Inclusive design can help meet therapeutic goals while lowering costs, travel time and inconvenience.
At business school, my memorable health economics lecturer Steve Morris drummed into us the principle that “healthcare demand is infinite whereas healthcare supply is finite”.
It is a maxim which still holds true, influencing health economic policies and therefore, the thinking of public and private payers that seek to ration expenditure through blunt instruments such as fee-for-service funding.
Australia’s health system funding has gradually evolved from block payment to activity-based funding in hospital care, but primary care funding remains resolutely based on the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme mechanisms. Both are coin-operated systems that are not designed to improve safety nor quality of care. This has to change.
A strong case for virtual care
Payers such as private health insurers and Medicare have historically demonstrated reluctance to fund telehealth and remote patient monitoring services that comprise virtual care, or as Fujitsu calls it, virtual connected care – where the connected part of the model is crucial to its success.
MBS item numbers that fund telehealth were initially introduced with expiry dates. The traditional thinking is that if healthcare demand is infinite then funding VCC could open the floodgates and become unaffordable. Surprisingly, the exact opposite is true.
Face-to-face care in Australia is incredibly costly. The historic process based on referring the patient to GP clinics and specialist bricks-and-mortar hospitals for the delivery of healthcare is slow and provider-centric. It burdens the population with out-of-pocket costs for their time and travel as well as incurring tax-funded provider costs. The Australian Institute of Health and Welfare states: “$89.7 billion spent on public hospital care ($3497 per person) in 2020–21 accounted for 41% of all health expenditure ($220.9 billion) and a further $19.1 billion was spent on private hospitals”.
By contrast VCC is relatively inexpensive to deliver and more importantly, is patient-centred. Patient time, travel and inconvenience are eliminated and conversely, the productivity of the clinicians delivering VCC is improved. Both the care providers and the patients consistently report high satisfaction levels, based on the rapid adoption where it has been offered. The large majority (85.4%) of patients utilising telehealth would use it again if it was made available.
Many aspects of patient care do not require a physical examination and can be conducted virtually. Even fracture clinics are being successfully trialled as telehealth clinics. Digital medical devices such as electronic stethoscopes and patient managed remote monitoring devices also have a part to play. The inexpensive and easy to use pulse oximeter clipped to the index finger proved its worth during the covid pandemic as VCC flourished.
There is an increased appetite for virtual care, with the NSW government, for example, implementing RPA Virtual Hospital during the pandemic and more recently its virtualKIDS urgent care service which redirects patients back to primary care, alleviating the demands on emergency departments demand.
Patients like it, care providers like it and it is more cost-effective. It is now time to fast-track the adoption and funding of VCC nationally as a priority.
Rethinking funding for better adoption
The funding model for VCC would benefit from a review. The historic funding of federally funded general practices and state-funded hospitals does not support VCC.
Rather than restricting funding, increasing funding would accelerate the adoption and decrease the volume of patients attending hospital in person. More patients could be supported at home by their primary care team. The net effect could reduce emergencies and elective waiting lists, yielding significant savings for payers while improving equity and access.
VCC needs an accessible funding stream that includes both fee-for-service as well as the cost avoided by meeting defined clinical governance criteria. Care that has historically been provided in acute facilities but is provided to the same level of care in the community needs to be funded in a way that recognises the cost saving generated by avoiding ambulance, ED or admitted patient care episodes.
Despite a prolonged review of MBS item numbers, Medicare is still a blunt instrument. It is a fee-for-service funding model that is no longer fit for purpose in a digital world.
There is no incentive for providing more complex care over simpler care at present in the VCC Medicare funding system. There is no incentive for safety and quality. There is no incentive for preventing avoidable hospital admissions. The VCC solution is already tested and proven, and it begins by funding care quality and outcomes in the community.
The well-known UK NHS Quality and Outcomes Framework is a stellar example of how paying GPs to document care outcomes has led to better funded GPs delivering better patient outcomes, resulting in fewer attendances at hospital. Applying this model to VCC would quickly decrease demand and reduce waiting lists for free hospital care. Unsurprisingly, patients prefer better, faster, accessible care with local doctors, nurses and allied health professionals who know them well.
The next steps in VCC
The journey toward augmenting humans with technology is a long one and AI is a catalyst for accelerating progress. As the digital literacy of the care workforce augments, care professionals are rapidly adopting intelligent ways to minimise administrative burden, freeing up more time to spend with patients.
Organisations like the Australasian Institute of Digital Health are pioneering workforce in digital health literacy. Trust in AI and other technologies hinges upon citizens participating and managing their own care responsibly with the support of healthcare professionals who deliver VCC with the same respect and dignity as face-to-face care. As AI governance, ethics and regulation improve, trust in positive care outcomes will increase.
The reassuring hand to hold and the physical examination will not readily be substituted; however, developments in technology could further reduce the need for face-to-face consultations. High-resolution cameras and eye-gaze technology using AI may become more effective than in-person assessments – in some cases detecting non-verbal communication for those with paralysis or dementia better than humans.
Keeping VCC patient-centric
Elderly, culturally and linguistically diverse and those from lower socioeconomic backgrounds may not have the knowledge, mobility nor budget to use the latest technology unless there is a focus on providing equitable access.
Australians in rural and remote geographies have long suffered from a two-tier health system compared with metro residents. Using satellite, wi-fi and mobile technologies to bring care provision to the remote patient has already dramatically improved timeliness and accessibility of care delivery.Designing inclusive VCC will result in more person-centred care, concordance with therapeutic goals and lower cost to serve.
In summary, my three recommendations are:
- Create a national Medicare quality and outcomes funding stream for VCC;
- Fast-track VCC as the preferred national mechanism for care delivery; and,
- Invest in VCC access and equity for priority populations.
Ian Manovel is a former pharmacist and is now Head of Industry (Health) at Fujitsu ANZ.