more_vert
TELEHEALTH restrictions introduced by the federal Department of Health on 20 July 2020 discriminate against women seeking early medical abortion (EMA), making an already hard to access procedure even more out of reach.
Professor Danielle Mazza, Head of the Department of General Practice at Monash University, told InSight+ that telehealth offers an opportunity to address limited access to EMA during the COVID-19 pandemic and beyond.
“Telehealth is an amazing tool to increase equity of access because if you can’t get that service provided to you locally, you can get the service provided to you by another provider in a different geographical location,” Professor Mazza said.
“At the moment, 2317 GPs in Australia are currently registered prescribers of MS2Step (mifepristone and misoprostol), but we think far fewer actually go on to actively prescribe.
“Actually, setting up this service in your practice involves a number of other steps and having the confidence to do it, plus having the support of your colleagues in your practice, the front desk manager and the reception staff.
“So, you can do the course [in order to become a prescriber], but that doesn’t mean you’re actually going to deliver the service.”
“Telehealth therefore helps women to overcome that problem of not having a local provider in their region.”
With the advent of the COVID-19 pandemic the federal Department of Health introduced temporary Medicare Benefits Schedule (MBS) item numbers for telehealth GP consultations to enable patients to see their doctors in a contactless environment.
But since 20 July, new restrictions to those MBS item numbers have been implemented, namely restricting eligibility to only patients who have visited the GP or practice in the previous 12 months or those who have been referred by a specialist, except for where there is a current lockdown in place.
“The changes that were introduced on 20 July were trying to support continuity of care, and that’s a very important principle,” Professor Mazza said.
“I’m a GP. I understand the benefits of continuity of care, but you can’t have continuity of care if you don’t provide a service.”
In a Perspective published today by the MJA, Professor Mazza and colleagues wrote that the new restrictions “will greatly reduce women’s access to EMA”.
“Placing restrictions on the eligibility criteria for MBS-subsidised telehealth services severely affects women’s access to GPs who can provide EMA, and discriminates against women who have not recently engaged with a GP due to various forms of disadvantage, such as family violence and unemployment.
“Exemptions to the restrictions have already been identified for people who are homeless and for children aged less than 12 months.
“Therefore, a further exemption should also be issued so that registered prescribers of medical abortion are able to use MBS telehealth item numbers for the benefit of Australian women.”
Telehealth, Professor Mazza told InSight+, was a vital link in the provision of EMA, particularly to women in rural and regional settings.
“A lot of women don’t even know that a medical abortion is an option,” she said.
“Because abortion is so stigmatised in our society, when women have an unplanned pregnancy and make a decision to have an abortion, think about who they might talk to, to get information.
“[Initially] it’s their friends and family, who may not know much about abortions.
“Then they might turn to their GP, who if they’re not a provider themselves may not be familiar with the whole process of medical abortion. Or indeed their GP might be a conscientious objector to abortion, and who, again, may not really actively assist that woman to navigate the system to find a service.”
The impact of COVID-19 could not be underestimated, she said.
“There’s been a lot of talk and research to demonstrate how COVID-19 has impacted women’s lives – not only from a sense of fear about the future and about safety and wellbeing, but also increased burden in terms of mental health issues, problems with financial insecurity, women losing their jobs because they are often working casually or part-time and are the first to go, or their partners might have lost their jobs.
“And, of course, we’re all aware of the increased rates of domestic violence that unfortunately women are suffering during the pandemic.
“So, if you think about women who find themselves with an unplanned pregnancy facing all of those issues, more women are seeking information about their options and considering the option of not continuing with the pregnancy in those circumstances.”
Professor Mazza said she and her colleagues have had meetings with the Department of Health and ministerial advisors about gaining an exemption for EMA.
“There have been concerns about things like needing to be able to offer follow-up care,” she said.
“We’ve argued very strongly that the international protocols and guidelines endorse the fact that follow-up can be done remotely via telehealth. You can ascertain what’s going on with a woman at the end of the phone and work out how to help her in the small number of cases where the medical abortion may have some complications.
