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Leading health and medical experts sound the alarm over telehealth restrictions

Marie McInerney writes:

Hundreds of leading public health, nursing, midwifery and medical experts and organisations have signed an open letter urging the Federal Government to modify new restrictions on telehealth provision.

In an accompanying statement issued yesterday, the Government is warned that the changes “may already be having a devastating impact on sexual and reproductive health during the pandemic”.

Since 20 July, Medicare-subsidised telehealth services, introduced as part of the COVID-19 response, have been wound back to provide access in most cases only when providers “have an existing and continuous relationship with a patient”.

Under the changes, announced just 10 days before taking effect, a “relationship” is defined as the patient having seen the same practitioner for a face-to-face service in the last 12 months, or having seen a doctor at the same practice for a face-to-face service during the same period.

The new requirements don’t apply to people under Stage 3 lockdown in Melbourne and the neighbouring Shire of Mitchell, and there are a small number of other exemptions, including babies (up to 12 months) and people who are homeless.

The open letter says that access to time-critical services, including medical termination of pregnancy, STI testing, blood-borne virus (BBV) consultations and pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV prevention, has become more limited due to the restrictions.

It says:

We ask that you urgently reinstate temporary MBS item numbers to enable access to sexual and reproductive healthcare.

In planning future telehealth reforms we ask that you consult with specialist providers in sexual and reproductive health, Aboriginal and Torres Strait Islander health, migrant and refugee health, disability health, LGBTIQ+ health, sex worker health, women’s health, men’s health, violence and suicide prevention.”

Signatories include the Australian Healthcare and Hospitals Association (AHHA), the Public Health Association of Australia, ACON, the Australian Health Promotion Association, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, the Australian Women’s Health Network, many family planning and women’s health organisations across the country, Hepatitis Australia, Wuchopperen Health Service Ltd, Headspace Cairns, the Women’s Electoral Lobby Australia, the Murrumbidgee Local Health District in NSW, the Queensland Council for LGBTI Health, and Women With Disabilities Australia.

Jamal Hakim, managing director at sexual and reproductive health service provider Marie Stopes Australia, told Croakey:

We know that people often don’t want to see their normal GP in every instance when it comes to abortion care or seeking sexual health care because it’s a stigmatised conversation still in Australia and it requires specialist knowledge as well.”

The Federal Government’s decision followed concerns raised by the major medical groups, including the Australian Medical Association and the Royal Australian College of General Practitioners (RACGP), about the rise of “corporate telehealth pop-ups, offering low value health services”.

Health and consumer health groups have generally welcomed the Federal Government’s decision to continue telehealth provision, and there is wide support for continuity of care.

Impractical, inequitable and counter-productive

However, some concerns about the impact of the new arrangements have been raised by a number of groups, including the AHHA, People with Disability Australia (PWDA), First Nations Disability Network, and rural and regional advocates.

The AHHA’s CEO Alison Verhoeven has called for the Federal Government to properly review the take-up of telehealth before it makes further decisions, to find out why people use it and how.

PWDA Communications Director El Gibbs said people with disability had been calling for widespread telehealth for years, so the PWDA was pleased to see the extension until September at least.

But, while it is still early days for assessing the impact of the 20 July changes, the PWDA is concerned  the narrow availability “will put up barriers to people with disability accessing health services”.

“This doesn’t make sense when the spread of COVID-19 is increasing,” Gibbs said. “Many people with disability will remain on lockdown for a long time, so putting restrictions on accessing healthcare is impractical, inequitable and counter-productive.”

Gibbs said PWDA’s recent survey of people with disability during the pandemic showed a high uptake of telehealth, for medical appointments and also for allied health.

“We believe that it is vital that telehealth access is improved, beyond this initial stage, to ensure equitable healthcare for people with disability,” she said.

The restrictions also raise concerns of “further exclusion and disadvantage” for Aboriginal and Torres Strait Islander people with disabilities, said Ashlee Kearney, Disability Royal Commission Project Manager at First Peoples Disability Network (Australia).

