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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 Minister for Health stated that the aim of the change is to “support longitudinal, person-centred primary health care, [which is] associated with better health outcomes”.
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.”
In the RACGP media release, and elsewhere, RACGP President, Dr Harry Nespolon, stated:
“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:
- inclusive:
- 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
- exclusive:
- 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.
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Yesterday my telehealth appointment was canceled because I had never attended the clinic in question- now I am left in dire straights as a result!
I know I have a severe urinary tract infection & need antibiotics, but I cannot access them, so I’m rapidly getting worse as time goes on.
I’m sure some GP’s may look down their nose at me ‘for diagnosing myself’, however, I know what I have from the symptoms I’m experiencing, especially since I get severe UTI’s every couple of months (I am currently waiting to be seen by a urologist to find out why these infections are happening to me so frequently) -as I live in a rural to remote area we have very limited GP appointments on offer. the soonest I can get in with my regular GP is 3 weeks time (which I do have booked in, for continuity of care) but I need help RIGHT NOW! I am in so much damn agony that I have tears rolling down my face, what state will I be in after 3 weeks have passed by!? Our local ER is always run off their feet, what I am supposed to do- go & add to their workload (I’m sure if this condition is left for too long, I will become so bad that it will justify me going to the ER to be treated!? Sometimes UTI’s can become dangerous, my mother almost died from sepsis thanks to her also not being able to access GP treatment for a UTI when she first contracted it!
I’m on the disability pension (have been for the last 17 years, & I hold a pension concession card, but apparently that still didn’t make a difference!
I simply don’t have the type of money that is being asked to pay for these telehealth consults.
It is ALWAYS the chronically ill & vulnerable people (especially in remote/ small towns) that suffer from these blanket (one size fits all) rules being implemented!
There is a lot of confusion in Victorian GP Practices over the telehealth eligibility as restrictions are eased. Some clinics are asking for face to face if the patient has not been seen in the last 12 months, others are allowing all consults to be over the phone as we are still in Stage 3 restrictions.
Could you provide a link to where you found the description below? I’ve looked at AHPRA, MBS etc but there is nothing as definitive as what is written here.
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).
I am writing this in anger …
I realize that this is an old thread but would like to share my recent experience with tele health:
Two weeks ago, on a Sunday, I woke up with a fever of 39C and a heart rate of 95, when it is usually 53 – 55, early in the morning. I had a headache, the shivers, was hot and cold. I decided to get a COVID-19 test on Monday, which came back Tuesday morning as negative.
On Tuesday, unable to hold down liquids I “Googled” (!!!) my symptoms, also rang the NSW Health Direct line, and then asked a neighbour to take me to the ER of the local hospital where I was promptly seen by the triage nurse, urine and blood tests were done within an hour and I was in a bed shortly after. As it turned out I had a UTI and an acute kidney infection, high fever during four days in hospital, six intravenous antibiotic drips, including saline drips. I was sent home with a ten-day course of antibiotics and asked to get a referral to see a specialist for further investigations.
So, now home, I rang my GPs clinic, told them my story. Yes, they do have the hospital records, but my doctor does only telephone consultations to first assess whether or not he was going to see me face to face. I told the receptionist that I needed a referral to a specialist and also would like a copy of the hospital medical records, possibly also urine tests, or whatever was ordered by the hosptial. She told me it was only telephone consultations first: “Now, do you want a telephone consultation or not? The next available is on Monday.” (Friday today).
Now, just imagine the situation if I hadn’t “Googled” and hadn’t rung the NSW Health Direct line to talk to a very competent nurse.
This would have been the scenario:
Sunday: High Fever, shivers, headache.
Monday: Covid test, shivers, headache, unable to hold down food and liquids.
Tuesday: Covid test negative, fever, headache and shivers getting worse. Urine dark honey coloured.
Tuesday afternoon: Ring clinic to make an appointment for a telephone consultation in one or two days.
Wednesday or Thursday, if I am lucky: Face to face consultation. Urine tests, maybe blood tests ordered with results probably back by the end of the week, maybe Monday. UTI confirmed. Face to face consultation in another three days and getting a prescription for antibiotics.
I was seriously ill and if I would have had to wait all this time for the diagnosis of my serious condition, I probably would not be writing this letter. What saved me was “Dr Google” and that nurse from the NSW Health Direct line.
