the red, in the RACGP red book, that we should be measuring the height and weight and calculating the BMI in all our patients, young and old, and if we do this routinely, just like we do blood pressure measurements in adults, then it is less likely to become a stigmatising kind of experience. Now in the children population, it is actually even more likely that we at least weigh them because many of the medications for example, as was indicated by some of my colleagues who have typed in some thoughts this evening, when we are prescribing prednisone or we are prescribing antibiotics or something else, we obviously need to know the child’s weight so we can prescribe the medication dose appropriately. So we are often doing the weight, but usually by the time they are at school we are not ding the height that often so we can plot their BMI for age chart. So that is something that we as primary health care practitioners and our team as a whole, need to be changing. It starts with a dialogue with the receptionist at the front desk, but also the nurses et cetera, we all should be on the same page to say, actually as part of the routine clinical examination, to measure the height of the child and the weight of the child and for us to plot in on these graphs just to make sure that the child is growing appropriately and developing well. So if it is done in that kind of a matter of fact way, then there will be less chance of offending or stigmatising anyone, because everyone is getting treated the same.
So, how would I raise the matter with Michael’s mother? Obviously we want to make sure that Michael is doing okay. But we need to do this in a very sympathetic and non-judgemental manner, otherwise we are going to lose the trust of the mother and potentially that of Michael, the patient. We should assure them as I said only a moment ago, it is best clinical practice. We measure all our patients, young and old. We do not discriminate. We do have to measure children so that we can prescribe medication at the correct dose, but as I said before, we want to monitor his health and growth and development to make sure that he is okay. Especially given that in the past, he has had exacerbations for his asthma that have required prednisone in the past. And so, bringing it back to the point of, we want to make sure that Michael is doing okay.
Now I would like to enter another case into the mix. And for those of us tonight who actually have teenagers of their own, I am sure they are having a little smirk here, but we need to cover both age groups. So, Sarah is a 14-year-old girl who presents with her father. She has been increasingly withdrawn at home and missing school. She is often picked last for sports teams which in a teenaged girl’s world is mortifying. Having teenaged girls myself I can speak from first experience. Sarah reports that she feels anxious and is down, but thankfully she does not have any thoughts of deliberate self-harm. She states that she has got no friends and sometimes gets bullied at school about her appearance and her weight. She has trouble sleeping, stays awake late watching TV and sometimes surfing the Net or on social media. Sarah is often home alone and arranges her meals because both her parents are working. This story is a very common one that I see in clinical practice and I am sure many of us here can relate to this. Not only do many of my fellow GPs report similar cases coming through their clinics, but this also rings true with the outcomes from the recent Health of the Nation Report that the RACGP published, which showed that as GPs the two issues that are concerning us the most, are mental health and wellbeing of our patients and obesity. So, Sarah really depicts both. So looking at her BMI for age and gender percentile chart, we can see that in her primary school years, she was in the green, so a healthy weight. At the age of about 14, 14 and a half, she was in the high yellow, so we saw a BMI of 27 and I mention this because BMI of 27 in the adult world has a different meaning compared to a BMI of 27 as you can see for a young person such as Sarah. And this is of concern, because there has been a sudden increase and this is consistent with the story that she gives us that she is feeling isolated and you know, rejected by her peers and this now having negative consequences on her education because she is not attending school et cetera.
So, how are we going to incorporate a holistic management approach for Sarah? I am just going to pause for a tick and just ask you, my colleagues who are joining us tonight, to just type in a few ideas. How would you broach the subject with Sarah? She is 14, she has already got concerns about her body self-image, having no friends, this, that, the other. Are you going to go in there guns blazing and saying you know, you are above a healthy weight and let us get cracking. Let us start looking at what you are eating and put you on a diet? Or are we going to take a different approach in this particular case? Thank you for participating.