Kearney said telehealth can deliver greater “self-determination” for First Nations people with disability, allowing many to have direct access to healthcare, without having to rely on family or carers.

It can also “remove some of the fear” many have about harmful and hostile health care systems, in the wake of “institutionalisation and intergenerational trauma”.

Many may still be eligible for telehealth, but she said even anxiety over whether that’s the case can make someone decide not to access health care if it seems “too hard or too complicated”.

Rural and regional concerns

Former CEO of the National Rural Health Alliance, Mark Diamond, now a consultant, is also a strong opponent of the changes, saying “the very people who stand to gain the most” from telehealth – those in remote and very remote Australia – will now miss out.

In an article to be published later this week at Croakey, he lists many critical rural and remote health services that “have managed to establish real relationships with people despite having never been in physical proximity to them”.

Melbourne GP Dr Andrew Baird also warned, in this article in The MJA, that the changes will “potentially disadvantage” people in rural and regional Australia, as well as many other patients who have not had a face-to-face consultation in the previous 12 months.

They include patients needing sexual and reproductive health care, people with mental health issues, and students who access general practice through secondary school programs, as well as patients whose GPs do not do face-to-face consultations during the pandemic for personal health reasons.

Calling for more research and interest into why patients have used pop-up services, Baird warns that the new arrangements amount to “registration by proxy”, by restricting a patient’s care to one GP or one clinic.

The statement released yesterday by Marie Stopes Australia and ASHM says that representatives from Australia’s sexual and reproductive health sector met with Federal Health Minister Greg Hunt’s office and the Department of Health last week to raise their concerns about reduced access to sexual and reproductive healthcare.

They argue that the Federal Government could easily address these concerns by making exemptions only for accredited prescribers of specific services: MS 2-Step, HIV s100 prescribers, HBV (hepatitis B) s100 prescribers and Fellows of the Chapter of Sexual Health Medicine.

“These exemptions will stay true to the concept of continuity of care that originally spurred the roll-backs,” Hakim said.

Without those exemptions, they say the 12-month rule will hinder sexual and reproductive healthcare access in Australia because some patients’ regular GPs:

  • work in clinics that do not always offer specialist sexual and reproductive health services
  • have not completed the additional training required to provide specific sexual and reproductive health services
  • conscientiously object to providing certain sexual and reproductive health services
  • experience a range of challenges in providing accessible services due to a range of access, equity and agency issues.

Alexis Apostolellis, Chief Executive Officer of ASHM, the peak body for those who work in HIV, viral hepatitis, other BBVs and sexually transmissible infections, provided Croakey with the comments below about specific concerns for some time-critical treatments and services.

HIV prevention

We are particularly concerned about the impact these restrictions will have on time-critical services, like PrEP and PEP for HIV prevention.

For PEP in particular, it has to be initiated within 72 hours of a possible exposure to HIV. If you’re a gay man who doesn’t feel comfortable talking to your regular GP about HIV prevention, for example, these restrictions could cause critical delays in access to PEP.

Post-exposure prophylaxis for HIV (PEP) is a form of HIV prevention that involves taking a month-long course of a specific HIV medication, beginning within 72 hours after a possible HIV exposure. Pre-exposure prophylaxis for HIV (PrEP) is an extremely effective method for preventing HIV that involves by taking a specific HIV medication, usually as a daily pill.”

Chronic hepatitis B

Patients with chronic hepatitis B require regular monitoring with a HBV DNA test, but for patients not on treatment, that test is only Medicare rebatable once every 12 months.

This already a barrier to care that can result in loss to follow up for many patients with chronic hepatitis B, and these new restrictions limit a patient to telehealth consults with a GP they have seen in the last 12 months. We are concerned that needing to physically visit a clinic during the COVID-19 pandemic could result in even more patients with chronic hepatitis B being lost to follow up.