Telephone consultations may be the next best thing in remote areas but in cities they ought to be banned! Telephone consultation doctors: There was a reason you chose to be doctors. If you are scared to see patients face to face you ought not to be doctors and do not deserve the status medicine allows you. My respect for General Practitioners has dropped to an all-time low. If I would have to put my trust into a structural engineer or a GP, I would choose the structural engineer.
I question whether Australia has the best health care system in the world. It is certainly the most expensive. Telephone consultation first, followed by a face to face consultation if you’re lucky = two consultations charged to Medicare! This is outright lousy medical care.
What about vulnerable parents that have to attend with a sick child or just for a referral. Stupid rule.
I had to seriously negotiate for a tele health app yesterday. Theyvsaid it was because they had not seen my daughter for 7 months, not even the 12 months as suggested in this article. They didn’t want to allow it. I only wanted her annual referral so she could see her pediatrician.. This from the same Drs that wrote me a medical letter confirming if I get Covid it would result in poor outcome. Yet they were trying to get me to come in anyway.
No vulnerable person should have to go anywhere near a gp. I should not have to wrangle to get a tele heath referral. Im not claiming money despite losing my business of 10 years. All I ask is I am not expected put my health in jeopardy to get a basic medical assistance that does not require an in person visit.
I am being discriminated against by this rule as someone with a Chronic illness I can no longer access a doctor. It seems this rule is to benefit doctors who are paranoid about losing their business to online doctors. Your patients wouldn’t leave you if you were a Great doctor. The only person you can blame is yourself. People wouldn’t be seeking out online doctors if their GP was providing adequate care
‘EXISTING RELATIONSHIP’
For GPs and OMPs, for a telehealth or phone attendance today to be eligible for a Medicare benefit, the patient must have an ‘existing relationship’ with the GP or OMP. The ‘existing relationship’ requirement is defined as one or more in-person attendances with the GP, or with another GP or a Practice Nurse, at the GP’s clinic, within the past 12 months. The criteria are met if the GP or OMP saw the patient at another clinic, within the past 12 months. The criteria are met if, at the time of the previous consultation within the past 12 months, the GP or OMP weren’t associated with the clinic, that is, the GP or OMP weren’t employees, contractors, etc, at the clinic.
For example, a telehealth or phone consultation with a GP or OMP is eligible for Medicare benefits if the patient attended a Practice Nurse or an Aboriginal and Torres Strait Islander Health Worker at the GP’s or OMP’s practice within the previous 12 months.
The exemptions to the ‘existing relationship’ requirement for eligibility for GP and OMP MBS telehealth and phone services are: children under 12 months; patients getting an urgent after-hours service; people who are homeless; people living in COVID-19 lockdown areas; and patients of AMSs and ACCHOs
BULK BILLING FOR TELEHEALTH AND PHONE SERVICES
Telehealth and phone consultations by GPs and OMPs must be bulk-billed for health care card holders, pensioner concession card holders, children under 16, and people who are COVID-19 vulnerable.
(People who are ‘COVID-19 vulnerable’ meet one or more of the following criteria: in self-quarantine or self-isolation related to COVID-19; age at least 70; First Nations’ person age at least 50; pregnant; parent of child under 12 months; being treated for ‘chronic health condition’; and immunocompromised)
The ‘existing relationship’ requirement and bulk-billing requirements do NOT apply to telehealth or phone consultations with Specialists or with Allied Health Practitioners.
Reference: COVID-19 Telehealth Services, MBS Consumer Factsheets, mbsonline.gov.au
Hi Anononymous, 27 July.
Thank you for your comment.
I guess you attended a GP or a Nurse Practitioner (NP) for an in-person consultation at a Pharmacy? The telehealth restrictions don’t apply. You are not required to have an ‘existing and continuing relationship’ with the GP or with another GP at the same Practice (I’m not sure where NPs fit in to this – I think previously attending a Nurse Practitioner would be equivalent to attending a GP at the same Practice. Does anyone know?).
You’re free to attend a GP or NP any number of times, even on the same day, even with the same practitioner (with some limitations). You’re still eligible for Medicare benefits for these multiple attendances.
You received suboptimal care: An on-demand prescription, with no attention to general health, opportunistic screening, chronic disease, or preventive activities. It’s not good general practice, but it’s some sort of medical care.
