Barriers to telehealth in danger of being rebuilt

Just as a long-awaited breakthrough occurred when the Australian Department of Health opened up the Medical Benefits Schedule to telehealth item numbers to help GPs deal with the coronavirus pandemic in March, that breakthrough may very well be in danger of being severely curtailed with new restrictions being placed on telehealth provision.

Under pressure from the doctors' lobby groups, Health Minister Greg Hunt announced on July 10 that restrictions would be placed on who can receive MBS-funded telehealth consults from July 20, limiting them to patients who have an existing relationship with a GP or practice and have been seen face to face in the last 12 months. Children and people at risk of homelessness remain covered.

The AMA and RACGP hailed this as a victory against corporate and pop-up telehealth providers, but it could just as easily be argued that it's a setback for a long list of patients who are unable for one reason or another to see a regular GP. As detailed in the comments on our story on Monday, this list could include people living in rural and regional areas, especially Indigenous people who live in remote communities; high school students; people looking for sexual and reproductive care; people with mental health problems who have been receiving care by telehealth already; and even people who have recently moved.

While the AMA and the RACGP say they support telehealth and want it to continue after September 30, it appears that is only if it's on their terms. We wonder how often anyone will check it a patient qualifies, whether there will be penalties for doing the wrong thing, and whether by introducing these new regulations, the government is tying up the whole system in such red tape that everyone just gives up and resorts to pre-pandemic business as usual.

New Zealand is providing an interesting lesson. A research team led by the University of Auckland has been surveying general practices since May, when New Zealand was under strict lockdown. Practices not surprisingly reported a vast decrease in patient volume, whether face to face or by telehealth, and plummeting revenue. In late June, after the restrictions had been lifted, there was an expected decrease in the number of telehealth consults, and now 90 per cent of respondents are reporting they are seeing most patients face to face.

Interestingly, NZ mirrors Australia's experience in the bulk of telehealth being provided over the phone. Almost all practices are still doing telephone consults, but this is for less than 20 per cent of consults overall. When it comes to video, just 43 per cent are offering it. It will be interesting to see what level this volume settles at in the next few months. There's some great data here.

Overseas, patients and practices in the UK and the US are also saying they are very keen on telehealth and hope it will continue in the future. The US has even experience bipartisan support in Congress to ease Medicare reimbursement rules for telehealth, which was previously strictly limited to people living in rural areas.

Like Australia, doctors' groups in the UK have been scathing about corporate-style telehealth providers qualifying for NHS funding, particularly Babylon Health, which provides a virtual service to people in parts of London called GP at Hand. Babylon has been accused of picking off the easy jobs – or “low value care”, as the AMA calls it in Australia – and leaving the burden of caring for the chronically ill and the aged to struggling bricks and mortar practices. They are correct in that – 94 per cent of GP at Hand's patients are under 45 – and Babylon has cleverly got around the NHS requirement that patients must be enrolled in a practice by offering that very capability. Babylon is also able to offer face-to-face consults through a few clinics in its target areas.

For the corporate or pop-up telehealth services in Australia that have attracted the ire of the doctors' groups here, they could consider doing the very same thing. In fact, a couple of them do, partnering with medical centre groups for after hours care. New Zealand also appears to be going down this path, with Auckland's Tāmaki Health launching its own bespoke telehealth consultation service, albeit to its own enrolled patients.

The question in Australia is whether the telehealth services can find a market of full fee-paying patients. It will be a struggle but some have in the past. It also remains to be seen if the Department of Health continues in the future with the new restrictions it will impose from next week or imposes further ones. That might come down to how much money this is all costing. If there is an increase in the number of MBS claims, whether for face-to-face care or virtual, then the future for MBS-funded telehealth may be a bit grim.

Two weeks ago, our poll question asked whether you thought MBS rebates for telehealth should only be available from the patient's usual GP. It was incredibly close, with 49.25 per cent saying yes and 50.75 per cent saying no. This week, we thought we'd look at the telephone versus video debate.

