Use it or lose it: new rules for telehealth
This article first appeared in the July 2012 edition of Pulse+IT Magazine.
In June 2011, Prime Minister Julia Gillard and Health Minister Nicola Roxon announced a $620 million telehealth initiative aimed at “transforming the way healthcare is delivered in Australia by removing distance, time and cost as a barrier to accessing care”. Not only would specialists and GPs receive a $6000 “on-board” incentive payment upon conducting their first telehealth consultation, but new items were added to the MBS to allow specialists to claim an additional rebate of 50 per cent and GPs 35 per cent to conduct a video consultation.
Eleven new MBS items were made available for telehealth consultations provided by specialists, consultant physicians and consultant psychiatrists. The new items allowed a range of existing MBS attendance items to be provided via video conferencing, with a derived fee adding to the base item fee.
New MBS items were also introduced for patient-end services, allowing GPs, nurse practitioners, midwives, Aboriginal health workers and practice nurses to provide face to face clinical services to the patient during the consultation with the specialist. The fees were restricted to eligible geographical areas outside metropolitan areas, aged care facilities and Aboriginal Medical Services.
At the time, the prime minister said participating health practitioners around the country would receive attractive Medicare rebates from July 1, 2011, to compensate them for their time invested in the consultation, and some support for the technology required. “These include increased Medicare rebates for telehealth, payments to cover start up costs of installing the technology, and bulk billing incentives,” she said.
The government set a goal of 495,000 telehealth consultations by July 2015. According to the most recent figures available, as of the end of February 2012 Medicare has processed 10,594 telehealth services, and according to Department of Health and Ageing (DoHA) statistics, more than 1700 doctors have provided a telehealth service.
“By the end of February 2012, the target of 2.7 per cent of specialists providing telehealth services for the 2011-12 financial year had already been met,” a DoHA spokeswoman told Pulse+IT.
“So far, 745 specialists have provided a telehealth service which equates to three per cent of specialists. More than 90 per cent of all telehealth services are bulk billed, meaning that patients face no out-of-pocket costs.”
However, in the federal budget handed down in May 2012, the government decided to tighten the rules. In the original plan, the on-board incentives were to be reduced from a lump sum payment of $6000 up to July 1 2012 to $4800 on July 1 2013, $3900 on July 1 2014, and $3300 on July 1 2015. The government has now decided to cut short that plan by a year, with the incentives to cease in 2014.
It has also decided to split the on-board incentive into two instalments — the first instalment of $1600 to be paid upon the first valid telehealth MBS claim and the second instalment of $3200 after the tenth claim. This will be reduced in 2013/2014 to $1300 for the first claim and $2600 after the tenth.
In addition to ensuring that money is not wasted on practitioners who only do a handful of video conferences in total, it was also a signal that the government is keen to use a carrot and stick approach to get doctors on board faster. The government itself said the changes aimed “to encourage early adoption and embed telehealth into normal practice”.
“The on-board incentives were designed to encourage practitioners to adopt telehealth as part of their normal practice,” the budget papers stated. “The original incentive structure has been highly successful at encouraging practitioners to trial telehealth, but has been less successful at encouraging full adoption.
“By paying the on-board incentive in two instalments, only practitioners who show genuine commitment to telehealth (by providing at least 10 services) will receive the full on-board payment.”
A 15km minimum distance between specialist and patient location will be also be introduced from November 1 this year, although this will not apply to residents of aged care facilities and patients of Aboriginal medical services.The government also said it would cease funding of the Telehealth Support Initiative from July 1 next year.
This major initiative, which provided funding of between $100,000 and $2 million over 18 months, was aimed at developing a range of training supports, including continuing professional development training, tools and guidelines to facilitate online telehealth consultations and to promote uptake to the initiative.
The estimated $183.9 million in savings over five years has now been redirected towards broader eHealth reform initiatives, including extra money to continue to build the PCEHR.
The Medicare rebates survived the axe, with the government budgeting for $58.2 million to be paid out as Medicare rebates for specialist telehealth consultations in 2012, $109.3m next year and rising to $221.2m in 2015-2016.
While the government’s reasoning is clear, not everyone is happy. The RACGP, which has been funded to develop a number of resources under the Telehealth Support Initiative, said that while it accepted the 15km distance requirement for people who were able to travel, the government was forgetting patients such as the elderly, for whom mobility was a major barrier.
