Turf wars pop up over telehealth

As has been widely reported here and elsewhere, the COVID-19 pandemic has seen a huge increase in telehealth provision in primary care. In Australia, MBS figures showing that 36 per cent of all GP consultations were done by telehealth in April alone, and that number is expected to remain high when the May and June figures are released. But now that the restrictions on movement are being lifted in many countries, doctors' groups like the RACGP are running a campaign to get patients back into general practice and not put off seeing their GP any longer.

In Australia, the RACGP is also running a campaign against what it is calling “pop-up” telehealth services, claiming that some of the new services are potentially providing sub-standard and inappropriate care. The AMA has joined the party and is actively lobbying the government to tighten the rules in order to prevent these services from potentially undermining the relationship between patients and their regular GP.

The new services that seem to have raised the particular ire of the AMA and RACGP are those that appear to be linked to pharmacy chains, including Instant Consult, which is being promoted by Chemist Warehouse, and Scripts Now, which involves a written consult with a GP within a Priceline pharmacy through a Sisu health station.

There is a whiff of a conflict of interest in this, particularly the Priceline offering, which allows patients to request a script through the health station. The request is checked and approved by a qualified doctor but the resulting script is emailed directly to the store’s dispensary inbox, which appears problematic. The Instant Consult offering uses a network of pharmacies, not just those belonging to Chemist Warehouse, but is being actively promoted by that banner group.

While these two services in particular have got the doctors' lobby hopping, we have only heard good things about other “pop-up” telehealth services. As one reader told us: “I just used the app called InstantConsult. From my phone, on a Sunday morning, I was able to initiate a video call with a GP who was able to write me another script for my standard medication. Bulk billed.

“Normally I would have to find time to find an appointment during the week at my GP (nightmare) and then pay a $60 gap for the pleasure of wasting 2 hours of my day. Done in 5 minutes. Script sent electronically to a pharmacy in my suburb for me to pick up today. Finally an example of healthcare catching on to technology.”

Denigrating these services by calling them pop-ups – particularly those allied to pharmacies, raising yet again the tedious prospect of inevitable turf wars – is really not very helpful. They are staffed by qualified GPs who have the same responsibilities when treating patients and prescribing medications as bricks-and-mortar GPs, and all of the doctors are registered with AHPRA and are RACGP or ACRRM members. In the case of some like My Emergency Dr, they are staffed by fellows of the Australasian College for Emergency Medicine.

Many of these telehealth services have been around for a long time and only now are being queried because, it appears, bricks-and-mortar GPs have woken up to how efficient and effective telehealth can be. One of the first to start up was GP2U, which has been around since about 2011 and names IPN as a user but which also works with TerryWhite Chemist, Priceline and Amcal.

There is Phenix Health, which has been around since 2013 and also provides technology that allows patients to see their regular GP. It is also an RACGP-accredited telehealth training provider. There's Doctors on Demand, operating since 2015, which charges a fee of $60 for a video consultation but provides repeat prescriptions starting from $27.95. It was co-founded by two pharmacists. There is Telstra Health's HealthNow, which has also previously had run ins with doctors' groups querying its existence, and our reader's favourite Instant Consult, which is based in Brisbane.

There is Medinet, which is more of a technology platform and aims to work with existing practices to allow patients to consult with their regular GP but also provides after hours services. It was in the news recently when a doctor using the technology provided a poor service and tried to bill Medicare incorrectly. There is also Access Telehealth, which provides specialist services to rural and Indigenous patients and GP and specialist services to nursing home residents.

If the AMA and RACGP are concerned over the newer telehealth providers popping up, what about these existing services? Are they also undermining the doctor-patient relationship and providing substandard care? If so, where is the evidence of that?

What appears to be the real problem is the spectre of telehealth services plucking the low hanging fruit of general practice – high paying, low acuity patients. During the coronavirus pandemic, when practice income has plummeted and there is a real question about the long-term viability of some practices if patients don't return through their doors, that is a cause for concern.

And while GPs appear to have embraced telehealth wholeheartedly – AMA president Tony Bartone called it a tremendous success – bulk-billed telehealth sessions are not going to make up for the loss of revenue from patients staying away. Hence the current campaign to restrict competition from pop-ups or other assorted blow-ins.

RACGP president Harry Nespolon admitted as much just this week, telling the RACGP's in-house news service that the MBS funded business model undermines the viability of brick-and-mortar practices by redirecting funding into services set up with the intention of “only dealing with the easy or administrative problems”.

Both the RACGP and the AMA want telehealth to only be accessible to patients through their regular GP. By this, they mean MBS-funded telehealth, as the government is not going to be able to unilaterally shut down the existing fee-paying services. They can bar them from continuing to claim the interim COVID-19 bulk billing items or claiming any new MBS rebate, but they can't actually stop them from practising.