Should telephone consults attract an MBS rebate?

Click here to vote or leave your thoughts below.

In light of this week's COVID-19 surge in Victoria, our poll question from last week might need reconsideration. We asked: Should Melbourne Health postpone its Epic big bang until later in the year? A slight majority agreed: 56 per cent said yes, 43 per cent said no, 1 per cent were unsure.


+2 # Vicki 2020-07-18 09:19
Unfortunately I think the AMA & RACGP have taken a paternalistic approach appearing to act on behalf of the “patient” without have the proper conversation with the Australian people about the issues Including continuity of care. I am a GP & obviously prefer patients to keep their care within the one practice but also understand that accessibility & convenience can play a part. The restrictions will be problematic for some of our patients as well as our shared after hours service across our region. These may be unintended consequences though & suspect a decision more about trying to cut out the competition.
+1 # Donald Rose 2020-07-18 09:50
The corporates are the problem and force rules to be made that limit everyone. But in reality it's the doctors who work for the corporates that bring us unstuck. They justify their decision by a variety of personal circumstances that put their survival ahead of good practice. Doesn't wash with me.
+2 # John Neilson 2020-07-18 12:01
Telephone consults are not Telehealth and the vast majority of 'Telehealth' consults were conducted by telephone, by doctors from their medical centres, not by 'pop-up corportaes' as claimed by the RACGP. The decision by the Health Minister to restrict Telehealth to bricks and mortar medical centres is a bad one and has been poorly thought out. Your editorial outlines just some of the people the decision will affect. From my own experience as part-owner of a large bricks and mortar medical centre employing 8 doctors, my doctors refused to work a rotating 1 in 8 week roster on Saturdays from 9am to 2pm with the result my medical centre is now shut on Saturdays. This is not good healthcare, is inconvenient to our patients and is a reason why Telehealth must be supported by the Government as it allows convenient access to medical practitioners, with some telehealth providers offering 24/7 coverage across the country and across all time zones. The AMA and RACGP have been slow to adapt to a landscape that is changing quickly and many of their members will be left behind as the medicine pivots to a more convenient and more comprehensive model.
0 # Penny Palmer 2020-07-18 12:12
Yes - but only with their regular GP . I think the new requirements from 20/7 are much more in line with good medicine.
0 # Melissa - Rural & Remote 2020-07-19 13:26
The system must address the needs of people with high needs who do not have a regular GP due to system issues of access, attraction & retention
+1 # Melissa - Rural & Remote 2020-07-19 13:32
It is important that the needs of the patients are met. For many rural & remote communities access to a regular GP is not possible. The system while being mindful of putting in barriers to prevent GP companies profiteering must be designed to address the significant service access disadvantage for rural and remote people where lower levels of health service access are consistently linked to poorer health outcomes.
+1 # Lynne Everett 2020-07-21 10:02
I would agree if only the definition of "good medicine" meant the same to people, especially Indigenous people, living in rural and remote areas as it does to people living in capital cities. But it doesn't and this restricts even further their ability to "see" a doctor. I live outside a small town in Tasmania but still have access to multiple GPs and practices; people who live in rural, remote and very remote areas don't.
+1 # Deana Scott 2020-07-22 12:39
This issue speaks to the heart of what is really missing in healthcare and that is proactive, patient-centric care. I agree with Lynne Everett that everyone has a different definition of "good medicine". In addition, a patient who last week could access a service and receive a rebate, this week does't have the same experience. This is only going to result in patients becoming frustrated and a breakdown in relationships with their practice/GP as they are on the frontline of the decision.
+3 # Paul Venables 2020-07-18 13:24
I’m a patient with a variety of chronic ailments, either down to my age or past health history. I’m supportive of Telehealth consults and think phone or video could be used depending on the circumstances. I’m unclear whether the new rules mean I can no longer access a consultation with a specialist e.g. cardiologist via Telehealth?
0 # Vicki 2020-07-20 08:12
Hi Paul
It does not affect other specialist only GPs.
You should be fine to continue Telehealth with your Cardiologist.
0 # Anthony 2020-07-19 07:30