“It’s very feasible, and it’s acceptable to women to have a medical abortion via telehealth.”
The response from the Department? “They’re looking into it,” said Professor Mazza.
The exemption from the telehealth restrictions is not the only thing that could be done to improve access to EMA, she said.
In their Perspective, Professor Mazza and colleagues wrote that there were other measures which would optimise the ability of telehealth to improve access to EMA for all Australian women:
- a national hotline or online platform, similar to the 1800 My Options service (www.1800myoptions.org.au) in Victoria, which directs women to local abortion service providers, is required to assist women to identify an appropriate provider;
- changes are required to current Therapeutic Goods Administration and Pharmaceutical Benefits Scheme provisions restricting the prescription of MS-2 Step (mifepristone and misoprostol) to up to 63 days’ gestation – these criteria are outdated and discordant with current evidence demonstrating that EMA up to 70 days’ gestation is comparable in safety and efficacy to 63 days’ gestation or less;
- modifications are required to EMA protocols, particularly during the COVID-19 pandemic – the Royal Australian and New Zealand College of Obstetricians and Gynaecologists has already advised that a clinician may appropriately decide not to administer anti-D IgG before 10 weeks for the medical management of abortion, particularly when an additional visit may increase exposure of women and staff to COVID-19;
- in situations where obtaining an ultrasound is a significant barrier or poses a significant risk during the COVID-19 pandemic, EMA may proceed without the necessity of ultrasound assessment but only after careful screening for risk factors for ectopic pregnancy and where an accurate gestational age can be estimated from the woman’s history;
- in South Australia mifepristone can only be supplied in a hospital setting – this precludes South Australian women from being able to access EMA through community-based providers such as GPs or via telehealth; the relevant South Australian legislation therefore requires a change.
“In women’s reproductive lives, they need help with pre-conception care and with contraception. Contraception sometimes fails or there are reasons why women haven’t been able to use it,” Professor Mazza told InSight+.
“We know about the impact of unplanned pregnancies, not only on women’s lives but also on the lives of their other children and families, if women are not able to access abortion services when they need it.”
Also online at the MJA
Perspective: Diagnostic error: incidence, impacts, causes and preventive strategies
Scott and Crock; doi: 10.5694/mja2.50771 … FREE ACCESS for 1 week
Perspective: Chimeric antigen receptor T‐cell therapy for haematological malignancies
Selim and Tam; doi: 10.5694/mja2.50783 … FREE ACCESS for 1 week
As a GP in both private practice and at Headspace in Brisbane this is 100% my experience also. RUOK is great but where do you go if you’re not OK, don’t have a regular GP you feel comfortable talking to about your mental health and are too anxious or depressed to leave the house? I’m very grateful for telehealth care providing the portal to an ongoing therapeutic relationship with many amazing young Australians during this time of extreme stress, unemployment and uncertainty. We should be doing everything possible to encourage our youth to talk to their GPs by any means they feel they can and to support the frontline GPs providing the overwhelming majority of mental health care to Australians.
Young people, in particular, are doing it tough during this pandemic. They are also especially vulnerable to barriers to accessing health care at the best of times. Despite its limitations telehealth appears to allow easier health access for some young people and needs to remain available as an option for them as well as other at risk groups such as those referenced in this article.
At headspace, we’re seeing increasing numbers of young people with depression, anxiety, substance use and eating disorders. Stress related to inability to manage on-line school, final high school examinations, loss of work, and to being locked down in a family with unhealthy relationships is skyrocketing. Those with pre-existing mental problems are suffering exacerbations; others are experiencing symptoms for the first time. Social isolation has reduced ability to self-manage. Waiting times for help are increasing, while health-care services are struggling beyond capacity.