Patients with chronic hepatitis B infection require regular monitoring with a HBV DNA test, in order to determine whether they need to begin treatment. Once on treatment, HBV DNA tests are Medicare rebatable once every three months, because more regular testing is required to monitor how the patient’s viral load is responding to treatment.”

Croakey will approach Minister Hunt’s office about these concerns and will later this week publish an article on related rural and regional health issues from Mark Diamond, former CEO of the National Rural Health Alliance.

Comments 3

  1. Dr Tim Smyth says:

    The now restricted access to Medicare GP telehealth is throwing out the baby with the bathwater. No one would disagree that the telehealth “cowboys” needed weeding out. And encouraging everyone to have a “home” in primary care with a general practice that provides quality care is goal we need to pursue.

    The “no telehealth with any GP unless you have been a patient of that GP or their practice in the previous year” will certainly cut the escalating Medicare bill for government. But as many others have commented, it will seriously disadvantage many patients and families, people in places where there is limited access to bulk billing practices and who now face an out of pocket expense of $50 or more, towns where GP practices have “closed their books” to new patients and vulnerable groups who do not have a regular GP (and this is not just the homeless who have been exempted).

    While trying to put the “cowboys” out of business, the restriction will also undermine quality after hours telehealth triage services and innovative service models that are proving their value across Australia. GPs, like the rest of us, sensibly want a work/life balance and increasingly they rely on these after hours services to provide care to their patients. These services are also supporting a growing number of residential aged care facilities and home palliative care services.

    Rather than “stage seven of telehealth reforms” as the government’s media release describes the change, this blunt edged restriction is a missed opportunity for Australia to embark on a journey to build a much better health system for all Australians. Telehealth presents great opportunities and is much more than just telephone consultations. As has been shown in other parts of the world, the intelligent use of telehealth, online and app triage, hospital in the home remote telehealth monitoring and other forms of virtual healthcare does deliver quality care, cost effectiveness for government (and we taxpayers) and patient satisfaction. It also utilises the skills of all the health care team, especially nurses and allied health professionals.

    Due to our federation, the multiple and often conflicting health service funding models, general practices so reliant on fee for service for their revenue and survival and private health insurers being unable to find a revenue stream to support out of hospital care for their members, Australia has lagged behind in adopting the good things that virtual healthcare can provide. Covid-19 must not keep us locked into the past.

    Telehealth and virtual healthcare is not the enemy of quality general practice and better healthcare. Applied sensibly across general practice, other specialist care, hospitals and home and community care, telehealth is an essential part of our toolkit to make Australia’s health system better, providing quality care where you need it, when you need it.

    Let’s hope a rethink of stage seven of the telehealth reforms gets us back on track to achieving this.

  2. Mark J Diamond says:

    Well said Tim – I agree. A missed opportunity indeed. Let’s hope there is some serious consideration of how to enable the advantages of what telehealth in all its forms can achieve. Especially for people in remote and very remote Australia.

  3. asd woman says:

    I was able to connect with my gp, a nurse and a psychiatrist via telehealth, before the recent changes. My GP had just moved clinics and was not seeing people face to face face. If i hadnt found her name online and been able to register my details entirely over the phone with the new clinic… Id not have seen a dr at all, let alone the one i trust and knows about my disabilities and cancer treatments. My poor immune system, history of abuse resulting in ptsd and botched emergency surgeries that led to extreme anxiety of all things medical, along with my ASD and ADHD already make it next to impossible to make myself leave the house, let alone do so to attend a clinic with new people or somehow despite the panic attacks that begin days before…have much chance of making it there on time…

    This issue has made it too difficult to want to follow up tests to track cancerous cells. The surgery i needed when i finally made myself go..4ish years later.. was traumatic. Sent home not even told i had stitches… my written consent restrictions ignored… a simple procedure that i should have recovered from in days- instead had be in agony, unable to move, bedridden for months..the hospital unable to read the notes to see what the surgeon even did… this brought back memories of waking up in another surgery for a few seconds… Ive been too scared to return for follow up treatment.