Like many of these comments, it does concern me that the AMA and RACGP and just looking after their self interest which has been an ongoing trend for many years. They have fought any form of proven technology improvements to make healthcare both safer and accessible to all Australian's. Can they just name one imperative they have actually championed which may not financially benefit them but actually provide healthcare the care Australian's deserve?
0 # Donald Rose 2020-07-19 16:05
Both the AMA and RACGP support the Modified Monash Model which favours rural doctors over outer urban doctors. Thousands of their members lost funding by their support of this model and they may well lose members for abandoning outer urban doctors in favour of rural doctors as many of these doctors look after rural patients but have lost their rural loading which they need to remain sustainable..
+1 # Bill 2020-07-19 11:45
Telemed should be tailored to the need of the patient and for various reasons a person may not interact with GP within 12 months. Also a video Telemed should attract a different MBS payment from a phone call, which from my perspective is open for abuse by GPs as well. Resent experience of my son requested by work to get a Covid test and he got a sms negative result. The GP practice also called him later and insisted that he speaks to the doctor, even though he expressed that he had already being notified of the result. That would have been a telemed charge. ;-)
0 # MAG 2020-07-19 12:03
I cant believe that this has actually happened at a time when we are trying to reduce movement in the community. we don't want people coming into GP clinic waiting rooms for consultations, we want to keep people at home. there are also a large number of people who have moved from metropolitan areas into regional settings recently, they want to be able to have healthcare via telehealth and they have certainly not been into the local GP clinic in the last 12 months. It is so disappointing that such a narrow view has been taken with an impact that is subsequently potentially monumental and ill advised.
+4 # Kate Barnett 2020-07-19 12:51
It is not a Yes or No ... they should both attract a rebate but video based telehealth should attract a higher rebate because it is a better way to practise virtual care.
+3 # Jane 2020-07-19 14:05
Current healthcare is born out of an unchanging legacy system that promotes passivity in people. This latest decision is another example of the "system" first and the needs of the patient second. People with chronic illness who see multiple doctors on an ongoing basis need this service and have not been considered
+3 # Alison 2020-07-20 13:41
I think there should be a phone rebate that is less than that for a video consult. I think the video consult should attract an (at least) equivalent rebate to face to face... so that there is an incentive over time for practises to shift to this model of care where it is appropriate.
-1 # Oliver Frank 2020-07-21 08:37
Making Medicare benefits payable from 20/7/2020 for telephone or video consultations only when they are provided by a GP in a practice that the patient has attended physically in the past 12 months is an inadequate solution to the problem of pubic funding supporting telehealth consultations between patients and GPs who have had no previous contact. The only adequate solution is to require all citizens to choose one general practice as their usual general practice, with Medicare benefits being payable only for services at, by or through that one general practice.
+2 # Lynne Everett 2020-07-21 10:09
I'm sorry but requiring people with a transient lifestyle, sometimes meaning moving between up to three different states and territories, to choose one health provider is not a solution. I understand this may not appear to be a significant percentage of the population, but many of these people have multiple chronic diseases and no regular GP, and the ability to contact a doctor via telehealth, especially when the doctors they are trying to contact aren't available for face to face consults every time they may seek medical attention, is very important.
There is no one answer to healthcare in Australia.
-1 # Oliver Frank 2020-07-21 10:23
I agree that there is no *perfect* solution. The real question is: is what we are proposing better overall than the current situation? If the answer is 'yes', we can then consider the question: For people whose needs are not met well enough by whatever strategy we implement, what workaround can we create that will best help them? Why could not itinerant Australians be enrolled in only one general practice that would authorise care from whichever other practices the person had to seek care in their travels, with mandated two way communication between the enrolled practice and the other practices, to enable and to maintain some kind of coordination and continuity of care?
0 # Lynne Everett 2020-07-21 10:44
