CHANGES to eligibility for Medicare benefits for GP telehealth and phone services will solve one problem but potentially disadvantage many patients as a result.
In May 2020, the most recent month for which data are available, 67% of Medicare services at levels B, C and D were provided face-to-face, 32% were by phone, and 1% were by video.
As of today, Monday 20 July, eligibility for Medicare benefits for the temporary Medicare Benefits Schedule (MBS) coronavirus disease 2019 (COVID-19) telehealth (video) services and phone services will be contingent on a patient having an existing and continuing relationship with the GP who provides the service. This relationship is defined as the patient having had at least one face-to-face in-person consultation in the previous 12 months with the GP, or with another GP at the GP’s practice.
There are four exemptions to the requirement for an existing and continuing relationship with the GP providing the service:
- homeless people;
- children under the age of 12 months;
- patients referred to a GP by a non-GP specialist; and
- people living under Stage 3 restrictions in Victoria (it is implied that this would also apply in the event that Stage 4 restrictions are imposed).
The temporary COVID-19 telehealth service and phone service item numbers will still expire on 30 September.
The change was introduced on the recommendations of the Australian Medical Assocation (AMA) and the Royal Australian College of GPs (RACGP). In their media releases on 10 July, the AMA and the RACGP have welcomed the changes. It is not known if the Australian College of Rural and Remote Medicine (ACRRM) was involved in the recommendations to the government.
I believe that patients will be disadvantaged by these changes because telehealth services and phone services will not be eligible for Medicare benefits in the following situations:
- Very vulnerable patients who require consultation with a GP by telehealth or phone who have not had a face-to-face consultation in the previous 12 months. For example:
- patients who attend headspace;
- students who access general practice through the Doctors in Secondary Schools program in Victoria and through similar youth health programs in other states and territories;
- patients who attend sexual and reproductive health clinics.
- Patients whose consultation with the GP, or at the GP’s practice, in the previous 12 months, was by telehealth or phone service due to the COVID-19 pandemic.
- A GP’s or practice’s regular patients who have not attended a face-to-face consultation in the previous 12 months.
- New patients who have difficulty attending a face-to-face consultation, or who prefer a telehealth consultation to a face-to-face consultation.
- Patients living in regional, rural and remote areas who have not had a face-to-face consultation with the GP, or at the GP’s practice, in the previous 12 months, and who would have to travel a long distance to access GP care.
- Indigenous people who have not attended the same GP or the same practice or health service in the previous 12 months; Indigenous people who have attended different GPs (eg, locum GPs, and fly in-fly out GPs) and different practices or health services, in the previous 12 months.
- Patients who attend new practices that have not yet built up a patient base or practice population.
- Patients who attend GPs who do not do face-to-face consultations during the pandemic for personal health reasons (for example, GPs who are immunocompromised and GPs who have respiratory disorders).
- Patients with mental disorders who have been receiving GP mental health care by video or phone may no longer be able to access this through Medicare – unless they have attended the GP or the GP’s practice for a face-to-face service, in the previous 12 months.
- Patients who develop mental disorders needing initial treatment on or after 20 July will be unable to access Medicare benefits for GP mental health care by video or by phone without a face-to-face service with the GP, or with another GP at the GP’s practice, in the previous 12 months.
- GPs who provide Focused Psychological Strategies will only be able to provide mental health care by video (MBS items 91818 and 91819) or by phone (MBS items 91842 and 91843) for patients whom they have seen face-to-face in the past 12 months, and for patients who have attended other GPs in the GP’s clinic for a face-to-face service in the past 12 months. Medicare benefits will not apply for video or phone consultations for new patients who have been referred to the GP from outside of the GP’s practice.
In the AMA media release, AMA President, Dr Tony Bartone, stated:
“The great majority of GP telehealth consultations to date have been in circumstances where a patient has an existing relationship with a GP, but we have seen the increasing and disturbing emergence of ‘pop-up’ telehealth models and models that are linked to pharmacies.
“Both the pop-up and pharmacy telehealth models are also unable to facilitate access to a face-to-face consultation when a patient needs one. [These] changes will put an end to these inappropriate models of care.
“[The changes preserve] the foundation of quality primary care – the very real benefit of patients having a regular ongoing relationship with their GP … This is the patient-centred approach that we know works so well in Australia.
“The AMA wants to see telehealth for GPs and non-GP specialists continue beyond [the expiry of the Medicare telehealth items at the end of September].
