Wednesday, June 15, 2011

I Wonder How The Telehealth Spend By the Federal Government is Justified? It Is A Lot of Money!

The following press release appeared a few days ago.

Telehealth Fees Unveiled

Patients in rural, regional and outer metropolitan areas will benefit from an increase in telehealth services with greater access to Medicare funded medical specialist video consultations available from 1 July this year.

6 June 2011

Patients in rural, regional and outer metropolitan areas will benefit from an increase in telehealth services with greater access to Medicare funded medical specialist video consultations available from 1 July this year.

Minister for Health and Ageing Nicola Roxon said that under the Gillard Government’s $620 million telehealth initiative, patients will be able to ‘see’ their specialist close to home without the time and expense of travelling to major cities.

“Improving access to specialist healthcare close to home is a key priority for the Gillard Government and Medicare funded telehealth services will remove distance and cost as a barrier,” Minister Roxon said.

“Telehealth is going to provide huge benefits to patients in rural, regional and outer metropolitan areas but also to health practitioners who, from July 1, will be able to access increased Medicare rebates for telehealth services.

New Medicare items will allow a range of existing consultation services to be provided via video conferencing and additional rebates on top of these items recognise the increased complexity of providing a service to a remote patient. There will be a 50% additional rebate for the specialist service and a 35% additional rebate for the service provided by the practitioner at the patient end.

“We recognise the time, complexity and administration involved in telehealth services so rebates will now also be available for the health professional located with the patient including GPs, nurse practitioners, midwives, practice nurses and Aboriginal health workers,” Minister Roxon said.

“Ensuring that telehealth services are available around the country is critical to delivering quality healthcare to all Australians so generous financial incentives to encourage all health professionals to incorporate telehealth services into their day to day practice including a $6,000 incentive when a health practitioner provides their first consultation will be provided.

“We encourage bulk billing with extra telehealth bulk billing incentives to be paid at a rate of $20 each time a practitioner bulk bills a service in the first year.”

The new Medicare items have been developed through intensive collaboration with key stakeholders including peak medical colleges and associations.

The rollout of telehealth will benefit greatly from the opportunities provided by the National Broadband Network and is a key part of the National Digital Economy Strategy.

The release and contacts are here:

Before commenting in a little more detail it is worth just noting this previous release and the date - Just a decade ago!

Telehealth joins e-health reform agenda

Professor Richard Smallwood, Chair of the National Health Information Management Advisory Council (NHIMAC), announces telehealth's move into the e-health reform agenda.

10 July 2000

Telehealth joins e-health reform agenda

Telehealth has taken a front row seat in health care delivery in the 21st century with today's announcement of its move into the broader e-health reform agenda.

Professor Richard Smallwood, Chair of the National Health Information Management Advisory Council (NHIMAC), said the Australian New Zealand (ANZ) Telehealth Committee (formerly an Australian Health Ministers' Advisory Council sub-committee) would become a sub-committee of NHIMAC - a step which acknowledges the important role telehealth plays.

The ANZ Telehealth Committee will advise Australian Health Ministers on national telehealth policies and strategies that are aligned with sound clinical practice and business objectives, and that link to the broader health reform and health information technology agendas -in particular, the strategic framework Health Online - A Health Information Action Plan for Australia.

"Health care is entering a challenging and exciting new age. A range of innovative and ever changing technologies offer huge potential to improve the delivery and quality of health care, and ensure better results for patients," Professor Smallwood said.

Telehealth involves the use of information and communication technologies to provide health services at a distance. Telehealth will have an important place in the health system of the future where there will be greater co-ordination of care, sharing of electronic records, and enhanced communication between geographically separated service providers.

"The role of telehealth in the delivery of everyday health care is growing. We are using the best that technology can offer to ensure that distance poses less of a barrier to receiving quality health care," he said.

"There is no better way to use the astounding innovations that telehealth offers than to meet the health needs of remote Australians."

A key task for the ANZ Telehealth Committee will be the development of a Telehealth Plan, which will identify strategies for action over the next five years. The Committee will identify issues and opportunities concerning telehealth at the national level; provide advice on a way forward; and focus on key areas requiring further development such as standards, funding and financing options, legal and regulatory issues, and data and evaluation issues.

More here:

Besides the obvious question about “What’s changed in a decade?” I was struck by the amount being expended ($620 Million over 4 years) especially when compared with the planned and uncertain e-Health funding of $477M to end in June 2012 unless renewed at some level.

There was some press reporting of this announcement here:

Govt couples telehealth rebates with $6000 set-up payment

6th Jun 2011

Mark O’Brien

THE Government will soon pay GPs $6000 to set up video-conferencing equipment, and another $40 each time they assist during a patient's telehealth session with a consulting specialist.

The incentive payments will be available from 1 July for practitioners who attend the telehealth consultation at the patient end, when the consultation takes place outside the "inner-metropolitan" centres or in a residential aged care facility or an Aboriginal medical service.

RACGP telehealth standards working group member Dr Nathan Pinskier said while it was encouraging to see telehealth being given priority, there were a number of issues for GPs to consider before "jumping in".