Certainly for our patients their needs would be met quite well if there were no face to face consult requirements with a "regular" doctor for telehealth, we don't need a workaround. We just need to do everything we can to facilitate doctor-patient consults. And why should a practice have to "authorise care" -- surely it's the patient who gets to decide who will provide their health care.
As for "mandated two way communication" -- we have yet to find an infallible way of sustaining such a thing between the many Aboriginal Medical Services to which our patients travel. We had a perfect example of the issues with two way communication on the weekend -- a visitor to a remote community with a life-threatenin g situation about whom we could obtain no information except her name. We could not contact her home clinic as they have no phone number for after hours services; patients just go to the house of the on-call nurse.
I understand this is an extreme example but it's a good example of the difficulties remote and rural patients face, and anything that restricts the ability of patients to access a doctor is not helpful to patients. These requirements do just that.
I'd agree that telephone consults and video consults should not necessarily attract the same reimbursement, but I don't believe we should be limiting access in this way.
0 # Oliver Frank 2020-07-21 12:49
You said: "We just need to do everything we can to facilitate doctor-patient consults". What other kinds of consultations are there between patients and doctors?
0 # Lynne Everett 2020-07-21 13:00
0 # Oliver Frank 2020-07-21 14:27
Telephone call between a patient and doctor? Is that not a doctor-patient consult?
+1 # Lynne Everett 2020-07-21 14:58
I do apologise Oliver, got distracted.
My point there was in regard to registering with one practice. Say a patient, who sees doctors in multiple communities, rocks up in one where there's currently a doctor and decides to get a check up. It's not the one where they're registered and they can't get in touch with the community where they are registered; if, in your scenario, their "home" clinic needs to authorise care, this will reduce their chances of seeing a doctor where they are right now. This doesn't seem like the best thing for the patient.
+1 # Marilyn 2020-07-21 09:45
I also believe that telephone Telehealth should not be reimbursed at the same rate as video Telehealth. The costs to the practice of video Telehealth are more due to need for cameras & audio provision, signing up to a Telehealth provider service, etc. It is also, in my opinion, a better way to practice when you can actually see the patient. However easier for me to say as I work in a specialist practice. However the costs to the practice for Covid-19 provision of services has been substantial with a loss of income.
+1 # Jackie 2020-07-21 10:01
Marylin, a doctors time is a doctors time. As per in person consultations they should be paid for time not delivery method. all of the issues you are stating are part of the argument why GP's are NOT using video. If you do some via video and some via telephone it will even out.
+1 # Jackie 2020-07-21 09:56
Remember that we have come a LONG way with telehealth in a short period of time. Adjustments will need to be made. One of the key issues has always been clinician acceptance. GP's have had this thrust upon them, in good faith they have accepted the challenge and are working on things. As we learn lessons we make adjustments (Agile legislation!). Let's take a deep breath try this for a while and see if we are still providing a good service. I don't mind there being a decision regarding this, at least they are making decisions!!! Now for remote monitoring!
0 # Oliver Frank 2020-07-21 10:15
We GPs have not had telehealth 'thrust' upon us - we have been lobbying successive governments for years for Medicare and/or other public funding to support and to enable us to provide telephone, video and email consultations.
+1 # Loddon Mallee Rural Health Alliance 2020-07-21 10:54
It is important to remember that not all patients can find a regular GP - we still have GP shortages in regional areas.
It is also important to ensure the phone consults are included in the MBS items as many regional patients do not have access to IT devices or internet at home, phone is the only option available to them.
0 # shyamala hiriyanna 2020-07-22 22:15
I work in a center where we provide mainly sexual and reproductive health service, Mental health service.
We also have patients on low income. Don't have family support , women with DV issue complex trauma. Some times they don't have a regular doctor . They find it hard to leave home due to mental health and other issue .Now many don't want to travel by public transport due to covid. I also feel not a good idea for too many patients to present at the practice . Telehealth was an option to provide service for at least 30% of patients.

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