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MY OWN review of Medicare data for GP services for the period 1 April 2020 to 31 March 2021 highlights some interesting trends in the use of video for GP telehealth consultations.
The Australian Government paid $49.5 million in Medicare benefits for Australian GP video telehealth services conducted in the period 1 April 2020 to 31 March 2021. It paid $1.8 billion in Medicare benefits for Australian GP phone services in the same period. For every Medicare dollar spent on video telehealth services, 36 Medicare dollars were spent on phone services.
In the same 12-month period, there were 149 213 674 GP services – 72.0% were in-person, 27.4% were by phone, 0.6% were by video, 97.7% of GP telehealth services were by phone, and 2.3% of GP telehealth services were by video. Video was used for 0.6% of Level A, B, C and D attendances; for 0.6% of chronic disease management items; and for 1.4% of mental health items.
The Medicare Benefits Schedule (MBS) states “videoconference services are the preferred approach for substituting a face-to-face consultation. However, in response to the COVID-19 pandemic, providers will also be able to offer audio-only services via telephone if video is not available”.
It seems that video was not used in 97.7% of GP telehealth consultations. This begs the question of whether video was not available for whatever technical reason, or was simply not preferred by either the doctor or the patient.
Compare those numbers with the following data on the telehealth consultations by consultant physicians, non-GP specialists and mental health clinicians. The source of these data is the University of Queensland Centre for Online Health, which analyses and summarises MBS service data on a monthly basis.
In March 2021, 12% of consultations by consultant physicians and non-GP specialists (excluding psychiatrists) were by telehealth – 78% were by phone and 22% by video.
In the same month, 32% of consultations by psychiatrists were by telehealth – 49% were by phone and 51% by video.
In the same month, 18% of mental health services by psychologists, clinical psychologists, social workers, and GPs were by telehealth – 50% were by phone and 50% by video.
What is clear to me is that, with the possible exception of mental health consultations, video is underutilised by Australian GPs for telehealth services.
So, what does the evidence say about the use of video telehealth in general practice? Despite considerable literature on telehealth generally, there is limited evidence about its use in general practice globally and very limited evidence on video telehealth in Australian general practice.
Video telehealth has improved access to culturally appropriate health care for people in remote Aboriginal communities (here and here).
A scoping review by Jonnagaddala and colleagues in 2021 reported that the COVID-19 pandemic has highlighted challenges in literacy, maturity, readiness and organisation in adapting telehealth to support integrated person-centred health care. They concluded that there is a need for more research into how telehealth can improve the access, integration, safety and quality of virtual primary care.
Thomas and colleagues (2020) highlighted five key requirements for long term sustainability of telehealth: developing a skilled workforce, empowering consumers, reforming funding, improving digital ecosystems, and integrating telehealth into routine care.
The most relevant overseas evidence is from the summary of the evaluation report by University of Oxford on the Near Me video consulting service for health care and social care in Scotland. Near Me uses the “Attend Anywhere” video platform, which has similar functionality to Australia’s “Healthdirect Video Call”. Near Me was introduced in 2018 and the rollout was accelerated in 2020 in response to the COVID-19 pandemic.
According to the evaluation, most patients, members of the public, and clinicians perceived video consulting as beneficial, both during the pandemic and longer term. Patient surveys showed positive outcomes in patient satisfaction. Quality of the video call had a significant impact on patient-reported outcomes. Problems with internet connectivity, digital access, and privacy in the patient’s home were highlighted as negative features of video consulting.
Approximately two-thirds of Scottish general practices used Near Me during the COVID-19 pandemic lockdown. This decreased to approximately one-third when lockdown restrictions were eased. GPs recognised the value of video consulting. They also described problems accessing video call technology and information technology support.
A systematic review from Canada in 2018 reported that video telehealth resulted in fewer medication errors, greater decision-making accuracy, and greater diagnostic accuracy compared with phone telehealth. There were no consistent differences between video and phone for patient outcomes and patient satisfaction. The authors concluded that the sample was small and that the findings could not be generalised. They recommended more research to determine the circumstances under which video is superior to phone as a telehealth modality.