The changes to the eligibility for the temporary COVID-19 MBS telehealth and phone GP item numbers were introduced, notionally at least, to support continuity of care. The changes were also about squashing the so-called ‘Pop Up’ ‘On Demand’ corporate telehealth services that do not provide in-person consultations. In this respect, the changes will be partially successful, as patients may be deterred from attending the ‘Pop Ups’, due to there being no eligibility for a Medicare rebate for the telehealth service.
If Medicare wants to squash on-demand in-person GP services in pharmacies, it will need to introduce a new tactic.
Hi Anonymous, July 27.
I assume that you’re seeing a GP or a Nurse Practitioner (NP) at the Pharmacy, as Pharmacists cannot prescribe S4 drugs (eg antibiotics).
If the consultation with the GP or NP is in person, then the telehealth restrictions don’t reply. The in person item numbers for a < 20 minute consultation will apply (GP=23/5020, NP=822000). You could visit any number of pharmacies, to see any number of GPs or NPs, without any restriction on Medicare benefits (even on the same day (note AN.07. mbsonline.gov.au)) .
Your description implies suboptimal care: An 'on demand' prescription with no review of general health, no opportunistic screening, no preventive activities, no attention to any chronic disease, and no continuity. Definitely not a model of good general practice. But it is sort of medical care.
The initiative to restrict the temporary COVID-19 MBS telehealth items for GPs to patients who have 'an existing and continuing relationship' is notionally about supporting the principle of continuity of care (albeit with significant loss of access to telehealth for many patients in disadvantaged groups).
The initiative is also about squashing the so-called 'Pop Up' corporate telehealth services that don't provide in person consultations, and in this respect the initiative will be partially successful, as Medicare benefits will no longer apply to non eligible services (although Pop Ups can continue to charge fees – it's just that the patient won't get a Medicare rebate).
The initiative is not, however, about squashing businesses that provide in person consultations. If Medicare wants to cut out benefits for attendances at a 'Pop Up' 'on demand' in person service with a GP in a pharmacy, it's going to have to play a different tactic.
How is it that all telehealth patient consults with a GP requires a recent existing relationship for continuity of service yet the same system states that if I wake up with frequency of urination I can pop down to my nearest pharmacy and get a script for antibiotics . No pre-exisitng relationship, no testing, no follow up.
Hi,
Thank you very much, everyone, for your comments.
Please continue to post comments here. It’s very useful to get others’ ideas and opinions, with the aim of improving general practice and lobbying the Government about the telehealth and phone service item numbers.
Let’s enable vulnerable and disadvantaged people to get access to GP telehealth services and phone services. The changes to the MBS GP telehealth and phone service item numbers exclude many people, particularly vulnerable and disadvantaged people.
To reduce the risk of transmitting SARS-Cov-2 to patients, staff, and GPs, in general practices, let’s reduce the number of F2F in-person consultations, and, commensurate with this, let’s increase the number of telehealth or phone service consultations.
To improve the care that our patients are getting, let’s increase the number of GP attendances for chronic disease management, mental health problems, and preventive activities, in addition to attendances for acute problems.
The latest Medicare data indicate that there has been a reduction in the total number of GP attendances since the onset of the pandemic. Has this phenomenon been analysed? Are patients scared of general practices? Are patients staying away because they ‘don’t want to waste the doctor’s time with something minor’ at a time when they perceive that health services will be overwhelmed? Are there other social and psychological factors here?
How do we get more patients to engage with general practice during the pandemic?
And just to come back to the theme of the article.
Since Monday, many people, including vulnerable and disadvantaged people, are now not eligible for Medicare benefits for GP video or phone services. GPs may continue to provide video and phone services to such people, but GPs will need to charge a non-rebateable fee – which most vulnerable and disadvantaged people would be unable to pay – so they won’t be able to access the service. Not equitable.
And to come back to the theme of my article, large groups of patients, including, significantly, vulnerable and disadvantaged patients, are no longer eligible for Medicare benefits for GP telehealth (video) services, or GP phone services, due to the changes that were implemented by Medicare two days ago.
Dear Dr Khan,
Thank you for your comments.
I agree with you.
