Who is the RACGP’s telehealth stance actually serving?

17 minute read

The college’s position on phone consults betrays an organisation so intent on self-promotion it is losing sight of the main game: patient wellbeing.

When our much beloved media cousins at Australian Doctor broke the story on Tuesday that, as of 1 July, the Department of Health had decided to stop rebates on phone consultations longer than 20 minutes, our journos were immediately on to the department seeking a confirmation, clarification and details.

Although a big story, it wasn’t really a surprise.

The DoH had from the start been worried about the low uptake of video by GPs (it’s less than 3 per cent) for the obvious reasons that a video consult, if you can do one, is a far more effective patient interaction than a phone consult, especially for anything a little more complex, such as a mental health assessment.

The department had been hinting from early on that they might be end up providing monetary signals to balance the situation if didn’t self-correct.

What was surprising was that there was no forewarning of, or detail to, the story.

The reason was the story had been leaked to the media, most likely by the RACGP.

The DoH did not want to confirm or deny anything to us because, as far as they were concerned, the announcement had been made before the final form of the initiative had been negotiated with the various medical colleges. It looked like medical college politics was playing a role.

UPDATE: A few hours after we published this story yesterday afternoon we received a response from the DoH, saying the remaining numbers represent the vast majority of actual billings; that there was no difference between rural and urban areas in the takeup of video; and that the schedule would retain some mental health phone services, including longer consultations, “to ensure people experiencing barriers accessing video based services continue to receive timely and appropriate mental health care”.

You can read more of that response at the end. The rest of this piece remains as originally published.

The next day, the RACGP went out with their own story on their own news service, quoting the president of the college, Dr Karen Price, just as Australian Doctor had done the day before.

Still the DoH had no comment for us.

If the DoH hadn’t completed negotiating with the medical colleges, why would the RACGP choose to leak the story?

And if it didn’t leak the story, why would the college president be happy to give extensive quotes on the college’s position while private negotiations were still going on behind the scenes, and then go out with its own story on its own news service?

One explanation is that the college was looking to promote itself by getting out in front of the whole thing by putting its president front and centre of the issue before any other party had a chance to publicly address the problem.

It wanted to be out in front of the issue before any other college, and it wanted its position and its profile in fighting for GP and patient rights in this matter up in lights.

It wanted to lift its advocacy credentials among its membership.

Sometimes, between the government and competing medical colleges, this is bound to happen.

You might do this to put external pressure on government negotiations that aren’t going anywhere. Or you might do it to look better than the other colleges.

But if you’re going to do it, you need to make sure you have your ducks in a row. You need to know what you are doing, or at least look like you know what you are doing.

Mostly you need to be right if you are going to stick your head out like this.

But that the college didn’t have its ducks in a row in any way at all was alerted shockingly and almost immediately it published its own story by the first comment it received from one of its GPs on its position.

“I’m a Female GP in Melbourne.

I am surprised that video conferencing is being so easily dismissed. My practice had a recent death of a patient who had a phone consult, and it seems her condition was not ‘seen’ well. Seeing a patient’s face and body language tells a lot more than listening to the words and trying to read the nuances of voice quality.

I’ve also used the ‘share screen’ function on videoconferencing to share results, or share diagrams, or discussing use of medications eg ventolin, or devices if discussing contraception.

Quality of care is being jeopardized.

I have several patients with mental health issues, or English as a second language, and this is not 20 minute medicine. I see less numbers of patients because of that. I believe this is the case with most female GPs, and there is a larger proportion of females in Family Medicine, who have longer consult times.

We are still practising medicine, just through a different medium.”

Other comments from members on the article reflected a similar position.

“I have no problem with shorter telephone consults, however access to longer video engagement with patients allows complex issues to be addressed with facial feedback that enables adequate assessment of the patient’s response. I have not been able to achieve that during a phone call.”

The same day as the college article appeared on its own media service, newsGP, damning the government move, the Rural Doctors Association of Australia (RDAA) came out with a very different stance on the DoH policy.

While the college vehemently held that stopping all phone consults over 20 minutes would create serious patient problems as a result of access, and disadvantage female GPs who generally do longer consults, the RDAA and to a lesser extent the AMA felt that with the right caveats on areas of poor internet access, incentivising doctors to do more video was probably better overall for patients.

RDAA president Dr John Hall went so far as to say that he did not feel rural communities would be particularly disadvantaged by a move towards video-based services.

“My view is that for people who are living remote that can access bandwidth via satellite – they’re certainly going to benefit from access to video consults,” he said.

“There are a number of remote communities where we are using video-based telehealth to support our hospital services, and it works beautifully.

“To use bandwidth as an argument to say that we shouldn’t roll out telehealth or that we should somehow be cautious, I think is not necessarily accurate.”

While AMA president Dr Omar Khorshid came out largely opposed to the cuts, vice-president Dr Chris Moy wasn’t that far off the RDAA position.