Donaghy and colleagues (UK, 2019) reported that the visual component of video consultations offers distinct advantages over telephone consultations. They noted that demand for video consultations in primary care is likely to rise, but that improved technical infrastructure is necessary to enable video consultations to become routine.
Seuren and colleagues (UK, 2021) describe the importance of trust in video consultations. Patients and clinicians must be able to trust the technology, trust one another’s capability to use the technology, and use the technology to build and maintain a therapeutic relationship.
Norwegian GPs expect that they will conduct 20% of their consultations by video in a future non-pandemic setting.
The key points in the literature about video telehealth can be summarised as follows:
- video telehealth is acceptable to health professionals and patients;
- health professionals and patients have a strong interest in video telehealth during and after the COVID-19 pandemic;
- outcomes of video telehealth consultations and in-person consultations may be equivalent;
- there may be access inequality favouring younger and more technologically literate patients;
- limitations include problems with internet connection, equipment, and telehealth workflows;
- there are complex challenges in embedding video telehealth in organisations that are hesitant to change;
- there is a need for more research into video telehealth to determine its role, health care outcomes, safety, efficacy and cost-effectiveness; and
- there is a need for education for health professionals and support for patients in using video telehealth.
Conclusions
This analysis of Medicare data and the literature review raise questions about telehealth in Australian general practice.
- Are patients getting good care?
- Is Medicare getting value for money?
- What are the barriers to video telehealth for GPs and for patients?
The proportion of telehealth services provided by video is higher for non-GP specialists and other health care practitioners than for GPs. Video telehealth is clearly underused in Australian general practice. GPs should consider putting the phone down and turning their webcam on.
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.
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14 comments = 4 pro-video + 6 anti-video + 4 by me.
I had expected more comments from GPs defending the use of the phone for telehealth, and expressing outrage and/or disappointment at the culling of the phone service item numbers. GPs have three more days for a Level C phone consultation (item 91810 and many others will be deleted from the MBS from 1 July).
I had expected more comments from GPs who are interested in using video for telehealth, but who have encountered difficulties with technology and workflows (which can be addressed and solved – particularly with PHN support). Some GPs’ difficulties with video may reflect negative attitudes to video.
There is research in Australian general practice ‘in the pipeline’ which when published will show that most patients sampled have positive attitudes to video as an alternative to an in-person consultation, and that most patients sampled expect their GP to provide this option. Patients are ahead of GPs on this?
Thanks Andrew for interpreting these changes for us.. I think what this recognizes is that GP’s provide allot of service , with simple sometimes perfunctory or reassuring phone calls and these can be bulk billed. I find it hard to imagine I could go near the level of comprehensive history and examination required for a LEVEL C..by phone I dont begrudge its loss and it would be prone to routing Speical rules for Mental Health are reasonable.
I do think with videoconferencing I provide at least a level b where my interraction is more human and comprehensive an the value of hat service can be privately billed in those that can afford it .However I like to imagine a place where the rebate is adequate enough for GP’s to provide persona;l viable face to face video or phone care but are paid by the patient the true value of our service.And we as a profession have enough compassion and generosity to ensure patients wont get left behind,.When there are enough GP driven organsisation that are empowered and not controlled , like the old divisions, we actually reach equitable service distribution. BUt hey there is no grandstanding or political power to push this.. My summary: of these changes are fair, lets adapt,,make them better with Videoconferencing and make them so valuable that patient would.not hesitate to pay for the service. This should not be another Bulk Billing stick to hit us over the head with. We aim to win the debate by surprising patients with the value of our service every time , consultation by consultation.We must go above what they want and educate them what they need and that’s where you’re value lies. A challenge every consult .
Please comment on the following.
With effect from the 1 July 2021, GP phone service item numbers will be culled, and will only apply to six services: attendances at Level A, attendances at Level B, mental health treatment plan reviews, mental health consultations, and attendances for focused psychological strategies (30-40 minutes, and > 40 minutes).