“[This change will limit access to specialist services for those most in need,” the college said in its official budget reply. “The college will be meeting with government to discuss these issues, as patient access to these services should be at the discretion of the GP if clinically required.”
It also said that while it knew the incentive payments were finite, the announced cuts were premature, as telehealth consultations have not yet become a part of usual practice for the majority of GPs.
“The RACGP believes that it is both short sighted and unrealistic to phase out the telehealth incentive earlier than planned, as uptake has been confounded due to both interoperability difficulties between GPs and other specialists, and the lack of a provider directory.”
Paul Mara, president of the Rural Doctors Association of Australia (RDAA), was more sanguine. “I think the subsidy that they put in in the initial stages was there to encourage people to try it out,” he says. “While I was fairly cynical about it, I can see that it actually does have some benefits. It is up to the government when they remove the incentive payments, and at the end of the day people will make their decisions in whether it is worthwhile or not.
“There is no doubt that the incentive is driving the initial uptake but that may also mean that people are beginning to get an idea of what the potential for it is and what the advantages and disadvantages in their particular circumstances might be.”
For Dr Mara, who has used video consultations in his own Gundagai practice a number of times, video conferencing has only provided limited value, but he can still see the potential. “It is probably useful for triaging in surgical cases where ... it saves the patient from having to go to see the specialist and go through all of the rigmarole. All of the paperwork can be done, the consultation can be done online and instead of the patient having a couple of trips to the major centre, they’ll just have to go in once to have their day surgery procedure or whatever.”
He also sees reasonable potential for routine follow-ups, and also for people with complex medical problems so they can save time on travel. “Potentially if you had better broadband it would be good for dermatology consultations and that sort of thing, but at the moment it is definitely not.
“In other circumstances like acute emergencies, we often do a combination of things, so we might take a photo of the x-ray and sent that digitally and get the reply back from that. There is more potential as the technology improves and the speed of broadband improves.”
However, there are some major drawbacks, teeing up a consultation being one of them, he says. “It takes an enormous amount of admin time. You often find that you have a patient there, the consultation is booked for quarter past four, and the specialist doesn’t turn up until five o’clock. It depends on both sides having the capacity to be on time, and that is not always the case. The technical literacy of the doctors is also another issue. It takes a while to get that sort of thing going.”
David Allen is a Sydney-based occupational health physician who runs Quality Occupational Health, a multidisciplinary team of doctors, therapists, counsellors and nurses providing occupational medicine services. He began providing telehealth services in 2007 when several large clients were experiencing problems accessing remote and regional care.
“We looked into doing IP-based video conferencing, which at that stage was not very commonly used and certainly not for telemedicine,” Dr Allen says. “We had to prove it to large employers, who were not going to spend money on expensive equipment if it was unproven in occupational medicine, so we demonstrated we could do it in a trial with one large employer in NSW, which was a finalist in the NSW WorkCover awards.”
Dr Allen’s team was able to show that using IP-based video conferencing was not only secure but cost effective or in fact cheaper than face to face care. He used conventional off-the-shelf hardware with good quality Logitech cameras. “It actually works remarkably well; if you know how to get the best out of off-the-shelf technology you don’t need to invest in expensive equipment, although some people do. I know that a lot of people promote high-end systems to doctors, and that’s part of the problem. It is not a problem in itself but it is an issue.”
Having gone through the experience of setting up a telehealth service, he decided to open it up to other doctors, for free. He established a not-for-profit, Telehealth Solutions Australia, to provide a free, secure, high-definition IP video conference system for health professionals across Australia and internationally, and has secured sponsors, including the internet service provider AINS, IT support company Empower IT, and Fujitsu PC Australia.
“We set up Telehealth Solutions Australia to make it easier,” he says. “What we were finding was that uptake was relatively poor so we have opened up our servers for free, basically. We already had an infrastructure in place, so we decided to do a not-for-profit Lync installation.”
Dr Allen is hoping Microsoft will soon enable video on its Lync mobile client to run on both iPhone and Android. “I’m hoping that will come out later this year. I’m looking forward to seeing that because with the bandwidth you’ve got now, you can certainly do reasonable video conferencing on mobile devices. There are other applications that will do it on mobile devices, like FaceTime on iPhones, but the advantage with Lync is that you’ve got a directory — it’s a commercial-grade unified communications and video conferencing system.”
