*** This story was updated on 27 August, 2020 to include answers from a spokesperson for the Federal Minister for Health. ***
Introduction by Croakey: With just six weeks until telehealth Medicare Benefits Scheme item numbers are set to expire, health groups are calling for the Federal Government to commit to a continuation of telehealth and to a broader digital health model for Australia.
The telehealth item numbers, which were swiftly introduced in March in response to the COVID-19 pandemic, have been widely welcomed by health professionals and patients alike. As reported in Croakey this week, telehealth has also been crucial in ensuring greater access to mental health services during the pandemic.
Last month, the Federal Health Minister introduced restrictions requiring GP providers to have an existing and continuous relationship with a patient in order to provide telehealth services. These restrictions were welcomed by the Royal Australian College of General Practice and the AMA, which said the changes addressed the “disturbing emergence” of pop-up models of care.
However, others condemned the move, saying that it restricted access to groups that already faced barriers to care, including people in rural and remote areas, young people who may not have a regular GP, and those needing access to sexual and reproductive health services.
In an open letter reported by Croakey, hundreds of leading public health, nursing, midwifery and medical experts and organisations urged the Federal Government to modify new restrictions on telehealth provision.
And Mark Diamond, consultant and former CEO of the National Rural Health Alliance, wrote in Croakey last month that for many people in remote and very remote Australia, the extension of MBS telehealth rebates to GPs until the end of September would have little or no impact. He said it was “more than a little ironic” that the people who stood to gain the most from this technological ‘genie’ would not benefit at all.
In the article below, Dr Tim Smyth, health consultant and former Deputy Secretary of the NSW Ministry of Health, says restrictions on access to MBS items and other virtual health funding should be based on safety, quality, and comprehensive care, not on protecting current ways from competition. Australia, he says, must take care not to miss the great opportunity to include telehealth in our toolkit to build a better, more accessible health system.
Tim Smyth writes:
In restricting access to Medicare GP telehealth, Australia 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 a 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, including 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, in 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).
Missed opportunity
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 described the July 2020 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 uses the skills of all the healthcare team, especially nurses and allied health professionals.
Due to 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 enjoying the benefits that virtual healthcare can provide. COVID-19 must not keep us locked into the past.
Widespread support
Telehealth and virtual healthcare are not the enemy of quality general practice and better health care. Applied sensibly across general practice, other specialist care, hospitals, residential aged care 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.
Stage eight of the “telehealth reforms” must not be just another tinkering with the Medicare Benefits Schedule telehealth items. Across Australia, patients, carers, health professionals, practice staff and advocacy groups are now talking about the difference telehealth is making.
In their July 2020 ‘Don’t Hang Up on Telehealth‘ petition to Minister Hunt, Australian Doctor lists more than 80 recent real life examples from frontline GPs of the benefits of telehealth for their patients.
The AMA’s 10 year framework for primary care reform, Delivering Better Care for Patients, released in late July, strongly supports continuation of telehealth.
While the past four months seem a bit like a lightbulb moment, with our health system discovering that telephones are now medical devices, Australia needs to make the most of this COVID-19 opportunity.
The Australian Healthcare and Hospitals Association released a blueprint on Effective and Sustainable Adoption of Virtual Health Care a few weeks ago. The blueprint noted that adopting and using already available digital tools and technology requires more than a MBS item (important though this is). The blueprint calls for health sector wide action with a virtual care agenda built around patient centredness, equity of access, leadership, governance, a digitally capable workforce, interoperability, quality assured technology and a greater mix of blended payments.
Where to now?
COVID-19 is, rightly, taking centre stage for health ministers, health departments and frontline staff. So how do we move forward with telehealth and virtual care in this environment?
First, at least maintain the status quo with a commitment from the Commonwealth that the MBS telehealth items will stay beyond September 30 and that there will be no further restrictions.
Second, to address the concern about the “cowboys”, rather than use blunt instruments to restrict access, we need agreed clinical governance standards and a move to using blended payments and block funding.
The clinical governance standards need to adopt a patient-centred approach and facilitate innovation, convenience and flexibility while ensuring quality, safety and continuity of care.
Working together, the Australian Digital Health Agency, the Australian Commission on Safety and Quality in Health Care and the Consumer Health Forum can build on the work already done in other countries, the Global Digital Health Partnership, our Australian Digital Health Co-operative Research Centre, and other professional and industry bodies.
Restrictions on access to MBS items and other virtual health funding should be based on safety, quality, and comprehensive care, not on protecting current ways from competition.
A good place to start with moving to blended payments and block funding is in the after-hours and telephone advice space.
Instead of a fee-for-service model, here the 31 Primary Health Networks (PHN) can take a role in being funded to contract quality providers to provide an integrated service linked with Health Direct, Nurse on Call (Victoria), 13 Health (Queensland), and the growing ambulance service hosted 000 secondary triage services (Victoria, South Australia and Tasmania).
Aged care benefits
The devastation caused by COVID-19 in residential aged care, especially in Victoria, highlights the potential to bring quality virtual health care into this sector.
Jointly funded by the Commonwealth and aged care providers, a network of virtual health centres staffed by experienced nurse practitioners with telehealth access to GPs, geriatricians, and the allied health team could be made available 24 hours a day.
We should not have to wait for the Royal Commission to recommend it. Again, these could be part of the PHN-contracted virtual health services and accredited by the Aged Care Quality and Safety Commission.