For attendances at Level A, B, C, and D, 85.1% of phone services were at Level B, 76.3% of in-person services were at Level B, and 71.2% of video services were at Level B.
Conclusion – Phone services are skewed to shorter consultations.
Females were 28% more likely than males to attend an in-person consultation.
Females were 65% more likely than males to attend a video consultation.
Females were 65% more likely than males to attend a phone consultation.
For females, for in-person consultations, the 10-year age-group mode spanned five age-groups, from 25-34 to 65-74 (about 7 million consultations for each age-group). For females, for phone consultations and for video consultations, the modal 10-year age-groups were 25-34 and 35-44.
For males, for in-person consultations and for phone consultations the modal 10-year age-groups were 55-64 and 65-74. For males, for video consultations, the modal 10-year age group was 35-44.
Conclusion – video consultations are skewed to younger patients and female patients. No surprise?
In the period March 2019 to February 2020, there were 142,204,547 GP services for the services reported in this article. All items were in-person, as this period preceded the introduction of the Medicare GP telehealth and phone items. There were 5% more GP services for these items in 2020-2021 (as in-person, phone, and video) than in 2019-2020 (in-person only). So GP services increased in the first year of the pandemic compared to the year before the pandemic.
Hi Rural GP,
I share your dislike, and your doctors’ dislike of phone consultations. However, I believe that they do have a place in GP-patient communication – for low-acuity health issues such as repeat prescriptions and notification of normal results – provided that there are no complexities that would require more detailed review. I think it is reasonable for a Medicare benefit to be payable for these services, but due to their simple and straightforward nature, Level A should suffice. I am not so sure about a fee for a phone consultation for triage to determine the necessity and urgency of an in-person or video consultation. Perhaps only if the triage call does not lead to a follow up consultation?
I think convenience for patients is reasonable in providing a general practice service. This may even lead to improved care if patients are more likely to be enabled to make appointments for preventive activities and chronic disease management. However, as you imply, patient service can become customer demand.
You are right that if there are increased referrals from GPs due to phone consultations, then the costs to the health system will probably increase. The health economics issue has not yet been researched or evaluated.
I believe that video consultations are one way of providing quality general practice. Not exclusively. But possibly a hybrid model with in-person consultations.
Great to read that you want to move to video. Please contact your PHN. They can set you up with Health Direct Video Call as the video consultation platform. It’s easy to use for GPs and patients. It fits in with practice workflows. And it has additional features such as enabling exchange of referrals and images (secure and encrypted). Both RACGP and ACRRM have information on setting up video consultations in general practice.
https://www.racgp.org.au/running-a-practice/technology/clinical-technology/telehealth/telehealth-video-consultations-guide/introduction
http://www.ehealth.acrrm.org.au/
Andrew (ex-rural GP)
Thanks Andrew for this important work
Doctors in our practice universally dislike phone consultations. These are not consults, they are transactions and patients are demanding conveniance and service first . You cant really bill for these services when there is no humanity involved. You cant diagnose General Practice problems. It is mostly ending in poor defensive medicine and thats why so many end up being referred. It will cost us patients and money. I reckon the trend comes from the patients, they will push towards what is easy, they feel powerful and emboldened because they get what hey want, quickly Once again we need to salvage a personal interaction, that is more therapeutic. How can we raise the level of debate without sounding patronising? Our practice wants to move to teleconferencing, charging a fee and no phone consulting , but getting nowhere. We need help .
I am in a low socioeconomic area with an aged demographic. I have managed one video call with a tech savvy patient and attempted one other which failed due to technical reasons. Telephone is great for the multitude of low acuity situations and fine for triage. Video consults via computer slow me down, as our internet is woeful in “the sticks”.