Dr Pinskier said practitioners had to consider how they would fit telehealth into their practice, whether the specialists they worked with would be equipped with the same videoconferencing platform, and how they could ensure the communications were secure enough for clinical information to be shared.

More here:

and here:

Specialists paid to embrace telehealth

Medicare rebates for telehealth services will begin on 1 July

  • AAP (AAP)
  • 06 June, 2011 14:48

Medical specialists who provide videolink consultations to patients in remote areas will be paid a 50 per cent bonus in an effort to encourage them to adopt the new technology.

Under Labor's $620 million telehealth initiative both city specialists and any healthcare worker physically with the patient will receive additional Medicare rebates.

Federal health minister Nicola Roxon said GPs, nurses, midwives and Aboriginal health workers who sit with patients during their video consultation will receive their usual Medicare fee plus an extra 35 per cent.

"New Medicare items will allow a range of existing consultation services to be provided via video conferencing and additional rebates on top of these items recognise the increased complexity of providing a service to a remote patient," Roxon said in a statement.

More here:

A key question that ran through my mind was to ask where the aggregate business case for this investment resided - accepting that there are definitely examples of various telemedical interventions that do work well - and how the planned scale of investment was arrived at.

The only obvious public information I can find comes from an Access Economics Report.

I discussed this in a blog about this time last year.

The bottom line was, as far as I could read they really did not know just what the cost / benefit looked like.

These 4 paragraphs from the exec summary say it all - the last paragraph especially.

“Tele-health offers the potential for significant gains to Australia’s population, especially for people who are elderly or who live in rural or remote communities. Unfortunately, however, despite a myriad of tele-health studies, it is difficult to measure such benefits. Tele-health studies to date have been constrained by poor economic and health data and methods.

Most studies have, however, shown that tele-health is cheaper and faster (and at least equally effective) compared to transporting patients or health care providers over large distances.

Thus, it should be possible to estimate time and money savings at a national level, if not health gains.

  • There does not appear to be sufficient data to estimate the benefits of online training for rural / remote medical professionals.

Using a combination of a national level United States (US) study into one aspect of tele-health (tele-consulting) and a national level Australian study that was mostly based on EHRs but had tele-health components, Access Economics estimates that steady state benefits to Australia from wide scale implementation of tele-health may be in the vicinity of $2 billion to $4 billion dollars per annum.”

The report is on-line here for your reading pleasure!

For this level of uncertainty to attract that amount of money really is amazing.

I know there are lots of good things going on in the telehealth / telemedicine space and I am keen to see technology deployed sensibly, but this amount of money runs the risk of attracting some less than ideal projects.

I have to say that in what I have seen there are not any really detailed plans about how each modality of telehealth / telemedicine is to be deployed nationally although I know of a NSW Health Hunter / New England Strategy that certainly provides more detail and can be found on the web.

The following from a 2008 Gartner Presentation is also hardly encouraging however (Page 7) for a strong return on a scattergun approach.

The evidence base for telemedicine is weak

AHRQ study

· Store-and-forward services: "the evidence for their efficacy is mixed"

· Home monitoring: "required additional resources and dedicated staff"

· VTC: "most effective for verbal interactions"

JAMIA study

· Effects on patients' conditions: inconclusive

· Patient compliance is high

· Effect on resource utilization is mixed

· Minimal evidence of economic benefit

The conclusions on Page 22 also seem pretty sound to me!


  • Treat telemedicine as a business opportunity and assess the business viability of each telemedicine application:
  1. Telemedicine isn't just a clinical opportunity, it's a business growth opportunity
  2. Nominate a business lead for telemedicine services and ensure that person has the backing of clinicians
  3. Ensure that your telemedicine projects include a business case to ensure long-term funding
  • Understand that telemedicine isn't just throwing technology at an existing process. You need to understand the different roles and relationships that it requires — different salary structures, training, workflows.
  • Create a road map for telemedicine applications that assesses them according to their adoption potential, impact and time to value.

The whole presentation is found here:

For all this money I just hope we have some careful and thorough evaluation, against reasonable criteria, done regularly as the money is spent. I leave it as an exercise for the reader to assess just how likely that is to happen!

I won't even bother mentioning we are years away from ubiquitous NBN deployment so the time frames have also to seem a bit stretched - unless the NBN is not actually needed.



Anonymous said...

This is typical of the mindset of the "Hollow Men" They buy credibility by attaching a large $$$ figure to the plan. In reality this causes the same dysfunctional environment as the pink bats fiasco where every man and his dog chase the pot of gold and in the end someone gets hurt.

A slow and steady path where some trials are done for a relatively small amount of money and standards developed and honed is just not sexy enough, even though its a much more sensible way to treat taxpayer dollars.

The same mentality is at work in the PCEHR. People would assume that if the government is throwing $500 million at something they must have a solid plan. Alas this is not the case for either case. The silly thing is that this money sensibly invested in eHealth compliance programs and supporting standards over a few years would make a huge difference. This would require someone who knows what they are doing however and almost by definition anyone who knows what they are doing and is sensible does not make it to the level of the "Hollow Man" who are "running" the public service. I guess they will eventually spend all the money and then stuff that works will surface and see some daylight.