He said the AMA believed the Department of Health’s changes were a way to nudge GPs towards using video consults rather than phone.

In March last year, when the temporary items were brought in, DoH guidance explicitly recommended that phone-only consults should be used only sparingly and that video consults should be the rule, not the exception.

“We understand that [level A and B make up] the majority of the consultations, and that part of this was to encourage general practitioners and patients to move towards video conferencing,” Dr Moy said.

Although he did express concerns over access to video consults for Australians who may have trouble accessing appropriate internet and technology, such as those living in rural areas, Dr Moy stressed that the AMA was working with the DoH to provide caveats for vulnerable groups.

College president Dr Price commented in Australian Doctor and newsGP about significant issues of rural and remote Australians’ access to care as a result of the changes.

“Many of the patients who benefit the most from telehealth are also the most disadvantaged when it comes to internet connectivity and reliability,” she told newsGP.

“By not allowing these patients to access fully funded longer telephone consultations with their GP, we risk leaving them behind – not only during a once-in-a-generation pandemic, but for the years beyond.”

The problem with the RACGP position is that GPs don’t use the longer phone consults much at all, and it’s wholly unclear at this stage that those who have used longer phone consults are unable to use video instead.

The vast majority of telehealth consultations by GPs are done using the two short consult items of under six and under 20 minutes.

In the March MBS data, of about $129 million claimed for telehealth, more than 80%, or $105 million, came from these items. Of the total $129 million for GP telehealth, extended time phone consults accounted for only about $20 million of rebates, of which $4 million came from mental health assessments, and $15 million from managed care plans.

We asked the college if they had any data to support the idea that those GPs who were using the longer phone items were in fact unable to use video for their patients because of access or unable to establish video facilities if they didn’t have them, but we got no response.

We also asked if the college had a more comprehensive position on the use of video versus phone than is featured in their guidelines on telehealth, which is as follows:

There is no need to use video if a telephone call will suffice. The decision to offer a video consultation should be part of the wider system of triage offered in your practice. It should be understood that the addition of visual images via a video link adds value to any telehealth consultation and can improve both quality and safety for more complex consultations. For some patients, a video consultation may be more appropriate than telephone – for example, where the patient is hard of hearing or deaf, a video consultation will provide them the opportunity to lip read. Video consultations allow GPs to view patients, which can assist in wound management and reviews and may assist in determining if they look unwell, given there is no opportunity to undertake a physical examination.

Notably there is no mention in this guideline of how much more effective video consults are likely to be for mental health consults, yet mental health assessments are a major focus of the college’s objection to dropping longer phone consults.

“[The policy] does not take into account the impact this will have on women’s health services, mental health patients who require much more than a 15-minute consultation, and rural and remote women seeking assistance,” Dr Price told her own news service.
“This is a blunt policy that does not recognise the complexity of the work that GPs do.”

The issue of video versus phone telehealth is obviously a complex one.

Certainly there are going to be some circumstances where the use of a phone consult longer than 20 minutes is likely to be the only means of doing such a consult with a patient with access problems, or a GP is simply not familiar with or set up to do a video consult at this time.

But these are issues that apparently the AMA was seeking to clarify and establish caveats for.

The key question in this move by the DoH for GPs is: are they seeking to establish better longer-term behaviours and infrastructure for patient care, or is this simply some sort of cost-saving measure?

It’s most likely both.

If the department is seeking to rebalance telehealth to longer-term better practice that does reflect better patient care, the next question that needs to be asked is: how many doctors and patients would really be seriously disadvantaged by pushing GPs towards more video in longer consults and how do you address that shortfall?

It seems like the AMA was trying to go down this path.

One problem for the RACGP position at this stage is that by coming out all guns blazing with a stance of no compromise, and a series of broad sweeping statements that don’t appear to be backed by any data – including the actual use of long phone consult items as revealed by the MBS – it risks actually promoting a position and behaviours that are, in the greater scheme of things, bad for patients.

Although data in Australia on telehealth consults versus video consults is lacking because the MBS regime hasn’t been in place for long, data from overseas and most experts say that video is a far superior telehealth experience to a phone consult.

Further, all the surveys, albeit by the major telehealth tech providers, actually suggest that patients far prefer video telehealth to phone by a factor of four to one.

In one survey conducted by leading telehealth provider Coviu, 44% of patients said they would be willing to switch to a GP practice that offered video.

The other factor put in play by the RACGP is that certain patient demographics simply can’t or don’t use video. While this feels logical, it’s increasingly being challenged by some experts who point to the change in society’s use of video communication overall, brought about the COVID pandemic.

As Holly Payne reported this week, Professor Jared Dart, who has a large practice in Taringa, Brisbane, with an older client base, treated many of his older patients through the pandemic using his newly developed telehealth app, Welio.

“We haven’t found it a burden for all of our elderly patients,” Professor Dart said.

“There are some people who are 97 who are not tech savvy and have found that [difficult] – but we’ve got some testimonials on our website [from older Australians], and I think the oldest is 82.