1 in 5 of my patients are home visits due to frailty, blindness, severe heart failure, respiratory failure, cancer, dementia, sever RA, osteoarthritis, autism, and their carers are already stressed and don’t need to organise separate video calls when I am seeing them face to face regularly anyway. The NBN is not very functional for those that have it (we don’t)
The MBS states: ‘Videoconference services are the preferred approach for substituting a face-to-face consultation. However, in response to the COVID-19 pandemic, providers will also be able to offer audio-only services via telephone if video is not available’.
Video has not been available in 97.7% of GP telehealth consultations.
Medicare does not seem to have batted an eyelid in response to the high proportion of services by telephone in lieu of video.
Why has video been ‘not available’?
– GP and/or patient do not have a smartphone, or a tablet/iPad, or a laptop computer, or a desktop computer with audio headset (or speakers and microphone) and webcam?
– GP does not have Health Direct Video Call or Coviu (or other health care video platform), or GP and patient do not have Zoom, or Skype, or WhatsApp?
– GP and/or patient do not have internet access?
– GP and/or patient interpret ‘video is not available’ as ‘prefer to use phone instead of video’?
Any thoughts on this?
A hybrid model of in-person consultations, video consultations, and phone consultations may support and improve access, equity, and care for patients in general practice.
There is a role for phone consultations in general practice, for low-acuity reasons, such as repeat prescriptions, repeat referrals, and notification of clinically non-significant investigation results. Phone consultations also have a role in triage to determine the urgency and necessity for an in-person consultation or a video consultation. Some apparently low-acuity reasons may be too complex for satisfactory management by phone consultation – for example, a repeat prescription for an antihypertensive medication may require a detailed review of cardiovascular disease risk.
I note Anonymous (3)’s perception that doctors (GPs?) have a low threshold for referring patients from a phone consultation to an Emergency Department, and the implication that this may not be appropriate management. There are no published reports on the transfer of patients to ED from GP phone consultations. Is there any research in progress in this area? Perhaps one could examine this from the GP’s perspective. If the GP is not satisfied that their management by phone addresses the presentation safely, then for reasons of patient safety, referral to an Emergency Department may be appropriate. Perhaps if GPs used video in lieu of phone, they could be more confident in their management and in patient safety. Indirect examination is enabled with a video consultation. There is not ‘no examination’. I have described the value of indirect examination by video elsewhere.
Paul, I am sorry to read about your dismal experience with video consultations. I have worked only two half-days per week in general practice for the past year. I have done hundreds of video consultations with patients across the spectrum of general practice. My experience has been positive. Feedback from patients who have had video consultations has been positive. Patients over 80 have had no problems with video consultations. Audio-visual quality has been fine (although patients and I are in metropolitan Melbourne, so internet access and connections are okay). Interestingly, I have had some problems with ‘tech savvy’ younger patients who have occasionally had difficulties in setting up microphone, speaker or camera across their various devices and various connections. They have confidently assured me that there is a problem with my system, and who am I to argue? In those rare situations, we have switched to a phone consultation.
I suggest that a video consultation is more than ‘staring at each other’s face through the screen’. Rapport, engagement, non-verbal language, and indirect physical examination are all enabled by a video consultation. In addition, video calls enable other features, such as secure and encrypted exchange of documents (e.g., referrals, investigation requests) and images.
Paul and I have clearly had different experiences with video consultations, and we have different opinions about their role and utility. Am I an outlier? Is Paul an outlier? Is the truth somewhere in between? We absolutely, desperately need more research in this area.
Using ‘Health Direct Video Call’ (HVC) as the video call platform has made video consultations easy for me and for patients. It is the Australian Government funded version of Coviu. HVC is used in hospitals, health services, and general practices. HVC is free to general practices via Primary Health Networks. The Australian Government has not guaranteed ongoing funding for HVC for general practice beyond 31 December 2021, but the word on the street is that funded HVC is likely to be part of the telehealth model for 2022 and beyond.
I have tried some video consultations using WhatsApp, Skype, and Zoom, but these consultations were more difficult to manage and more difficult to set up. These are business and social videoconferencing applications which have not been designed and developed for health care settings – unlike HVC.
