The Telehealth Arena Is Getting a Little Contentious. Here Are Some Perspectives.

First we have this pretty in-depth article from AMA Insight.

Telehealth: latest changes may exclude some patients in need

Authored by Andrew Baird

Issue 28 / 20 July 2020

CHANGES to eligibility for Medicare benefits for GP telehealth and phone services will solve one problem but potentially disadvantage many patients as a result.

In May 2020, the most recent month for which data are available, 67% of Medicare services at levels B, C and D were provided face-to-face, 32% were by phone, and 1% were by video.

As of today, Monday 20 July, eligibility for Medicare benefits for the temporary Medicare Benefits Schedule (MBS) coronavirus disease 2019 (COVID-19) telehealth (video) services and phone services will be contingent on a patient having an existing and continuing relationship with the GP who provides the service. This relationship is defined as the patient having had at least one face-to-face in-person consultation in the previous 12 months with the GP, or with another GP at the GP’s practice.

There are four exemptions to the requirement for an existing and continuing relationship with the GP providing the service:

1. homeless people;
2. children under the age of 12 months;
3. patients referred to a GP by a non-GP specialist; and
4. people living under Stage 3 restrictions in Victoria (it is implied that this would also apply in the event that Stage 4 restrictions are imposed).

The temporary COVID-19 telehealth service and phone service item numbers will still expire on 30 September.

The Minister for Health stated that the aim of the change is to “support longitudinal, person-centred primary health care, [which is] associated with better health outcomes”.

The change was introduced on the recommendations of the Australian Medical Assocation (AMA) and the Royal Australian College of GPs (RACGP). In their media releases on 10 July, the AMA and the RACGP have welcomed the changes. It is not known if the Australian College of Rural and Remote Medicine (ACRRM) was involved in the recommendations to the government.

I believe that patients will be disadvantaged by these changes because telehealth services and phone services will not be eligible for Medicare benefits in the following situations:

• Very vulnerable patients who require consultation with a GP by telehealth or phone who have not had a face-to-face consultation in the previous 12 months. For example:
• patients who attend headspace;
• students who access general practice through the Doctors in Secondary Schools program in Victoria and through similar youth health programs in other states and territories;
• patients who attend sexual and reproductive health clinics.
• Patients whose consultation with the GP, or at the GP’s practice, in the previous 12 months, was by telehealth or phone service due to the COVID-19 pandemic.
• A GP’s or practice’s regular patients who have not attended a face-to-face consultation in the previous 12 months.
• New patients who have difficulty attending a face-to-face consultation, or who prefer a telehealth consultation to a face-to-face consultation.
• Patients living in regional, rural and remote areas who have not had a face-to-face consultation with the GP, or at the GP’s practice, in the previous 12 months, and who would have to travel a long distance to access GP care.
• Indigenous people who have not attended the same GP or the same practice or health service in the previous 12 months; Indigenous people who have attended different GPs (eg, locum GPs, and fly in-fly out GPs) and different practices or health services, in the previous 12 months.
• Patients who attend new practices that have not yet built up a patient base or practice population.
• Patients who attend GPs who do not do face-to-face consultations during the pandemic for personal health reasons (for example, GPs who are immunocompromised and GPs who have respiratory disorders).
• Patients with mental disorders who have been receiving GP mental health care by video or phone may no longer be able to access this through Medicare – unless they have attended the GP or the GP’s practice for a face-to-face service, in the previous 12 months.
• Patients who develop mental disorders needing initial treatment on or after 20 July will be unable to access Medicare benefits for GP mental health care by video or by phone without a face-to-face service with the GP, or with another GP at the GP’s practice, in the previous 12 months.
• GPs who provide Focused Psychological Strategies will only be able to provide mental health care by video (MBS items 91818 and 91819) or by phone (MBS items 91842 and 91843) for patients whom they have seen face-to-face in the past 12 months, and for patients who have attended other GPs in the GP’s clinic for a face-to-face service in the past 12 months. Medicare benefits will not apply for video or phone consultations for new patients who have been referred to the GP from outside of the GP’s practice.

In the AMA media release, AMA President, Dr Tony Bartone, stated:

“The great majority of GP telehealth consultations to date have been in circumstances where a patient has an existing relationship with a GP, but we have seen the increasing and disturbing emergence of ‘pop-up’ telehealth models and models that are linked to pharmacies.

“Both the pop-up and pharmacy telehealth models are also unable to facilitate access to a face-to-face consultation when a patient needs one. [These] changes will put an end to these inappropriate models of care.

“[The changes preserve] the foundation of quality primary care – the very real benefit of patients having a regular ongoing relationship with their GP … This is the patient-centred approach that we know works so well in Australia.