If the government does move to restrict MBS rebates for telehealth to the patient's regular doctor or practice, then new regulations will be required. Patients will have to enrol with a practice or Medicare will have to trust that telehealth claims are being made for active patients. Medicare's compliance regime would suggest the latter is unlikely. How it would be policed is unclear.

The Department of Health could introduce restricted items or quarterly payments to practices to provide telehealth services for particular patients, such as those who were eligible in the past for the Health Care Homes trial, but that immediately raises the red flag of capitation.

And is there actually evidence that the care provided by telehealth serives is substandard? One argument is that telehealth GPs do not have access to the patient's medical record or a good understanding of their history. The counter-argument is that it is still the doctor's responsibility to get a medical history when they are seeing a new patient, whether in person or remotely, and what about (cough) My Health Record? Nine in 10 have one now, after all.

The question of telephone versus video consultations needs to be sorted too. The argument against telehealth in the past was always that doctors and patients need to see each other face-to-face for optimal outcomes. The fact that 90 per cent of consults during the pandemic were done by phone seems to have blown that one out of the water.

There is little doubt that the government will continue with MBS-subsidised telehealth in primary care in some form or another. The decision to offer practices free use of healthdirect Video Call until September 30 to help them adjust to new business models is evidence enough of this. But it has taken many years and a global pandemic to get telehealth used more often, and it would be a shame if telehealth, now that it has proved its worth, is restricted over turf wars just when it was getting started.

That brings us to our poll for this week:

Should MBS rebates for telehealth only be available from the patient's usual GP? Vote yes or no here.

Last week, we asked: Has the $2 billion investment in the My Health Record been money well spent? Er, no, our readers say: 79 per cent said no, 21 per cent said yes.

We received dozens of substantial comments in response to last week's question about the My Health Record, so we have decided to allow readers to leave comments on all articles on our website, whether they are logged in or not.

This blog has been amended to show Chemist Warehouse is promoting Instant Consult, not Instant Script.

Comments  

0 # Reader 2020-07-04 08:56
Your story has an error
Chemist Warehouse is promoting Instant Consult
It is not using Instant Script
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0 # Kate McDonald 2020-07-04 11:00
Thanks for that. I've now fixed that error and changed it to Instant Consult.
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+4 # Leanne 2020-07-04 08:59
Not all patients have a regular GP, there is still a GP shortage in regional areas. This would place regional communities at a disadvantage, again.
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-1 # Oliver Frank 2020-07-04 10:58
All urban dwellers can choose one general practice to be their usual general practice, and preferably would choose one of the GPs in that practice as their usual GP. Because no GP can be available at all times, Medicare benefits for telehealth would be for consultations with any GP within that practice. One could make a case for different arrangements for under-doctored rural and remote areas.
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0 # Oliver Frank 2020-07-04 09:19
Kate McDonald said: "... it has taken many years and a global pandemic to get telehealth used more often". No - what has enabled telehealth to be used more often has been the introduction of Medicare benefits for telehealth. GPs had been ready and willing for years provide telehealth, but the government had refused to provide any support for it through Medicare (apart from the very limited rural scheme).
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+1 # Jon Patrick 2020-07-04 09:23
TeleHealth clearly has opposite effects depending on need. My wife has not been able to get a face to face appt with her regular GP but is always fobbed off to at best a practice nurse or a telehealth session. Perhaps some regular practices have found it profitable to take more appointments that are shorter and so increase income/turnover . Has anyone computed the cut point at which it is more profitable to do only or mostly telehealth appointments?
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+1 # Dr Ian Colclough 2020-07-04 09:47