Alexander Bell patented the telephone in 1876. Let’s not wait till the sesquicentenary in 2026 to embed telehealth and virtual care in Australia.
Dr Tim Smyth was formerly Deputy Secretary, NSW Ministry of Health and has more than 30 years’ experience running hospitals and health services. Now based in Melbourne, Dr Smyth runs a health consultancy practice. He has particular interests in innovation, digital health and developing a sustainable patient centred quality primary care system. Dr Smyth is a Director of the Black Dog Institute, which is a significant player in the digital mental health space – advocacy, policy, research and development of apps, tools and website resources. He is also a member of the Australian Information Industry Association, has facilitated a webinar on health IT standards for the Australian Institute of Digital Health recently and is a member of an informal virtual health discussion group. Dr Smyth has also provided legal advice to clients in relation to health software and other IT transactions.
Questions for the Federal Health Minister
The following questions, compiled by Croakey and Dr Tim Smyth, were put to the Federal Health Minister, Greg Hunt, on 18 August. The responses below (received on 24 August) are from a spokesperson for the Minister.
Health and medical groups are calling for an extension of the MBS telehealth items beyond September 2020, with a long-term commitment to embedding telehealth in Australia’s health system. What are the Federal Government plans?
The Australian Government has made telehealth a key weapon in the fight against COVID-19 and has delivered 10 years of reform in 10 weeks.
As the Minister said in his statement to the Parliament on 13 May 2020, “Telehealth is helping to keep both GPs and patients safe from infection, and I hope and intend for it to be an abiding legacy of the crisis.”
That work is now underway with ACRRM, AMA, RACGP, RDAA and others to build on this once in a generation opportunity, to modernise our health system with the permanent implementation of whole of population telehealth, a decade earlier than anticipated.
While welcomed by some medical bodies, the restrictions to telehealth MBS item numbers introduced last month prompted other groups to raise concerns about access to telehealth to those most in need, including people in rural and remote Australia. How do you plan to ensure equity of access to telehealth services?
The Government has long recognised the potential for telehealth to improve rural and remote patients’ access and outcomes, and telehealth services have been included on the Medicare Benefits Schedule (MBS) for this purpose since 2011. Commencing with private specialist services, the Government has incrementally expanded the MBS to include mental health and GP services in recent years.
The Government’s $550 million Stronger Rural Health Strategy (SRHS) will deliver comprehensive reforms over five years, from 2017–18, providing Australians living in rural, regional and remote areas with high quality health care from qualified health professionals.
The SRHS is co-designed and supported by major health peak bodies including the ACRRM, AMA, RACGP, RDAA.
With your colleague Senator Richard Colbeck, will you convene a high level working group to have a funded network of 24/7 virtual care health centres in place within 6 months to provide quality care for residential aged care residents and support for staff caring for them?
The Morrison Government’s highest priority at this time is to ensure the safety of aged care residents and workers providing essential care and services.
We acknowledge the significant contribution of the aged care workforce for the care they are providing for our most vulnerable Australians each and every day.
Our Government is providing significant support to the aged care sector during the COVID-19 pandemic, with a range of measures in place totalling over $1 billion.
With less than 5% of GP MBS telehealth claims being for video consultations (compared to over 15% already in other specialties), when will the MBS telehealth schedule be revised to provide a higher payment for video consultations?
The inclusion of audio-only telehealth services by phone has been implemented for COVID-19 telehealth items on the advice of key stakeholders who have expressed concern in relation to access by disadvantaged groups.
The design of options for future telehealth, and addressing any barriers to the adoption of video, are matters of ongoing discussion between the Health Department and key stakeholders.
Why not use the network of 31 Primary Health Networks to commission high quality after hours virtual health services using blended payments?
Primary Health Networks (PHNs) commission health services to meet the identified and prioritised needs of people in their regions and address identified gaps in primary health care.
This may include working with others in the community to plan and deliver innovative services that meet the specific needs of the communities in their regions.
There is an existing PHN After Hours Program that provides a mechanism to commission services that are responsive to local needs, and to focus on system-wide co-ordination and planning. PHNs are already delivering a diverse range of activities under the program.
The Australian Government is currently developing a Primary Health Care 10 Year Plan that will set a vision and path to guide future primary health care reform, as part of the Government’s Long Term National Health Plan.
Under the 10 Year Plan, the Government is committed to ensuring the primary healthcare system is more person-centred, integrated, and efficient and equitable, including in relation to the provision of after hours primary care.
The Government currently invests over $900 million per annum in after hours services, through the MBS, HealthDirect, funding to the PHNs, and funding to practices through the Practice Incentives Program, and the role of all of these elements in supporting after hours care needs to be considered.
Australia has the potential to be a world leader in virtual care use, innovation, and technology as part of our post-COVID-19 economic recovery. What are the Federal Government’s plans to build a telehealth and virtual health care model that can benefit all Australians?
The Government released the Long Term National Health Plan (Plan) in August 2019, which outlines our vision to make Australia’s health system the best in the world.
A priority of the Plan is the development of the Primary Health Care 10 Year Plan to drive reform of the primary health care system in Australia over the next decade.
The COVID-19 pandemic has transformed the delivery of primary healthcare in Australia and reset the landscape for primary healthcare reform.