“Simplicity is the key – if it’s a predictable flow, an older person can learn it.

“They may not be able to install an app themselves, but their children or grandchildren can often help them install it.”

By going first, early and hard with a stance that rejects any lessening of rebates for phone-based consults, the RACGP may be initially have been seen to be taking the lead on an important issue for doctors and patients.

But it looks like the college went first, behind the backs of the DoH, the AMA, ACRRM and the RDAA, and leaked the status of negotiations before the DoH had a final position in order to look good.

If it didn’t leak the story, then by allowing its president to take the stance she did in the story in Australian Doctor, and then the next morning in its own media story, the same effect was achieved.

By taking the position it has without reference to any proper data as evidence for its position, the college may have ended up in the extraordinary role of promoting the extension of a healthcare practice that , as one of its own members has pointed out in very stark terms, can occasionally result in disastrous patient outcomes.

It won’t often prove lethal, but to do, for example, a long mental health consult over the phone just sounds like suboptimal care.

As has been stated, this is a complex issue. There will be times when the better health of a patient could rely on a long phone consult, simply because video is not feasible. This needs to be addressed in the DoH changes.

But in the bigger picture, the use of phone consults versus video is way out of whack.

That we are in this situation isn’t anyone’s fault.

GPs have been dealing with a pandemic in very difficult circumstances and quite simply, the phone is familiar and easy. The DoH seems to have recognised this and let things ride during the worst times of the pandemic.

But that doesn’t mean we should in the longer term keep using phone for the majority of our telehealth consults, most especially for longer, more-complex consults.

We should be trying to rebalance the system in time for better patient outcomes and a more fulfilling doctor experience.

The DoH hasn’t exactly got a great track record of prioritising patient outcomes over cost initiatives, and this move has of course elements of cost saving to it.

But the DoH has big cost problems to deal with that are going to get only worse as the massive budget spends during the pandemic eventually have to be addressed. Things will need to give.

In this case they are trying to combine better care with less cost. 

In terms of patient outcomes, someone needs to dive into the current MBS data and answer the questions that remain around whether those doctors now using longer phone consults are able to switch or not. Thankfully at least not that many are actually using the phone for long consults anyway, something the RACGP apparently doesn’t realise.

But if most of those that are using the phone for longer consults now can make the switch to video for their patients, the balance of this equation of patient outcomes is clearly saying we should be promoting a lot more video over phone, not less, as the RACGP is suggesting.

We don’t know for sure yet, but it looks like the RACGP is promoting poorer patient outcomes overall.

Potentially disastrous ones in some cases.

We asked the DoH what the reason was for dropping all but two of the numbers, whether there would be exemptions for rural areas with patchier broadband, and whether any particular systems were encouraged. Here’s its (lightly edited) response:

The broad range of GP attendances that were replicated for telephone delivery in response to the pandemic will be replaced with a smaller number of telephone items.

·       a short consultation item (less than six minutes) for straightforward care, such as repeat prescriptions and diagnostic referrals, equivalent to a face-to-face or video Level A consult; and

·       a longer telephone consultation item (six minutes and over) for more complex attendances, equivalent to a face-to-face or video Level B consult.

This approach is consistent with the use of telehealth items by GPs over the course of the pandemic. Since the introduction of the items, around 6 out of every 7 GP telehealth consultations, across the range of items available, was a phone consultation equivalent to a Level A or Level B attendance.

In addition to the short and longer telephone general consultation items, from 1 July 2021 some mental health treatment services, including longer consultations, will be retained to ensure people experiencing barriers accessing video based services continue to receive timely and appropriate mental health care.

At this time, no infrastructure-related exemptions for telehealth services are proposed. While acknowledging that different levels of broadband coverage exist across Australia, it is also important that the same quality standards apply to MBS services regardless of where patients live.

The Government acknowledges that there continues to be significant opportunities for telehealth to improve equitable access to services in areas of workforce shortage, and also that there are a range of factors that influence a practitioner’s decision to offer telehealth, whether by phone and/or video, or at all. Broadband connectivity is only one of these factors.

As evident in MBS claims data, while overall there have been significantly more phone than video services in all communities across Australia, the proportion of telehealth video consultations has been similar or higher in remote and very remote communities in comparison to more populated regions.

No specific equipment is required to provide Medicare-compliant telehealth services, noting that MBS telehealth services require the practitioner and patient to participate synchronously, or in real-time, as per a face-to-face consultation.

Practitioners are free to determine the solutions most likely to work for them, guided by the services they intend to offer and in accordance with their business requirements. Practitioners must ensure that their choice meets their clinical requirements and its use satisfies relevant privacy laws.

Improving the digital capability of general practices is a longstanding strategy of the Government. General practices are encouraged to keep up to date with the latest developments in digital health and adopt new digital health technology as it becomes available, with e-health incentive payments of up to $12,500 available to eligible practices per quarter ($50,000 per year).

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