Perhaps it 's now an appropriate time for the government to exercise some control over the location and distribution of medical practices in metropolitan and rural areas, in combination with registration of patients to each practice (capitation) and govt funded telehealth also registered to the patient / practice. The goverme t pays the money so ut has the right to say how it will be used
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0 # Oliver Frank 2020-07-04 10:55
I am a strong proponent of Australians being required to be enrolled in only one general practice at a time, in exchange for government support (via Medicare) of their health care. This does not mandate capitation - the current fee for service system could be retained, with the difference that Medicare benefits would be payable only for services provided at, by or through (that is, on referral from) the practice in which the person is enrolled.
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+3 # Helpless consumer 2020-07-04 10:11
Consumers want convenience of Telehealth and do not want to be locked in to a particular gp
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+2 # Oliver Frank 2020-07-05 12:37
Did you know that patients who have a usual GP or general practice have better health outcomes than those who don't? A GP who knows you and has an understanding of your health issues, problems, needs, wants, concerns and questions, and who knows what your attitude to your own health and to its care is, is more likely to be able to provide care that is appropriate. If I have a patient complaining of a headache, it makes a big difference if I know that this person has never before complained of headache, or attends every week complaining of headache. It is hard to appreciate the value of this background and the value of a long term relationship with a competent and caring GP if you have never experienced it. Don't let the fact that our health system doesn't encourage or require you to choose and attend a usual GP or general practice lead you to believe that it doesn't matter.
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0 # Oliver Frank 2020-07-04 13:17
All urban dwellers can choose one general practice to be their usual general practice, and preferably would choose one of the GPs in that practice as their usual GP. Because no GP can be available at all times, Medicare benefits for telehealth would be for consultations with any GP within that practice. One could make a case for different arrangements for under-doctored rural and remote areas.
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+3 # Donald Rose 2020-07-04 18:34
Apart from S8s we are able to give a patient 6 months supply (some up to 12 months if they have a GPMP or if it is the COCP) and when deciding the number of repeats that is when we believe the patient needs a review. We don't want pharmacists or kitchen table virtual doctors providing any repeats as that pushes them over their scheduled review and is low quality care health care.
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+2 # remote consumer 2020-07-04 22:01
Hey ladies and gentlemen of the medical profession
Please don't forget about us consumers who have overstretched GP services most of whom are locums in our nearest town 400 kms away.
Once a year we go to the city and on our holidays try to develop a "regular GP".
The concept of a regular GP is a joke in most of the NT and northern WA and northern Qld.
Any GP we can talk too via telehealth is absolutely the best thing that has happened in the north (except rain).
So from the point of view of rural remote consumers please give up on the pipe dream of a "regular GP" until your Colleges can provide Australian speaking permanent GP s in northern Australia.
Not just locum IMGs we cannot understand.
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+1 # Roslyn Jones 2020-07-04 22:08
Let patients choose. Good GPs who offer a service can then be selected. Patients want a service that is convenient
Up to medical profession to start providing it
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0 # Oliver Frank 2020-07-04 22:49
We all want services of any kind to be convenient. Is it more important to you to have a medical service that is convenient, or to have a medical service that is high-quality, safe, ethical and that advises and does only what is in your best interests?
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+1 # Dan 2020-07-05 09:27
False dichotomy – there is no evidence to suggest that telehealth services are low quality, unsafe, unethical, or not acting in a patient's best interests.
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0 # Oliver Frank 2020-07-05 11:48
https://www.theaustralian.com.au/nation/telehealth-triggers-gp-boycott-call/news-story/61dd441129074ad379dfc109cd54601b

