3 November 2020
Where is video telehealth heading?
Wild Health and Coviu were joined by a panel of some of Australia’s top digital health influencers last Thursday night for a live webinar and Q&A on the topic of video telehealth.
After being thrust into a new era of telehealth with no forewarning, training, or infrastructure in place, most GPs are using phone over video. This is despite the fact that video consults are widely considered more effective, so much so that the government may differentiate the pricing as way to encourage them. But after such a tough year, the prospect of moving to video may be alarming some GPs without a clear idea of how to get there.
There is a lot to unpack in this topic. But the panellists agreed that the telehealth shift has been potentially the most important and costly change ever to happen in general practice. The model itself has transformed into a merge of face-to-face, telephone, video, and text. And while this is incredibly disruptive, it also paves the way for massive opportunity and flexibility.
The attendees were invited to ask questions of the panellists, and there ended up being too many to answer in just an hour. Below are some of the unanswered questions and comments along with Dr Andrew Baird’s responses.
Q: The phone (like the fax) is reliable and easy to use for simple tasks. How do you get them to use telehealth for more complex tasks effectively?
A: Embedding video telehealth in general practice will be a major project in change management. To drive change, GPs will need to perceive significant advantages to implementing video telehealth, with no disadvantages. It seems likely that in general GPs have negative attitudes to video telehealth, and this is a barrier to change. See the ‘diffusion of innovation model’.
Consider taking a ‘whole of telehealth’ approach in general practice – including audio-only, webchat, asynchronous text (e.g. e-consults), and video.
Q: The question is what the MBS rebate is – if it pays half of face to face then won’t behaviour follow?
A: I think this question relates to reducing the MBS benefit/rebate for phone consultations to one-half of the benefit/rebate for equivalent video consultations.
A reduced rebate for phone may drive a change in behaviour, but what will change?
- Increased uptake of video ?
- Abandon telehealth, and revert to an ‘in-person consultation’ based model
- Increased use of telephone to compensate for the reduced rebate – this could see some imaginative strategies for income generation (e.g. all patients get a follow-up phone call)
Q: Are we measuring the patient experience?
A: No studies/surveys/research have yet been reported/published for patients in Australian general practice. There are data from the UK which indicate that patients have positive experiences with video consultations. There is a survey in progress for patients in general practice and allied health in SEMPHN and NWMPHN (Victoria).
Q: To what extent are patients prepared to pay for telehealth so that they can reap the benefits? ie stay at home / work / not wait in a waiting room or car park / be able to consult with any doctor in the country?
A: Good question. What cost for convenience? What cost for reducing other costs (eg travel, parking, time off work)? What cost for access/availability (any time, at the click of a button)? I don’t know. No surveys have been reported about patient choice regarding consultation cost versus convenience/other costs/access. It’s likely that some people who can pay will choose to pay for these reasons. For them, the benefits justify the expense. However, many people will be unable to pay the fee for a private telehealth consultation (no Medicare rebate/benefit, no bulk billing of course).
Q: After hours care for an enrolled population is really important BUT will enrolment be on the table for the future? Clearly being able to provide care for a known group of patients is safer than being an after hours service for all comers.
A: Good question. The concept of ‘registration’ (like in the UK) seems to be anathema to Australian GPs. ‘Enrolment’ seems to be ‘registration-lite’. What are RACGP and ACRRM views?
Q: Telehealth has led to a net increase in cost to government. That’s not surprising because access to a GP is easier than travelling to a GP practice. What would you say to the federal Treasurer to justify the extra expenditure? If he asked, would you suggest any limits on the use of telehealth that might reduce the expenditure growth?
A: I did not know that Medicare costs had increased ‘due to telehealth’. There are many other factors to consider regarding telehealth costs. The effects of the pandemic (increased demand for medical care / mental health care), the uptake of telehealth by allied health practitioners, psychologists, clinical psychologists, and specialists. I thought that the number of GP level B, C, and D consultations was essentially the same since the introduction of telehealth in March (just that one-third have been by telehealth, but the total is essentially unchanged).
To justify expenditure on video consultations, I would point to research/cost-analysis/health economics from UK. We don’t yet have data for Australia. I would also point to improved access / equity of access, and the potential for improved outcomes through enhanced chronic disease management and preventive medicine (which are areas that are ideal for telehealth).
Q: Are you seeing the adoption of telehealth within residential aged care facilities?