Anonymous said...

"money sensibly invested in ... supporting standards over a few years would make a huge difference."

Well, actually, we seem to have spent quite a lot on this one already. Hs anyone added up NEHTA's expenditure to date on standards, and can they point to any differences (positive) that this has made?

Just askin'.

And whilst we are on the telemedicine topic, it would seem that money spent on incentives is probably smart (think PIP). Money spent on technology seems less smart. For most consults in primary care, would not a commercial grade version of something like Skype not do it? That's all there will be in the home on the other side of the line. If there are high quality still images then email does the trick. Its only when there is a genuine need for real time imaging (rare in primary care?) that we would need specialised equipment?

Anyone have any experience with this? Hasn't the mass consumer adoption of point to point video made the old fashioned approach to telemedicine with its specialised boxes a dinosaur?

Anonymous said...

"Anyone have any experience with this? Hasn't the mass consumer adoption of point to point video made the old fashioned approach to telemedicine with its specialised boxes a dinosaur?"

Absolutely. The risk is the RACGP have been given a heap of cash to develop standards, despite their rubbish track record in all things e-health and stated intention to throw their weight around in the commercial market. Don't be surprised if some convoluted recommendations emerge that involve overpriced kit (remember broadband for health?) and some winner picking recommendations that will likely end up in the next ePIP. Just what is RACGP's relationship with Telstra again?

In a well lit consolation room, Skype (free), plus an external camera to aid in ergonomics at the GP end (sub $500) is more than sufficient. In actuality, a speaker-phone would pass muster in the vast majority of these new fandangled consultations, but let's not rain on Nicola's parade any further.

Anonymous said...

Standards need to bubble up from the coalface and not down from the whiteboard, so Nehta spending money on standards is not helpfull in any way.

We need to concentrate on existing standards that are working and compliance with the same. Inventing a new standard, that is totally unproven and a compliance program for the same, when it may not work, is a total waste of money.

So we have spent almost nothing on standards. What we need is to encourage industry engagement with existing standards by insisting they comply with them. Currently there is no free speech about what Doha/Nehta are doing as they are holding all the funding and few are game to speak out. What they say privately does not inspire faith in Nehta or Doha. In fact neither does what they say about each other!!

Anonymous said...

Some comments from my experience in a Telehealth program:

Skype won't cut it. Proprietory protocols, poor sync, lack of confidentiality, poor video rendering. "Big Box" systems work better than Skype etc. for a reason.

Comms channels need Quality of Service for this to work reliably. ADSL connections don't provide this (as well as other reasons ADSL works poorly for high quality video connections)

Standards based only, to allow interoperability. Skype fails this.

Technical agility. Video and audio protocols change rapidly.

Finally, Telehealth needs (no, must) be built into service delivery models to ensure success. Also, it must be driven by clinical services, not by some technical "want" or "wish list". It must also be supported, rather than adopting the simple "drop and run" approach that seems to be so popular in technology driven projects.

Telehealth is not technology. It is a revision of the service delivery model.

Anonymous said...

Skype won't cut it
[what won't it cut? What exactly are we talking about doing here? Certainly not remote surgery or anything where super high resolution is important.)

Proprietory protocols (so what? a pervasive proprietary protocol is far more likely to be adopted than a standards based one bolted to expensive hardware that requires networking capacity that doesn't exist)

poor sync (evidence?)

lack of confidentiality (evidence?)

poor video rendering (30FPS 720p not good enough for you?)

"Big Box" systems work better than Skype etc. for a reason. (That's simply FUD. We had a 35K system installed last year (fortunately paid for by a third party) and it's an unwieldy piece of junk. On the occasions when the IT guy that set it up has it working, the transmitted picture quality is no better than what a commodity netbook can produce. No doubt it could be made to talk to other 35K systems, even ones manufactured by different vendors, but that's of no benefit to anyone if practices can't be convinced this level of expenditure is worthwhile.

Oliver Frank said...

Being able to save patients and medical specialists unnecessary long distance travel is a good thing. The opportunity costs and the benefits of this scheme need to be evaluated.

However, to refer to video consultations with medical specialists as 'telehealth', as if that is all that there is to telehealth, is a bit like referring to ants as the animal kingdom. Video consulting by medical specialists is just one way of using technology to improve the quality and efficiency of health care. It is possible, if not likely, that government support for other methods of electronic communication (including telephone, email, SMS, Websites and others), between all parties involved in health care, including the patient, may be as cost-effective or more cost-effective than video consultations with medical specialists.

Bruce Farnell said...

I think Oliver is onto something. Aside from the MBS requirement - why use video conferencing at all? I suspect that only a minority of consultations would benefit from video and of those a lower cost video option would probably suffice.

I have had some experience with some of the higher-end VC solutions in a clinical setting over the past couple of years. Due to the current huge capital and operational costs and the relatively small number of patients where it actually makes a difference it is hard to argue that it is cost effective. Perhaps that is why we don't have access to a cost/benefit analysis. The numbers don't stack up.