Lots more here:

“The AMA wants to see telehealth for GPs and non-GP specialists continue beyond [the expiry of the Medicare telehealth items at the end of September].

“Telehealth is key to continuity of care and quality of care.”

https://insightplus.mja.com.au/2020/28/telehealth-latest-changes-may-exclude-some-patients-in-need/

Also we have:

MBS telehealth reform extended to medical deputising services

Patients will be able to access bulk-billed telehealth consultations through approved medical deputising services, but under tight restrictions.

Medical deputising services will now have access to the MBS telehealth items, as an extension of a patient’s regular practice.

Anastasia Tsirtsakis

20 Jul 2020

Approved medical deputising services (AMDSs) will only have access to the COVID-19 telehealth items under the Medicare Benefits Schedule (MBS) if they have a formal agreement in place with a general practice to provide services to its patients.
 
And patients will only be eligible to obtain a service through an AMDS if the practice has provided, or arranged, at least one service for the patient in the past 12 months.
 
The AMDS will be providing services for and on behalf of the patient’s usual general practice.
 
The new requirements are part of the Health Insurance (Section 3C General Medical Services – COVID-19 Telehealth and Telephone GP Attendances) Amendment, in effect from today, 20 July, with the intention of ensuring greater continuity of care during the COVID-19 pandemic.
 
Dr Nathan Pinskier, member of the RACGP Expert Committee – Practice Technology and Management (REC–PTM) and President of the General Practice Deputising Association (GPDA), welcomed the reform as a great move for patients and the profession.
 
‘The inclusion of medical deputising as the extension of the practice for and on behalf of the regular practitioner is an appropriate move,’ he told newsGP.
 
‘Otherwise doctors and practices will be having to provide their own after-hours.
 
‘It would also be creating a risk for deputising doctors whereby they couldn’t do telehealth services. We [would] then have to go and see the patient face-to-face where it may not always be necessary, and that creates a potential infection control risk as well.
 
‘I want to actually thank the RACGP for its strong advocacy in ensuring that medical deputising was included in the ongoing MBS telehealth item numbers. It’s a great outcome for the industry.’
More here:

https://www1.racgp.org.au/newsgp/professional/mbs-telehealth-reform-extended-to-medical-deputisi

There are also some views here:

Telehealth roll-backs are short-sighted and dangerous

By Dr Catriona Melville

July 21, 2020 — 4.34pm

COVID-19 has tested the world’s healthcare systems. Movement restrictions and second wave infections have forced healthcare providers to innovate to deliver medical services to patients. Telehealth is one innovation that healthcare providers globally have expanded to provide timely services to patients during the pandemic.

At the start of the pandemic the Australian government acted swiftly to broaden the Medicare Benefits Schedule, or MBS, to support expanded telehealth services. This included broadening the criteria for access to the MBS item numbers for telehealth consultations by GPs and other health professionals to new patients. This has meant that patients have had more choice in the doctors they can consult via telehealth for services that are not provided by their regular GP. This includes the medical termination of pregnancy, STI testing and treatment including HIV prevention services.

On Monday, the criteria for MBS support of telehealth during this pandemic was wound back so that patients can only access telehealth services under the scheme if they are a regular patient of a GP or practice and have been an active patient within the last 12 months.

The premise of this rollback is that the MBS changes under COVID-19 have led to a proliferation of what the college of general practitioners classifies as "low-value" pop-up telehealth services, mostly aligned to pharmacies. Unfortunately, the change will significantly impact the provision of established, reputable telehealth services to patients who are unable to access specialised healthcare through their regular GPs, ultimately disadvantaging patients, limiting the provision of timely services and placing additional strain on health providers.

Take for instance medical abortion via telehealth. Abortion is classified as an Essential Category 1 service across the country. It is a service that many people may not be able to access through their regular GP, may not want to access through their regular GP for fear of rejection or conscientious objection, or may not feel comfortable accessing through their regular GP. During COVID-19, the demand via telehealth for medical abortion, which is the use of medication to end a pregnancy, has grown as restrictions limit people accessing clinics, particularly in regional areas. In the past three months Marie Stopes alone has seen a 140 per cent increase in the use of medical abortion through telehealth.

More here:

https://www.smh.com.au/national/telehealth-roll-backs-are-short-sighted-and-dangerous-20200721-p55e21.html

What seems to be going on here is that availability of a benefit for telehealth was made available in a rush by the Government and a few smarties decided to play fast and loose with harvesting payments.

This led to a clamp down on the rules which may have gone too far and now we are gradually homing in on a sensible policy which works to address the need and the new found adoption of the “technology’ while not setting up a free for all!

In less difficult times this may have all happened in advance rather than reactively!

David.