Deady et al 2 have described the suicide risk of future widespread unemployment. Young people are faced with reduced end-of-school employment and career choices. They have also lost the excitement normally due in this time of life. The suicide rate for Australian youth is already high. Modelling predicts that it will increase. “In crisis periods, it can be the most disadvantaged groups that are disproportionately affected and marginalised and at-risk populations require specific attention.” With Covid-19, we believe it is young people, with their whole lives ahead of them, who most need special care and attention and we predict that they will need primary care services more than ever if we are to avert more crisis presentations in high-risk groups.
Current restrictions to telehealth are too limited and should be widened.
An unpublished audit at one headspace practice compared attendances over April-June 2019 to April-June 2020. Attendances during telehealth increased, cancellations and no shows decreased. This concurs with anecdotal reports from other headspace services, from other practices, and with an ABS survey showing that people with mental problems were more likely to use telehealth 3. Such early observations suggest that telehealth overcomes some of the barriers perceived by young people trying to access care.
We must retain the capacity to see each young person, in person, when appropriate, and when preferred. We also need continuing scrutiny of telehealth, including extent of engagement and long-term outcomes. Will better attendance hold true once Covid-19 has passed?
While we are seeing more young people in distress, we are concerned that, with increasing disruption of their life plans, a mental health surge is imminent.
GPs will, appropriately, be expected to manage this surge. They can be touchstones for the young trying to negotiate life’s obstacles – and the health-care system. But first, we must reduce barriers to primary care.
Telehealth might offer a soft entry point to primary care and, in turn, to mental health services. Medicare rebates must be continued post Covid19. In addition, there needs to be an exemption to the ‘12-month rule’ for all GPs caring for young people because many, who do not already have a GP, will be seeking help for the first time.
We will all need to be tuning in to young people, checking wellbeing and risks. The health system must play its part and get the groundwork in place.
References
1.https://www.health.nsw.gov.au/kidsfamilies/youth/Pages/access-study.aspx. Young people and the health system in the digital age.
2. Deady M,Tan L,Kugenthiran N,Collins D,Christensen H and Samuel B Harvey. Unemployment, suicide and COVID‐19: using the evidence to plan for prevention, Med J Aust 2020; 213 (4): 153-154.
3.The Australian Bureau of Statistics Household Impacts of COVID-19 Survey
MS-2 Step Training and the MS-2 Step website could be updated with specific reference to consultations by telehealth (video) and phone, including information about ePrescribing.
As an index prescriber ( from the original trial)
I believe this.
A pre treatment ultrasound is vital.
Gestational history alone will not exclude late pregnancies and ectopic.
Thank you for advocating for access to EMA via GP telehealth (video) and phone.
The ‘usual medical practitioner’ requirement has disadvantaged many people in vulnerable groups who now don’t meet the eligibility criteria for Medicare benefits for GP telehealth or phone attendance.
The Department of Health’s response about EMA via telehealth – ‘They’re looking into it’ – isn’t good enough.
Has the Department of Health made a commitment to report back on their decision?
Are the AMA, RACGP, and ACRRM supporting this?
Professor Mazza presents an unarguable case for women to have unrestricted access to EMA via GP telehealth.
It’s up to Medicare to decide how to implement this, for example, one or more of:
1. Add ‘patient attendance related to EMA’ as an exemption to the ‘usual medical practitioner’ requirement
2. Add ‘patient attendance related to pregnancy’ as an exemption to the ‘usual medical practitioner’ requirement
3. Exemption linked to GP-EMA Prescriber’s Provider Number
4. New item numbers for telehealth consultations related to EMA, with no ‘usual medical practitioner’ requirement (levels B, C, and D, video and phone)
I believe that all pregnant women should have unrestricted access to GP telehealth (video) and phone services anyway. Based on RANZCOG advice, pregnant women should be considered ‘COVID-19 vulnerable’, and telehealth consultations should be considered as a replacement for routine visits. It may not be possible for a pregnant woman to see her usual medical practitioner.
If pregnancy is made an exemption from the ‘usual medical practitioner’ requirement, then all pregnant women can have unrestricted access to GP telehealth, and there does not need to be a special case or exemption for consultations related to EMA via GP telehealth