HVC consultations enable GPs to send messages, referrals, investigation requests, patient information, images, and diagrams to patients through the call and this is secure and encrypted. Similarly, patients can send the GP messages and images, and this is secure and encrypted. This could not be done by phone.
HVC also facilitates workflows using a sequence of virtual check-in, virtual consultation, and virtual check-out (billing, next appointment). Video consultations have not created more work for reception at the Clinic where I work.
HVC does not need to be installed or downloaded. It is browser-to-browser web real time communication. All the patient requires is a device (phone, tablet, laptop, desktop computer) with Chrome (although HVC does work with any browser).
I agree with Meredith Hinds. Some patients will be excluded because they do not have the confidence and/or competence to use video technology. Some patients will be excluded because they do not have the equipment or an internet connection (HVC is not bandwidth-hungry).
However, all patients have to do is to click on a link that takes them to the virtual waiting room. HVC ‘finds’ their microphone, speaker, and camera. Patients do not have to set these up.
I agree with Meredith Hinds about compromised privacy in the home setting. I have had consultations with patients who have been in their bathroom, their laundry, their car (parked, private place), and their garage. Not ideal. But private. There are also concerns about women in domestic violence situations who may be unable to access a phone or video consultation without the perpetrator being present.
Video consultations may not be inferior to in-person consultations. They are different. Video consultations have potential advantages over in-person consultations for patients regarding reduced risk of transmitting infection, reduced costs (e.g., travel, parking, childcare, time off work), time saving, and convenience.
I agree with Anonymous (2).
Maureen Fitzsimon notes that her elderly patients will not use video communication, and do not have computers or mobile phones. Video consultations are not the solution for all general practice encounters. However, I have seen many elderly patients quite successfully by video, and these patients have appreciated this as they have had the consultation in the comfort of their home, rather than having to travel to the Clinic. A home visit by proxy? I have also seen elderly patients by video consultation with their relative or carer in attendance – as would often occur with an in-person consultation. The relatives and carer provide the ‘tech savvy’ input, although privacy may be compromised.
There has been virtually no research conducted in Australia on video consultations in general practice. The articles in the literature that I have reviewed are mainly from the UK, and yes, the elderly populations have been considered.
In my review of Medicare data for April 2020-March 2021, I examined the demographics (age-group, gender) for consultations by video, by phone, and in-person. Consultations by phone and video were skewed to younger age-groups and to females compare to in-person consultations. But there was still substantial representation for both video and phone in the older age-groups. I have the charts for this.
Thank you, Antje Vogelsang Sharman, for you comments. A basic laptop or tablet device from Harvey Norman, and a WiFi or mobile data connection will suffice for a video consultation. HVC (vide supra) is designed to be user-friendly at the ‘patient end’. Click and go. It’s also user-friendly at the clinician end. I agree, there is definitely a role for the phone consultation in general practice. We have been using the phone in general practice since phones became available in our Clinics and in patients’ homes. And I believe that such phone consultations should attract a Medicare benefit (the ubiquitous item 91809). Video may be better than in-person if the in-person consultation would not otherwise have happened. Video may be better than an in-person consultation if there are benefits to the patient in respect of reduced risk of infection, time, travel, cost, and convenience.
With fewer patients travelling for in-person consultations, we may make a bit of a dent in general practice’s rather large environmental footprint.
Thank you, Nicolas or your comments as a psychiatrist providing secondary consultations to GPs. I know that these secondary consultations are via HVC. I am surprised that some GPs have opted for phone in lieu of video. I would have thought that most GPs had a smartphone that they could have used for the consultation, or possibly an iPad or other tablet device.
It is likely that many GP Clinics do not have webcams and audio headsets. However, if their computers have enough ‘grunt’ to run Medical Director and similar clinical management programs, then their computers will have the sound card and graphics functions to run a video consultation. Maybe a trip to Officeworks with the business credit card … Reasonable headsets cost about $50, and reasonable webcams cost about $100.
Most GP Clinics will have internet access, either wired and/or via WiFi. There should not be a problem accessing a video call.