As I said in my previous comments, when I see a new patient, I will take a relevant focussed history, and obviously that includes PMH, DH, Allergies, SNAP, Occupation, and relevant preventive activities. I will always check BP as a routine, irrespective of clinical context. Frankly, I probably wouldn’t do a full clinical examination, but I would certainly do a relevant/appropriate general examination (which could be a full examination in some situations), and I would advise the patient to come back or see their regular GP for a full examination if this were indicated. I think you would agree that this is good and appropriate medical practice. This would apply if I were seeing the patient in-person or via telehealth (although BP can’t be checked unless patient has their own BP machine – some do, and direct physical examination is obviously not possible).
Do you do telehealth consultations (video and/or phone)? If you do telehealth consultations, what has been your experience?
I also agree, GPs don’t of course automatically acquiesce to patients’ wants re the patient’s medical care, but we do need to heed their wants/needs re systems of care, eg access (availability of appointments, telehealth etc)
I don’t have evidence to back this belief, but I understand that in Australia, most GPs and most patients do not want to move to a system of registration. Certainly, it’s not being pushed by AMA, RACGP, or ACRRM (although in rural and remote areas, patients typically have ‘registration’ by default as there may be only one practice in their location)
Dear Dr. Baird,
You say ; ” Like all GPs, I have many patients whom I have seen in the past 12 months for one-off consultations because they can’t see their ‘usual GP’ at another practice in the area, or for some other reason of necessity or convenience. I haven’t seen the patient before, and I probably won’t see the patient again. ”
Yes, I too see such Patients.
But, I do not limit my Assessment of this Patient’s Visit to me, for the Purpose of his Visit only.
He/ She may present to me with Acute Tonsillitis & wanting a ‘Sickie ‘, saying he/she is unable to see the Regular GP.
I do not simply examine the Throat & manage it – I take a thorough Past Medical History / note down his / her Regular Medications / any Allergies / Smoking & Alcohol history / Occupation / Family Background / Family History, etc. Plus I do a Full Screening Clinical Examination.
Hence, I may not be his ‘Usual GP ‘, but I have had at least one Face to Face Consultation & a Full Clinical Assessment of this Patient.
In this Situation, I am able to do a Telehealth Consultation much more Competently, as I have some Baseline Assessment of this Patient.
In the absence of such Baseline Assessment, I will be extremely handicapped in providing Competent Care to a totally New Patient, who I have never ever seen before face-to–face.
If GPs start to appease Patients & cater to their ‘ WANTS ‘, as you say, then we would be lowering the Standard of Clinical Care of Patients.
Maybe this is an Opportunity to have Patients Nominate & Register their preferred GP, as in New Zealand & in UK.
I dread the Day that appeasing the ‘ Wants ‘ of Patients at all Costs, becomes the deciding Factor of how we run General Practice in this Country.
Dear Dr Khan,
Thank you very much for your comments.
I note your points about ‘regular GP’ and about ‘continuity of care’.
I absolutely agree. Probably most GPs agree. For a patient to receive optimal care in general practice, the patient should have a regular GP (or at least a regular practice), and there should be continuity of care. These concepts are as fundamental to good general practice as person-centred holistic comprehensive care, and coordination with other healthcare providers.
I wish to respond to your comments, in no particular order.
A practice may wish to look at ways of providing some of the services that patients are seeking when they choose to attend a so-called Pop-Up telehealth business. For example, a practice may set aside a time for short ‘booking on the day only’ appointments for video or phone consultations for issuing repeats of regular prescriptions, or for issuing medical certificates for work purposes, or for discussing investigation results. Even though these are short appointments, a GP can still ask about issues related to chronic disease and preventive activities, and can arrange for the patient to schedule a F2F, video, or phone follow up appointment as appropriate. By providing this service, patients may be less likely to divert from the practice to seek a similar service from a ‘Pop Up’ (which offers convenience and immediacy). As system and workflow issues, it’s up to a practice to determine how it approaches this, if it approaches it at all.
With the implementation of the changes to the MBS GP telehealth service and phone service item numbers, large groups of vulnerable people and disadvantaged people, as described in the article and in the comments, are now not eligible for Medicare benefits for telehealth services or phone services.
The term ‘regular GP’ has no formal definition, no formal recognition, and no formal significance. Patient X may identify Dr Y as their ‘usual GP’, and practice Z, where Dr Y works, as their ‘usual practice’. However, patient X may at any time attend Dr A at practice B, or Dr C at practice D, and so on.
