Published in The Medical Republic, 9 June 2020
Starting in mid-March 2020, the government drip-fed changes to facilitate telehealth in primary care. Two groups of items were introduced: one for video-conference consultations, and one for telephone consultations if video was not available.
Telehealth has been advocated for decades as a way of enhancing access to care for people living in rural and remote Australia. But telehealth has faced numerous barriers, not least equivocal Commonwealth government support, and poor internet connectivity in rural and remote Australia. Take-up was low.
Telehealth is prone to a “woodwork effect”. That is, where demand comes out of the woodwork when a new benefit is available. The risks of over-servicing, misuse by some providers with predatory business models, and fraud, are real, but the benefits of telehealth are undeniable. However, especially in the context of increasing prevalence of chronic disease, telehealth items should enhance continuity of care, which benefits patients and reduces costs, and not further fragment the primary care system.
New telehealth items ought to have been introduced long ago. It is a tragedy that it took a pandemic to get the policy ball rolling. The issue becomes how to ensure new items are not abused; for that reason, the COVID-19 items may not be suitable for the new normal.
Telehealth should not be seen as a simple substitute for a face-to-face consultation, although it can do that. In the new normal, health professionals and their patients need to assess when telehealth should be the preferred medium because of the nature of the presenting problem, distance to be travelled and other factors.
The Australian College of Rural and Remote Medicine has published a set of standards which could be used as a basis for developing revised items. These standards include 11 core principles, one of which is:
The integrity and therapeutic value of the relationship between client and health care practitioner should be maintained and not diminished by the use of telehealth technology. Telehealth must enhance the existing clinician patient relationship (not fragment it). Telehealth arrangements should complement existing services (where available), build on rural workforce and referral patterns to avoid further service fragmentation, and address practicalities of coordination, scheduling and support from the patient’s perspective to improve their continuity of care.
Although framed for rural and remote practice, this principle is relevant to telehealth delivery anywhere. In line with that principle, specifically that telehealth “must enhance the existing clinician patient relationship”, new telehealth items should be limited to patients with an established relationship to a practice, such as having at least half of their primary care visits in the past year being to that practice. In the case of people over the age of 70, telehealth should be limited to the practice in which the patient is enrolled.
The current items specify that telephone consultations are supposed to happen only if video is not available. Yet during the pandemic telehealth, at least in general practice, was primarily by telephone. After the pandemic, it may be appropriate for a limit to be imposed so that no more than half of a practice’s telehealth consultations are by telephone until evidence is created as to the most beneficial balance for patients and providers. Telehealth items should be bulk-billed, and subject to strict electronic verification requirements.
During the pandemic the structuring of the telehealth items mirrored face-to-face items. In the new normal there might be quite different tiering, splitting the standard consultation item into two or three items as there can be more accurate automatic verification of consultation length.
But expanding telehealth will not be problem-free and will not be appropriate for every patient. The “digital divide” means that a patient’s digital and health literacy will need to be assessed in customising care.
Telehealth may have perverse effects, too. Although a boon for rural and remote patients, if wider access to telehealth reduces viability – or trust in – specialists who are based in regional centres, it may be a net negative.
Policies which limit telehealth access in a way which promotes continuity of care may reduce the risk to rural specialty practice.