Nicolas’s comments raise the issue of using video for communication between health care practitioners, not just between health care practitioners are their patients. An emerging and evolving area.
Interesting article.
As a psychiatrist in regional practice my experience has been that , as has already been noted, many patients don’t have the capability or confidence to use video conferencing. Many don’t have computers or cannot use them, some don’t have mobile phones, and a few don’t have a phone at all. The platforms shouldn’t really be a problem for those with computers, as they are quick and easy to install.
Teleconferencing, whether by phone or video is definitely inferior to face to face consultations, and much gets missed or is not mentioned by patients, but it is much better than nothing at all and it can be useful for patients who have forgotten their appointments. It is definitely more work for reception staff and maybe this is a factor in general practice, with large numbers of short appointments.
Another significant factor limiting teleconferencing , which we didn’t initially appreciate , but was reported by patients was their lack of privacy at home, and their inability to control who else might be in their room or the house.
For a short period in 2020 we were seeing a majority of patients remotely ( never all), but as soon as it was deemed safe, the majority of patients wanted to be seen in person interestingly including patients who had to travel considerable distances.
As a non GP (specialist surgery) TH user, 99% of my TH consults are by video. I recognise that far from all initial and follow up consults are suitable for TH but for over 12 months, in my practice, the low rate of audio- only consults reflects only patient capability with technology, modified occasionally by patient preference.
How about actually examining and treating patients rather than getting paid for telling people over the phone to go to the Emergency department for real medicine.
This issue is killing our Emergency departments
I practice in an area with a very old demographic. Over 90% of my patients are old age pensioners. Many do not use a mobile phone. They rely on family members to do anything on a computer. These are the people who do not drive, are very physically immobile, and most in need of easy access to their GP. They will not, and cannot, engage in video communications.
When we need to see them face to face, there is a thing called a “home visit”, or a carer or relative arranges transport to the surgery.. Do your surveys take this group into special consideration?
While the merits of video consultation may seem obvious, my own experience in establishing telehealth was that the effective refusal rate was too high. Andrew, I am not sure how often you have tried video conferencing with patient, but the successful connection rate with older patients is woeful. It is difficult enough asking them to ensure that they have a charged mobile phone, available to answer, at the time of the consult rather than asking them to log onto a videoconfrence arrangement. They simply can’t cope. In reality, provide you triage presenting complaints to either FTF vs remote consultation, then rarely is there tangible gain in staring at each others face through the screen rather than simply talking, taking an appropriate history and then making a decision to either bring the patient in for FTF consult, or ordering appropriate investigations. In my experience over many months of attempting video platforms for video consultation it was simply too much of a challenge for too many of my patient.
1.
you need up to date either phones or computer screens with camera and audio – for small older surgeries a luxury
2
in GP land we know our patients – normally – very well . straight forward things like scripts IF straight foward – can be done very quickly by phone
3
if you have lots of older patients PHONE is already difficult but so much more would be video re technology on both ends AND pts inability to use properly.
4
you need a secure platform which will be FREE ( and not only saying ‘ will be free until ….. ) otherwise you set the whole thing up and at some stage surprise surprise the surgery has to pay for this service.
and last – video is NEVER better then face to face – nothing can substitute for the human factor in the room
Thanks Andrew, very interesting article and comments. My limited experience in having provided video secondary consults to GP’s in primary care, a pilot initiative via PHN’s, shares some of your conclusions. Quite a number of GP’s I have spoken to opted for a phone call over a Video call, as they did not have the tech platform available. Some of these were in solo practices too. I wonder if this reflects the nature of General Practice and the business model, often on a tight reign, particularly with small practices. State funded services, such as mental health, as well as private specialities, have clear priorities and allocated/available funding including potential staffing who have been very proactive during this early Pandemic, to get the systems going. It may be a different story for a significant number of smaller practices, pressured at the outset to continue to provide services. It’s only now that there is ongoing funding, as well as time and space, to play catch-up on the practice infotech facility front, investing in webcams etc.