His advice to practices considering providing a telehealth service is to talk to him, or to consult their colleges. “Most of them will approach their colleges — that’s what they are doing at the moment. Because there are hundreds of solutions that will basically do the job, what people in reality are doing is speaking to colleagues or the medical colleges or healthcare organisations about what to do.
“What I say is that doctors have been doing telehealth for decades — in fact, for over a hundred years. The first telehealth was the ECG transmission over telephone lines by Willem Einthoven from his laboratory to a hospital about a mile away in 1906. You don’t have video — you can still giving advice of course without it. When I talk to clinicians, I say you are just adding a video image that gives some more information, rather than making it sound complex. And now they can get reimbursed for doing it.”
The $6000 incentive is quite a large one – although it will be dropping to $4800 from now on – but that money is not necessarily aimed at allowing practitioners to buy the latest whizz bang technology. “The word from the government is that the payment is an incentive – it is not designed to just pay for hardware,” Dr Allen says. “It is designed to encourage people to do it. There haven’t been huge numbers taking it up but it does encourage people to do it and I think that’s a good thing.
“The cost of accessing care can be difficult for the patient – they have to drive eight hours there and back to the specialist – that cost is not seen by anyone else. The savings for the community are huge, just in transportation costs. So I think it’s worth it. And patients love it – they really enjoy telehealth consults and the fact that they can access care from home or from work. We do it indirectly into their workplaces and see them in the first aid room, and they just love it. And we run 24/7.”
The government has also made it plain that while the main aim of the telehealth incentive system is to get specialists on board, general practitioners and other healthcare professionals are a large part of the equation. The Medicare rebates from the patient-end of the service are available to GPs, nurse practitioners, midwives, practice nurses and Aboriginal health workers.
In the aged care setting in particular it is usually a nurse who sits with patient during the consultation, and in rural and remote areas this will become routine. Nurses are the glue that is going to hold of all of this together, Dr Allen says.
“In rural and remote practices, they are the doctors with patients who have the most to gain from telehealth but they are the ones who have the least amount of time to actually do it,” he says. “Solo doctor practices in rural and remote areas are far too busy to stuff around with technology, so that’s where nurse practitioners and practice nurses come into play, and Aboriginal medical workers.
“They are the ones who can be on the end of the line with the specialist and that also means that they’ll be in the consultation, they’ll get a Medicare reimbursement for being there with the patient and they are learning from the specialist whilst they are there, so they are actually more involved than they’d ever be if the patient went to see the specialist.”
Gary Holzer, business development manager for SA-based telehealth provider Healthbank Consult, agrees. He regularly travels to rural parts of the state to assist practices in setting up a service, which usually links back to consultants and specialists in Adelaide.
“What we have found in our experience over the last six months is that it really is the practice nurse that needs to be the lead,” Mr Holzer says. “Under the Medicare (number) the GP just has to be in supervision, so they see their regular patients face to face and next door the nurse will be sitting with the patient talking to their specialist in Adelaide.”
And while allied health professionals are not yet a target area, perhaps they should be. Clinical software developer Precedence Health Care, which has developed the cloud-based cdmNet chronic disease management platform, has recently added telehealth functionality to its system to allow GPs and allied health professionals to access different technologies.
“cdmNet shares the data only with the care team members, so it is a restricted setting and we do that mainly for privacy reasons, but often there’s a need for a telehealth consult,” Precedence Health Care’s CEO, Michael Georgeff, says. “The telehealth component is really a single button — when you are logged into cdmNet there is a single button and when you press it it quickly brings up the whole care team and says, there is your care team, who do you want to communicate with — the GP, the specialist or whatever — and from that point on it automates the process.
Professor Georgeff says Cisco is providing much of the functionality through its WebEx video conferencing product and Precedence was leveraging that functionality into its technology. “The idea again is to try and bring everything back to one click, to make it simple enough for the GP or the allied health or the specialist so they don’t have to wade through a whole lot of different technologies — it is all there in one place.”
Dr Allen agrees that for chronic disease management in particular, telehealth could even be seen as better than face-to-face care. “The nurses are going to be so important in this and the ones that I have spoken to have been very keen,” he says.
“And I think nurse practitioners are going to have a huge role to play. And for semi-retired or part-time doctors, if they have school-aged kids – if you can work from home doing video consults it’s a nice way of staying in touch, I think.”
Posted in Australian eHealth