A: Some clinics are already using video telehealth for RACFs. It’s an excellent solution. The GP does not need to attend the RACF, can videoconference with the resident/patient, and with nurses, carers, relatives. Medication charts can be updated/changed online. ‘Paper’ work can be completed online.
Q: What are the views of panellists on setting video capable consulting rooms at the clinic for patients and doctors can work from home or somewhere?
A: I think any consulting room can be easily adapted to be a video-consulting room for a GP. A consulting room is private and quiet. You would need a plain background, and to ensure that there was nothing patient-related in view of the camera. You can use a practice laptop which can be moved from room to room as required. You can use the desktop computer in the consulting room – you will also need an external webcam, a headset (mic/earphones), and an internet connection (probably WiFi to the clinic’s network – obviously security needs to be checked thoroughly).
I hadn’t thought about the concept of the GP being at home, and the patient being at the clinic! Interesting idea. I guess this would depend on the clinic’s facilities. There would need to be a room that could be used by the patient for the video consultation. This would be exclusively for this purpose. It would need to be private, quiet, suitably furnished, and to have appropriate equipment (computer or laptop, webcam, probably preferable to use computer microphone and speakers, rather than provide a headset (infection control issues)). Or the patient could use their own device/smartphone. There needs to be internet access. There may be security concerns re using the clinic’s network. The patient must not use one of the GP consulting rooms – there’s the risk that the patient would see private information, there’s the risk that the patient would help themselves to items in the room (e.g. needles, equipment, etc). It’s definitely doable, but it needs to be thought through.
For ‘consulting from home’, you need secure remote access to your clinical management program – e.g. cloud-based clinical management program, VPN, or even something as old and clunky as LogMeIn. Otherwise, a quiet, private room, plain background, laptop or desktop computer, or other device (even a smartphone). You may also wish to connect to your practice management software re billing and appointments.
Q: Remuneration for communications (live or asynchronous) within a day or two which might include F2F, video, phone, email and text? Is that a 91810?
A: If the F2F is to complete the phone consultation or the video consultation (eg direct physical examination, procedure) then the F2F is regarded as a component of the phone or video consultation, so you charge, for example, 91800 (video) or 91809 (phone), but you don’t charge for the F2F. You can’t bill for the 91800 or the 91809 until you have done the F2F – this is in order to satisfy the MBS item descriptor! There’s an argument that you should bill a 23 (in person level B) for the F2F and not use the phone or video items. Medicare hasn’t given a directive here. Certainly, you can’t bill 91800/91809 AND 23. There are no MBS benefits/rebates for email or text messaging as standalone consultations, however, if they are part of a phone or video consultation, it’s legitimate to include the time spent on email or text in the time for the descriptor for the phone or video consultation.
Q: What about access to GP with a special interest that supports access often to disadvantaged patients (medical terminations, sexual and reproductive care, post-partum care etc.) but may not be able to contribute to continuity?
A: Really important point. In July, the Australian government introduced the requirement for a patient to have an ‘existing relationship with a GP (or practice)’ (defined as at least one in-person consultation with the GP or practice in the preceding 12 months), in order for the patient to be eligible for MBS benefits. This was an attempt to stymie the ‘pop-up’ Telehealth services, and in this respect, it was somewhat successful. Unfortunately, this requirement has disadvantaged many people, as it has cut off access to GP care for these people, many of whom are in disadvantaged groups. Maybe GPs providing services to disadvantaged groups could be exempt from this requirement (e.g. linked to provider number)?
An after-hours service provider can contract with a clinic to provide the clinic’s after-hours services – in which case, patients who have had in-person consultations at the clinic within the previous 12 months will be eligible for MBS rebates/benefits for after-hours care by that after-hours service provider.
Another option is ‘voluntary enrolment’. A patient enrols at a clinic, and the patient is eligible for all MBS services provided by that clinic (this would include telehealth without the requirement for an in-person consultation in the preceding 12 months).
The webinar featured the following speakers and was moderated by Wild Health publisher Jeremy Knibbs.
- Associate Professor Charlotte Hespe, GP, Head of GP (and Primary care research) UNDA (Sydney) and Chair NSW/ACT RACGP.
- Dr Amandeep Hansra, GP, Founder of Evermed Consulting, Founder of Creative Careers in Medicine and Digital Health Expert.
- Dr Andrew Baird, GP, Digital Health Advocate and Tutor for Medical Students in Professional Practice at the University of Melbourne.
- Leanne Wells, CEO of the Consumers Health Forum of Australia.
- Dr Silvia Pfeiffer, CEO and Co-founder Coviu, Author and Telehealth Expert.