So I am going to read out just a couple of things. So, yes it has to be done in a sensitive and non-judgmental manner. Asking the patient, have you ever been concerned about your body weight? Definitely. Asking dad to leave the room, just say look, Sarah is old enough to have a consultation with us one on one and you as the GP know what the dad is like, so if you have to find an excuse, inverted commas, for the dad to leave the room and you know, I have done that where I have spoken to a girl and I have said look, I will take you to the bathroom so you can pee in a pot when she did not really need to pee in a pot, but it was an excuse to have her to myself to say look, is there anything else going on that you want to tell me without mum or dad around. Because sometimes as we all know, parents do not want to leave the consulting room. So sometimes we have to leave the consulting room with the patient. But yes, talk about other things, you know how are things going at school? Is she worried about her weight or other factors? And then someone has already thought of my next question, you know, do we do any screening questionnaires? But I definitely agree that we should not really directly jump into the weight management at the moment. The worst thing that we could do with Sarah is say well look, here is a diet plan and start hitting the gym and just eat less and exercise more and you will be sweet. Because we will just you know, ruin the therapeutic relationship with her.
So, it is important for us to ask her, what is important for you? Do you have a fear of missing out at school? Is it bullying? Is it the fact that you have got few friends? Is it the fact that you are being picked last at team sport? How do you feel about yourself? She is a young lady and she needs to be empowered to be involved in the discussions about her health, and let her come up with a priority of what she thinks is important and what you can tackle. And I often like to do a little bit of a list with patients of this age group and say, okay let us just brain storm. Some write lists, some do thought bubbles, especially if they are the artistic type, I just give them the pencil and the paper I go, l let us just brain storm. Just blurt out what is happening and what is on your mind, and then I get my highlighter and I say, okay let us prioritise, which one shall we start, tackle first so to speak, and just have a bit of an action plan and also chunking things. But this raises the issue, and this is what I would like to ask my colleagues, for a teenager, which mental health questionnaires would you use to screen for depression? So I am just going to pause for a tick and just give you an opportunity to answer.
So I am getting HEADSS. I am getting DASS 21. DASS 21. K-10. Cool. Okay, thank you. Thank you everyone for participating. So there are a number of questionnaires that have been used, DASS 21, Beck Depression Inventory Score, DMI-10, K-10, USPSTF. So there are quite a few there, however interestingly not all of them have been shown to be validated for the teenage and young person age group.
Now I am cognisant of the time, so I wanted to make sure that I did get to cover the management billing items because that is the main crux of tonight. So, as you can see here, these are the item numbers and how often we are allowed to do them et cetera. So, I would like to just ask you, the audience, how would use these Medicare billing schedule item numbers with Michael? He was the young chap who has got asthma. So, would you do a GP management plan? Would you be doing a team care arrangement? What would you be doing? What do you think might be appropriate for this person? Obviously he is not in a residential aged care facility, but that was just for completeness’ sake obviously. But definitely not relevant for a six-year-old young boy. Excellent, yes. Thank you for participating, guys. Ah yes, a GP management plan and a team care arrangement. And this really dovetails nicely to some questions that were typed in before. Essentially, I would like bring to your attention and I am happy to show you the slide again at the end if need be, but earlier on in the piece when we talked about chronic care plans, essentially when you go on the Department of Health website, you will see that the inclusion, that there are actually no inclusion or exclusion criteria. So, unlike ten years ago where there were a certain number of health conditions that were specifically listed as being appropriate or inappropriate for care plans, that no longer exists. So at the moment, the definition for who is eligible for a chronic, a GP management care plan, is that they have to have a chronic health condition that needs to be present for at least six months, and that they would benefit from a multidisciplinary / integrated health care team approach. There are no inclusion or exclusion criteria. You will also notice that the Department of Health has removed the word “disease” from there. So they do not need a condition to be a disease, and therefore in the case of the questions that someone asked me earlier on, is obesity a disease or not, that is a topic on its own, and I would love to talk about it but I am aware that we have only got about five or six minutes left tonight. However, though that is a different discussion altogether, for the purposes of these GP management care plans and team care arrangements, the wording specifies chronic health condition. So, I think the answer is yes.
So, moving right along. I now want to ask you, how would you use these item numbers to help Sarah? Now Sarah was the 15-year-old teenager with symptoms suggestive of depression but no self-harm, and social withdrawal, was missing out from school, poor body self-image, negative thoughts, but none of deliberate self-harm. So thank you for answering. Yes, doing a mental health care plan would be appropriate in this young lady, especially when you have filled out, got her to, sorry, participate in one of the screening questionnaires, and therefore accessing assistance from a clinical psychologist would be valuable.