If Patient X last attended practice Z 18 months ago, Patient X will not be eligible for Medicare benefits for a telehealth or phone consultation today with Dr Y, or with any of the other GPs at practice Z. Patient X still regards Dr Y as their ‘usual GP’.
If Patient X attended Dr A at practice B ten months ago for a one-off F2F consultation because there were no appointments available at practice Z (and X just wanted a medical certificate for work), then Patient X is eligible for Medicare benefits for a telehealth or phone consultation with any of the GPs at practice B. Dr A is not X’s ‘usual doctor’, and practice B is not X’s ‘usual practice’.
This seems to be a bit of a paradox. If X needs a telehealth or phone consultation today, X is not eligible for Medicare benefits for this service with X’s ‘usual GP’ or ‘usual practice’ – but is eligible for Medicare benefits for this service with a GP and practice that X only attended once as a temporary one-off. Perhaps X will transfer from practice Z to practice B?
Private general practice in Australia follows free market principles. Patients can choose to see any GP (subject, of course, to availability and access). Patients can choose to have any number of ‘usual GPs’.
Clearly, this is different to the patient registration system (UK) and the patient enrolment system (NZ), where there is one nominated GP for each registered or enrolled patient.
The MBS criterion for ‘a continuing relationship with a GP’ is >= 1 F2F (in-person) attendance with the GP or at the GP’s practice, in the previous 12 months. If this criterion were a diagnostic test, then it would be a test with low sensitivity and low specificity. It’s not good enough. We need a better ‘test’ of continuing relationship.
Like all GPs, I have many ‘regular patients’ whom I have not seen for over 12 months, and who have not attended the practice for over 12 months. Not everyone conforms to the advice to see their GP at least once per year for a general check-up. (We even miss out on patients who attend a pharmacy for their annual flu vaccination in lieu of attending the GP for this.) Since yesterday, these patients are not eligible for Medicare benefits for phone and telehealth services provided by me.
Like all GPs, I have many patients whom I have seen in the past 12 months for one-off consultations because they can’t see their ‘usual GP’ at another practice in the area, or for some other reason of necessity or convenience. I haven’t seen the patient before, and I probably won’t see the patient again. However, this patient is eligible for Medicare benefits for phone and telehealth services provided by me, or by one of the other GPs who work at the same practice as me. Perhaps, as a consequence of getting a Medicare benefit for a telehealth or phone service, such a patient will transfer to me as their ‘usual GP’??
When I see a new patient, whether they will become a ‘regular patient’, or whether they will be a ‘one off’, like all GPs, I’ll get a focussed medical history that’s relevant to their presentation, assessment, and management. However, I don’t have a record of correspondence, investigation results, previous consultations, and previous prescriptions. But that information could – potentially at least – be obtained from My Health Record, if the patient has a My Health Record, and if it has been maintained. Of course, if the patient becomes a ‘regular patient’, I’ll request their records from their previous ‘regular GP’.
I contend that indirect physical examination of a patient by video can be an appropriate clinical examination. Obviously, there are limitations with an indirect examination. A direct (in-person) examination is clearly required for eyes, ears, lumps, chest auscultation, abdominal palpation, sensation testing, reflex testing, and so on. But indirect examination by observation, movement, and manoeuvres, provides useful clinical information. (We probably need to learn new techniques and modified techniques for effective examination via video).
Dear Dr. Baird,
Also, this Comment of yours is very Concerning :
” I agree. Pop-up telehealth businesses are a challenge and a threat to the traditional general practice model. However they are providing something that our patients are want. We can at least look at what’s going on in the Pop-up phenomenon, and see if we are interested in accommodating those ‘wants’ in the way we provide care. ”
You appear to be by-passing the 2 MAIN CLINICAL REASONS for Telehealth now being strictly RESTRICTED to the Patient’s ‘ Regular GP ‘
1. The Patient’s Regular GP has at least once over the last 12 months made a Face-to-Face Consultation & a CLINICAL EXAMINATION has been made by the Regular GP – also, this GP has in front of him / her, a COMPREHENSIVE Record of the Patient’s Current Health Status – the Patient’s Pathology / Radiology Reports / Specialists Reports / Current Medications / Allergies / etc.