    I did however make it to one Psychiatrist app. It was hard, i was late, i wasnt comfortable, he joked that he expected to see me on time next week, now i knew where to go..Next week i felt sick with anxiety, and had no one to drive me in. I was 35mins late. Parked outside the clinic in a one way street, I went to pay with my note, only to see the meter only accepted cards. i had no money on my card. I cried, I went home and felt hopeless. People are angry when you are late, they reprimand you, or feel you dont respect them. They often refuse to see you or refuse to book you in again. They dont understand the hours you spent trying to get there.. that you dont mean it..and when you have anxiety about getting medical help, and about getting there, being on time and the appointment being of value, the events not influenced by staff being annoyed at you, rushing or telling you off repeatedly until you want to just leave and the reasons you came fade, and you dont get to mention all of them..

    Then i didnt call them, i felt so rude and pathetic i didnt know what to say. So i suffered on for months, even after a close friend died, my health deteriorated as i also avoided another clinic with app i really needed to attend.. as it was at the same hospital i had received the cancer treatment for.. I searched again and again trying to find a service with telehealth that bulkbilled or accepted clients that were not living in rural areas. Never was i eligible.

    Then covid-19 came, and I heard about telehealth services being expanded. I put aside my fear and emailed the psychiatrist receptionist, apologising and explaining what had happened and asking if the Psychiatrist would see me via telehealth. The next week, i picked up the phone, on time, sitting at my kitchen table, surrounded by my familiar, comforting environment and talked easily with him for an hour. I could answer honestly, not uncomfortable as i didnt need to worry about looking in someones eyes or them watching me do things i do when im nervous, that easy betray so.. It was easy and it made me hopeful, i could finally receive the help I needed without the factors that prevented me getting it for years..

    Even back then though, there were limits, as we made our next appointment, he advised he really did need to see me face to face until he got to know me atleast. Crestfallen and bemused that he had infact been able to talk to the real me that hour, an event that never would eventuate no matter how many times he saw me, anywhere else, as my home is the one place i feel comfortable,rational; unclouded by fears. I agreed, knowing full well it would take a damn miracle. i wanted to…i didnt.

    I had a telehealth app with my gp once i was ready to try again, for a telehealth Psych clinic that actually agreed to take on Melbourne city area patients.. it wasnt bulkbilled, its just usually you need to be rural even to access the service. But i needed a refferal first before they would even check Dr availability and disclose the fee. My GP agreed, but had just moved clinics so no longer had access to the two years of my seeing her records, or the ten years of previous records i had transferred there. She wanted me to come in before she would issue my regular prescription, bring in the records and then she would write the referral. So months later having not been able to go in, both from concern for my health due to chronic health issues, and reduced immunity but also from anxiety and other asd linked issues.. i still havent been able to get my prescription, Or book in with an Psychiatrist to help me via the only way my conditions would allow me to access that help.. via telehealth.

    Recently i also finally had a long app over the phone with a nurse, to finally address issues caused by the last surgery, that ive been too uncomfortable to address in person.. all because i knew i didnt have to go in. when she called via facetime unexpectedly, I panicked, i stuttered speaking to her as seriously i was considering just hanging up on her. Instead i managed to ask her if she would call me back normally as i would find it much easier. She happily obliged, and the rest of the appointment we t smoothly and was helpful.

    I am aware that my situation is unique to my situation, as many others will think im just being ridiculous or difficult and stupid for not accessing the help i need that is out there. I agree, but the issues from asd and ptsd are many and their voice louder than the one of reason, when it comes to seeking medical help. And i think explaining my experiences can give people and understanding into atleast two groups in the community that will benefit from ongoing telehealth without the new restrictions, in ways not often spoken about and that is access to people with disabilities, physical, developmental and emotional or mental health issues that have services in place already… but many of the people needing them.. like me.. wont get that help under the current system.

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