Health consultant Shane Solomon, who helped set up Telstra Health’s telemedicine service, said his private information was passed to a market researcher after he consulted a telehealth pop-up ­service.

“This is a breakdown of trust in primary healthcare,” said Mr ­Solomon, who is the chairman of the independent Hospital Pricing Authority.
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0 # Dan 2020-07-05 10:11
Great piece. I just wanted to clarify this point:
> There is a whiff of a conflict of interest in this, particularly the Priceline offering, which allows patients to request a script through the health station. The request is checked and approved by a qualified doctor but the resulting script is emailed directly to the store’s dispensary inbox, which appears problematic.

Australian law actually disallows this practice of "channelling" – e.g. see here: "[clinical software must] maintain patient choice of prescriber and pharmacy for supply of their medicines" https://www.health.gov.au/initiatives-and-programs/electronic-prescribing

Indeed, I have used the SiSU units in Priceline Pharmacy, and it asks you which pharmacy you would like the script delivered to; you are able to specify any pharmacy you prefer.
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+1 # George Margelis 2020-07-05 19:33
The challenge is more than just "opportunistic" use of MBS rebates. Telehealth can "disrupt" the primary care model of care in a positive or negative way depending on how it is implemented.
What we need to do is work on integrating telehealth into a better primary care delivery system. That requires us to redefine the payment model to support it.
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+1 # Dave 2020-07-06 09:16
Myself and my wife do not have a "regular" GP. We see a GP at best once every 2-3 years when needed.
I work in a GP clinic and we have found the majority of our clients (aged, low education) find telehealth overcomplicated . The practitioners have resorted to phone calls to enable a full consultation within the timeframe.
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0 # Oliver Frank 2020-07-06 19:18
Are you saying that you consult just any GP more or less at random, who will know nothing about you and who will have no long term commitment to you or your health care?
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0 # eHealth NSW staffer 2020-07-06 09:46
If I were to have a true National Health Record, which I control access, then I can choose the service-provisi on that suits the consult and me. I have chronic illness and I need regular medication scripts and my GP charges me $75 each time to write a script. If i want to discuss anything about altering my meds then GP insists I do that with my specialist. So what is the GP value here. Anyone with access to my health record can see my 25 years of medication use, and can simply issue the same. GPs need to have flexible charging on the basis of the consult also. That's why we are using Telehealth!
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0 # Oliver Frank 2020-07-06 18:23
The prescription might be the visible product of the consultation, but if your GP is any good, she or he will first review the status of the condition for which the medicine was prescribed, check for whether any monitoring of it or of its treatment is needed and due (for example, kidney function and cholesterol if the medicine is for high blood pressure) and if so, arrange that monitoring, consider whether any change to your medicine is desirable (including reducing or stopping that medicine or changing to some more appropriate possibly newer medicine), review your general health status and check whether any of a wide range of preventive care is indicated and due for you. If your GP is not doing this for the $75, I suggest that find a GP who will do that.
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+2 # Tony Firth 2020-07-06 11:35
Putting aside any questions around the quality of care from a telehealth consultation for one moment, the fact that a pharmacy is offering this service, even with the ability to get a script filled anywhere, seems to running pretty close to the line with respect to channelling. So a GP can’t align with a pharmacy, but a pharmacy can provide GP telehealth services.
I have always found it interesting that a doctor can’t own a pharmacy (because by the Guild rules, you have to be a pharmacist to do so), but a pharmacist can own a medical practice!!
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0 # John Neilson 2020-07-06 19:03
Who is Oliver Frank? Sounds like an advocate for the RACGP or AMA who are against Telehealth other than from bricks and mortar clinics. And yet 98% of telehealth consults from these outlets were by phone, not video! The horse is out of the stable! Telehealth provides quick and convenient access to a GP and some providers even provide a 24/7 service. I'm an owner of a large medical centre with 9 GPs who all enjoy excellent conditions. Because no one would agree to go on to a rotating roster where they worked 1 Saturday in 8, we are now closed on Saturdays! Crazy! I'm afraid bricks and mortar clinics will not provide services in what could be called unsociable hours and as a result Telehealth will become an important part of providing affordable, convenient access to medical advice when patients want it.
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+1 # Oliver Frank 2020-07-18 15:48
I'm not hard to find.
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+1 # Rachel Hyne 2020-07-10 17:46
'Increasing access to care should NEVER come at the cost of patient health and safety'. A Doctors consult is not the same as an online Woolies order - they are not prescribing lollies. They are responsible for their patient's healthcare. A very big responsibility. The sanctity of this relationship is incredibly important.
Yes, patients want access to Drs via Telehealth but to receive a Medicare rebate this should only be claimable through their GP or Practice. Practices are more than ready & willing to supply this service and have in fact have already been, without the benefit of a Medicare rebate. They should be supported to supply this service as they have ready access to the patient's history and identification details.
Your article says '...and what about (cough) My Health Record? Nine in 10 have one now, after all.' True, however according to our practice experience, 9 out of 10 of those records do not have the patients full & current medical history uploaded. Just because a patient has a MHR doesn't mean it's complete.
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0 # Optimist 2020-07-11 15:00
Does it mean that 9/10 of your practice’s GPs don’t do the right thing adding information into MHR? Is it to lock-in patients into the practice through data ownership? Ignorance? Negligence?
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0 # Oliver Frank 2020-07-11 16:38
GPs don't add information to My Health Record because they see little point in doing so in case some unknown person at some unknown time in the future decides to look there for some unknown reason - by which time the information is likely to be out of date. Most of the My Health records in existence have never been viewed by anybody.
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0 # Mark 2020-07-18 12:26
AMA and RACGP lobbying efforts on this are clearly driven by self-interest. There is no evidence that these new models of service provide sub-standard care. Patients should be given choice and if they choose convenience in preference to seeing GP who knows them - that is up to them. Many patients are not well known to an existing GP anyway.
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0 # Oliver Frank 2020-07-18 15:45
https://www.theaustralian.com.au/nation/telehealth-triggers-gp-boycott-call/news-story/61dd441129074ad379dfc109cd54601b

The Australian
Natasha Robinson
HEALTH EDITOR
3:48PM June 27, 2020

Health consultant Shane Solomon, who helped set up Telstra Health’s telemedicine service, said his private information was passed to a market researcher after he consulted a telehealth pop-up ­service.

“This is a breakdown of trust in primary healthcare,” said Mr ­Solomon, who is the chairman of the independent Hospital Pricing Authority.
Reply
-1 # Oliver Frank 2020-07-18 15:47
Mark said: "Many patients are not well known to an existing GP anyway." Medicare statistics from before the COVID-19 emergency show that 87% of Australians consulted a GP face in each 12 months to face. Would you call 13% of the population "many"? I would call it a small minority.
Reply

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