2. The Patient’s CONTINUITY OF CARE is being severely compromised.
In the absence of all of the above, a Pop-Up Clinic GP who has not seen the Patient Face – Face & has not CLINICALLY EXAMINED the Patient within the last 12 months preceding the Onset of COVID Restrictions, will be providing a vastly INFERIOR Level of Patient Care & will destroy the very Fabric of Australian General Practice, which today leads the World in Primary Care.
DR. AHAD KHAN
Yesterday (20 July), the Australian Government Department of Health updated its MBS Factsheet for GPs. It’s available from this webpage: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TempBB
Some interesting points.
1. The existing relationship requirement includes attending another medical practitioner (not defined), or Practice Nurse, or Aboriginal Health Worker, at the same practice (or health service) in the previous 12 months – not just attending the same GP, or another GP, at the same practice (or health service) in the previous 12 months.
(Although not explicitly stated, it’s assumed that it’s a requirement that these previous attendances were F2F).
2. Attendances by after hours doctors will be eligible for the video service and phone service item numbers if the after hours doctor participates in the Approved Medical Deputising Service program, the Deputising Service provider has a formal agreement with the practice, and the patient attended the practice for a F2F consultation at least once in the previous 12 months.
3. Patients receiving an urgent after hours service are exempt from the existing relationship requirement (!) – which seems to contradict or override the requirement for a formal agreement between a Deputising Service provider and practice as described above !
4. Patients who are subject to quarantine due to COVID-19 infection control restrictions are exempt from the existing relationship requirement (so this is in addition to patients who live in a Stage 3 ‘lockdown’ area)
5. Patients of medical practitioners at AMSs and ACCHSs are exempt from the existing relationship agreement
6. New patients of a practice and regular patients who have not attended the practice in the last 12 months are encouraged to book their next appointment as a face-to-face attendance. Subsequent services may be provided by telehealth, if it is safe and clinically appropriate to do so.
Medicare defines ‘telehealth’ as an attendance by video, not as an attendance by video or by phone. There are separate item numbers for telehealth (video) services, and for phone services.
Medicare states that: ‘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. There are separate items available for the audio-only services.’
Some questions:
32% of GP Level B, C, and D attendances in May 2020 were by phone. 1% of GP Level B, C, and D attendances in May 2020 were by video. In what proportion of those phone attendances was video genuinely ‘unavailable’? Video is available to any GP and to any patient who has a laptop, tablet, or smartphone. Does ‘unavailability’ include low proficiency (subjective or objective) in using video? Does ‘unavailability’ include preferring to use the phone?
Should there be a higher benefit/rebate for providing a service by video than for providing a service by phone?
Hi Belinda,
Thank you very much for your comments. I am very sorry to read that you feel you have been forced into providing ‘free telehealth’ and ‘charity consultations’. It’s great that your duty of care and beneficence to your patients exceed the imperative of income, but it’s clearly not sustainable.
Your loss is not only the Medicare benefit for the service, but, for patients who are bulk-billed, it is also the loss of the bulk-billing incentive payment (either for COVID-19 vulnerable patients, or for children under 16, or for concession card holders)
Would you charge patients a fee for a telehealth service, even though there would be no Medicare rebate? Many vulnerable and disadvantage patients would be unable to pay a fee.
You have described groups of vulnerable patients who will be disadvantaged by this change in the MBS GP telehealth item numbers, with one or more of: Rural location, chronic disease, mental illness, and immunocompromised state. I agree.
You have also described another very important group that will be disadvantaged by this change: Vulnerable GPs – that is, GPs who are at increased risk of COVID-19, and/or complications of COVID-19, due to medical conditions such as immunocompromised state, chronic respiratory disease, heart failure, diabetes, malignancy, or obesity, or increased risk due to older age. These GPs may choose not see patients for face-to-face in-person consultations in order to reduce their risk of SARS-CoV-2 infection.
I am not aware of any modelling, but it certainly does seem likely that increasing the F2F:telehealth ratio for GP consultations will lead to increased opportunities for transmission of SARS-CoV-2, and therefore increased incidence of COVID-19. Does anyone know of any modelling for this?
Also, if the number of telehealth consultations decreases without a commensurate increase in the number of F2F consultations, then this may indicate that patients are not engaging with general practice when indeed they should be engaging with general practice (not only for acute care, of course, but for chronic disease management, and preventive activities, etc). At this time, surely we need to be making general practice as accessible as possible, particularly in view of the expected increase in mental illness due to the pandemic and its repercussions.
