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.

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