As we are aware, management plans are more financially viable for us as GPs, but they are more time consuming. But they also involve a lot more effort because there is a lot more that we want patients to get out of the integrated health care approach. It is, as we have said earlier, the responsibility of the GP who is writing the care plan or the mental health care plan, to ensure that they are claiming correctly against these item numbers.
Now, I know you may have mentioned this before, Garry, but I just thought since we are on this slide, could you clarify for shared medical appointments, what item numbers people may wish to use?
Garry: Yes, well the main one on there is item 23 of course. You could say in theory that you are consulting for over an hour or about an hour for ten patients if you have got ten patients in there. No restriction on the time now as there was before. But if you add to that the 10991 and the 10997 I think it is, which is the nurse practitioner, or the nurse involvement, and the Medicare item number, then that makes it up to about $50 per head. And if you are dealing with about ten patients in an hour, then you are working at about $500 for a session. But, and that is what we pay for research projects that we are doing down on the south coast at the moment, but I have to say that this is still under review by the MBS. It has been under review since 2013. We cannot get a response one way or the other, but the latest response that we have got as I have pointed out before, is that two or more patients cannot be attended to simultaneously although patients may be seen consecutively. So that implies for me that an item 23 can be used in the shared medical arrangement situation. And of course you have got all those other benefits from shared medical arrangements, shared medical appointments that you do not get in a one-to-one consultation.
Georgia: Thank you. Thanks for clarifying, Garry. So, was there anything else that you needed to add to that, Garry? Are you happy with the next slide that is on the screen?
Garry: Yes, that is the slide that I was just quoting there.
Georgia: I thought so.
Garry: But there, we are still waiting for clarification from the MBS review committee and it has been 12 months now. I have written to them twice and asked for some clarification. They have not given it to us. And I should also say that the Australasian Society of Lifestyle Medicine is now looking to challenge the MBS on this issue, because it is so important now, not just for weight control or weight management, but for a whole range of chronic diseases. Most chronic diseases require more than the standard six minute consultation that can occur on a one-to-one basis with a clinician. And you get that in a group shared medical appointment type arrangement. And it is much more convenient and much more enjoyable for the provider as well as for the patient in that situation. So, I guess just watch this space at this stage. We are using these shared medical appointments under existing MBS arrangements, but that is under research conditions and I guess most people will want to know when this is open to more use. And I guess if anybody wants more information on that, they can email me directly. I think, have we got, are we giving emails at the end of the session, Georgia or Sam?
Georgia: Yes, we will be. We will be. So, thank you for that, Garry. So, we are now coming to the close of tonight’s webinar. I just wanted to remind you that this is part 2 of a webinar series on tackling childhood obesity. As you can see here, there are a number of links. In particular, I would like to bring to your attention the Pro.healthy kids link because there are the conversation starters that might be of interest for my fellow GPs and particularly GP registrars, which helps to guide clinicians on how to manage and how to raise the issue of children being above a healthy weight et cetera. But there is a lot of good resources there, so, and these are going to be made available to you at a later date. And so, I would like to finish off tonight by just revisiting the learning objectives, just to make sure that we have covered them all. We hope that by having participated in tonight’s webinar, that you feel more confident in utilising the current prevalence data to understand childhood obesity in the Australian setting, that you are more aware of the associated comorbidities of being above a healthy weight, that you are aware of how to assess a child’s weight status and to facilitate early intervention and effective management, how to utilise appropriate MBS items to effectively manage children who are above a healthy weight. And this includes team care arrangements and also mental health care plans. And finally, that you are aware that there are commercial models of managing children who are identified above a healthy weight in general practice, and that these may be utilised.
Thank you everyone for your participation tonight, and we look forward to seeing you hopefully at GP 18 this week.
Sammi: Great, thanks Georgia. So just a reminder to everybody that this is a CPD activity. Thank you so much Garry and Georgia for joining us and to everybody online. We hope you enjoy the rest of your evening.
Georgia: Thanks, Sammi. Thanks, Garry.