“Telehealth is key to continuity of care and quality of care.”
“This [change] will ensure telehealth is not exploited and the community receives the highest quality care.
“I urge all patients to use telehealth or telephone services connected to their usual GP or clinic [due to the risk for inappropriate practice and fragmented care].
“With the expansion of telehealth we were very concerned to see the proliferation of corporate telehealth pop-ups, offering low value services. These businesses promise a ‘quick fix’ for patients but there is no commitment to the ongoing care … the doctors won’t know the patient’s medical history or have a connection to their clinic.
“[Telehealth businesses] completely undermine the high-quality services offered by general practices … something had to be done. At the RACGP we recognised the threat these businesses posed to both health outcomes of our patients, as well as to the viability of traditional family GP clinics, particularly those in rural and remote communities.
“Increasing access to care should never come at the cost of patient health and safety.
“The RACGP is strongly in favour of retaining telehealth and telephone consultations.”
We are all agreed that telehealth services funded by Medicare must be accessible to patients (within the constraints of equipment and technology), and represent high quality general practice (patient-centred, with continuity of care).
However, in my opinion the Health Minister’s decision to limit Medicare benefits for telehealth services and phone services with a GP to patients who have had a face-to-face attendance in the previous 12 months with the GP (or with another GP at the same practice) discriminates against patients who do not meet these criteria. It does meet the objective of the AMA and the RACGP in preventing eligibility for Medicare benefits for telehealth services and phone services provided by “pop-up” telehealth businesses, however.
In defining the criteria for eligibility for Medicare benefits for telehealth services and phone services, there are alternatives to a model based on a patient’s previous face-to-face attendances within a period. Discussions involving the AMA, the RACGP, the ACRRM, the Australian General Practice Alliance, and the government could consider other options for authenticating GPs and practices for provision of Medicare funded telehealth services.
For example, eligibility could be:
- accredited practices;
- practices that are affiliated with a Primary Health Network;
- primary care health services that are not traditional family general practices and that provide high quality patient care (eg, headspace, sexual and reproductive health clinics, youth health programs);
- accredited medical deputising services
- only practices that provide face-to-face attendances.
Providing prescriptions, investigation requests, referrals, and medical certificates “on demand” is not exclusively the domain of pop-up telehealth businesses. Unfortunately, this also happens in traditional general practice.
There are no data on the number of services provided by pop-up telehealth businesses, so the scale of the problem is not known. Therefore, stopping the Medicare income stream for pop-ups may not resolve the problems described by the AMA and the RACGP.
The emergence of corporate pop-ups may be viewed by traditional general practices as an opportunity rather than a threat. Traditional general practices may review their services, appointment systems, and workflows with a view to making changes, if possible, to meet some of the needs that patients are expressing by attending pop-ups.
A patient’s face-to-face attendance at a general practice within the previous 12 months is not necessarily an indicator of continuity of care, as this may not be the patient’s regular general practice. Some patients attend multiple general practices for face-to-face consultations. This change in eligibility for Medicare benefits for telehealth will have no impact on the patient behaviour, which leads to patients taking a nomadic approach to attending general practice, thereby compromising their continuity of care.
If, for Medicare eligibility, a patient was restricted to obtaining GP care from one GP, or at one GP Clinic, this would be registration by proxy. It is thought that most GPs and most patients oppose registration. GPs and patients want patients to have the freedom to choose GP care whenever and wherever they wish.
There are data on the use of telehealth and phone services by state or territory, and by gender and age group. However, there are no data on the reason for consultation. This may be a useful subject for research. There is anecdotal evidence that telehealth and phone services are enabling improved access to general practice for people with complex needs who have difficulty attending a general practice in person; for example, people who are experiencing domestic violence, people whose mental health precludes visiting a clinic, and people who have financial and geographic constraints on their ability to travel to a clinic.
In summary, the AMA and the RACGP support telehealth and phone consultations, but only when they are provided by a patient’s regular GP or regular clinic, in a traditional general practice model, and not in a pop-up telehealth model.
Telehealth services and phone services are important and valuable for providing care in general practice. In their ongoing discussions with the government about “further refinements that can support the broad retention of telehealth,” the AMA and the RACGP should promote patient-centred, continuing care, and aim to ensure that access to telehealth in general practice is equitable for all Australians.
Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria. He is a tutor in professional practice for medical students at the University of Melbourne.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.