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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.