Telehealth and Medicare: where should we be going?
It has now been just over two years since Medicare introduced rebates for real time video telehealth in Australia and since then, over 50,000 video consultations have been completed through the MBS. While this might sound like a lot, crunching the statistics from the Medicare website indicates that video consultations are approximately 0.1 per cent of total equivalent consultations, although this figure rises to the dizzying heights of 0.5 per cent for psychiatry.
When outer urban areas were no longer deemed eligible to participate in telehealth at the beginning of 2013, there was a drop of approximately 30 per cent in the number of service episodes, but the figure is increasing again now.
From a clinical point of view, rural patients have undoubtedly benefited from telehealth initiatives. Our practice operates a rural telepsychiatry and telepsychology service and has seen hospital admissions avoided, leading to grateful patients and satisfied GPs.
Most GPs’ current experience is that conducting telehealth is, at best, cost-neutral. Dr Wade developed a model of the financial viability of telehealth in rural practice that indicates the most important factor is volume: at three or four video consultations a month telehealth is not viable; when the numbers were raised to a (still modest) amount of around 20 consultations a month, additional income for the practice was generated.
Often neglected in debates about telehealth are referral pathways. Telehealth increases referral options, allowing a wider range of specialists available to patients, with some telehealth organisations offering a ‘bank’ of specialists to the whole of Australia.
We would argue that this is not the ideal model for two reasons: the larger the number of different providers that become involved in patient care the more fragmented the care becomes with a higher rate of adverse events, and secondly, if the patient does need to be seen in person then an out-of-area specialist with no existing relationship to the practice cannot effectively advance the patient’s care. Telehealth should be part of a tool kit for delivering healthcare, not a replacement for existing services.
Minimum distance requirement
Removing the outer urban areas from telehealth eligibility, and adding the 15km minimum distance requirement to MBS telehealth rebates, threw the baby out with the bathwater. Prior to this, our practice was operating a service delivering specialist psychiatry and pain management to the outer northern suburbs of Adelaide; both services that were very much needed in this underserviced area, and both patients and GPs alike were disappointed when the service was removed.
In August 2012, the RACGP provided feedback to the federal government that the 15km distance requirement prevents many patients, who have clinically justifiable reasons for a video consultation, from receiving timely healthcare. This is particularly the case for patients with limited physical mobility and patients who have restricted access to transportation.
The 15km minimum distance rule means that the provision of healthcare via video conference is based on an arbitrary kilometre criterion rather than clinical appropriateness.
Telehealth in practice
Opening up the MBS to allow GPs to consult directly with patients has great merit for the future of telehealth consultations. There are four specific situations where this would be particularly valuable:
1. GP to patients in residential aged care
Due to increased pressure of work in general practice, it has become harder for GPs to leave their practice for ad hoc visits to aged care facilities. Our practice tested the value of telehealth in this setting four years ago, for situations from skin conditions to behavioural issues. We found that telehealth was useful, particularly for residents who were anxious about health issues, accepted by patients, and valued by the aged care staff.
2. GP to patients with a disability
People living with a disability are having their needs better recognised by government and it seems obvious that telehealth options should be available to better serve this group. A patient’s carer will also be able to benefit from having telehealth as an accessible option.
3. GP to nurses in remote areas
Rural GPs serve large areas and many provide medical back-up to small healthcare facilities staffed by remote nurses. Rebating telehealth for this circumstance would deliver valuable assistance to very remote health services and benefit patients with poorer than average health outcomes.
4. GP to children in schools and childcare
This is an issue which has not received a great deal of attention, but research from the US indicates that implementing telehealth to childcare centres can reduce children’s attendance at EDs and is cost-effective for the entire healthcare system. Telehealth can deal with minor injuries on the spot, expedite care for more serious matters, or provide reassurance to staff who are unsure about whether the child should be sent home or not.
The purpose of telehealth and video consultations is to offer a possible solution to transcend the conventional boundaries of distance, time and institutional structures. There is a great need for more research and evaluation, shifting the focus from activity and satisfaction to demonstrating positive effects on patient outcomes without restrictions.
Dr Victoria Wade BSc, DipAppPsych, MPsych, BMBS, FRACGP
Jeremy Hamlyn BEng, MfSci, MIEEE, PE
Dr Victoria Wade and Jeremy Hamlyn are both research fellows in telehealth at the University of Adelaide. Dr Wade is clinical director and Mr Hamlyn operations director of the Telehealth Unit of Adelaide Unicare, which manages a group of general practices and a women’s health centre.
Posted in Australian eHealth