Good luck with patients remembering whether or not they have attended a particular GP or a particular practice within the 12 months prior to a scheduled appointment. For regular attenders, this won’t be a problem, but for infrequent attenders, the date and location of their previous attendances may be less clear. Patients, GPs, and practices can obtain the patient’s Medicare history from Medicare and/or from My Health Record. However, this involves an extra administrative step, and therefore extra time.
Please make sure that if you’re commenting here, you also send an email to ama@ama.com.au and healthreform@racgp.org.au so that our advocates for this poorly thought out change, at potentially the most risky time, know we are unhappy with them.
Yes, the naysayers will continue to deny the validity of GP centred telehealth services provided by their colleagues ;using the derogatory terminology of “pop up” .
FYI my GP triage telehealth service was established 15 years ago and provided free medical consultations to SE qld during the floods. Since then it has been operating as a paid, non rebateable , medical service.
The Covid 19 crisis has changed the general societal landscape for the foreseeable future ;and with that the way medical services are delivered. Speak to the procedural specialists and their patients, whose lives have been so severely disrupted . Speak to the city GP clinics where patients fear to tread.
Yet there are those who seek desperately to maintain a status quo to protect their income and status under the banner of “continuity of care” ,to the disadvantage of the public who so desperately seek and need Telehealth by GPs.
Interestingly ,the majority of telehealth consultations are NOT covid related, but are the whole gamut of medical presentations one would expect in an emergency department.; especially in the after hours period.
We ,the experienced Telehealth GPs are at the frontline of public health. We assess ,diagnose, treat ,reassure ,assist and refer where and when necessary.
People are terrified of covid and each other; doctors are terrified of covid and patients with the remotest symptoms; social distancing is the norm.
The telephone +/- video offers a safe and convenient platform where medical information can be exchanges safely and securely between trained GPs and worried patients.
It just makes no sense to restrict GP provided Telehealth item numbers at this time ; and is in fact adding more cost and danger into our already stretched health care systems.
Some stats….between 5 -8 pm today,I took 15 calls. 2 met the criteria and were bulk billed. 3 were happy to pay the fee; and 10 advised that they would not pay. 2 of the 10 said that they would take their concern to the hospital. one of the paid consults was going to take their child to hospital but did not need to go after the consultation.Another required immediate antibiotic for a developing tooth/gum infection and the other paid consult was diagnosed with early zoster and referred to her GP in the morning for continued management. You do the sums.
The comment below was posted by Andrew Baird, not by Anonymous
July 20, 2020 at 2:17 pm
Patients can still attend a ‘Pop Up’ telehealth service for their medical care – or any GP or GP practice that they haven’t attended in the previous 12 months – it’s just that they won’t be eligible for a Medicare benefit for the consultation … (etc)
My first patient today 20/7/20 -with potential Covid19: Now a charity consultation :
I arranged covid19 testing for and management for his condition but I will not get paid as he previously saw me over 12 months ago
I had to encourage him not to go to work – also now another unpaid community service similar to the covid19 testing !
The second patient had anaphylaxis – After management – I asked if she had seen me in past 12 months at the previous clinic I worked in. She had once so was lucky.
Now there are 2 classes of patients. The ones who know I am doing consultations for no money and the ones who feel lucky as saw me in past 12 months when I was at a clinic (that did not allow me to do telehealth), before I left.
I have an interest in chronic fatigue syndrome and patients with complex illness and receive referrals from naturopaths for people who usually would never see a doctor. Some of these patients are in remote regions.
A country patient and her daughter, both of whom have not met me, phoned and want a consult later today. I have had consultations with them in past few months. They advised local GP does not want to arrange testing.
The daughter lies in bed weak and spasming and twitching in rural area. I will continue free telehealth. I had arranged tests and a physician’s appointment
Another local GP in other town I was advised by his receptionist – does not answer his phone even when is the on-duty doctor after hours for the hospital – I was trying to contact him re a patient with a possible PE
Many of my patients even in Adelaide prefer telehealth where possible as they want to reduce risk of exposure to covid19. Many have low immunity whether due cancer, chronic infections, diabetes and other causes or have chronic health conditions including COAD, cardiac conditions and recurrent anaphylaxis. Some have depression.
Some patients have not seen a local GP in past 24 hr
People will be forced to have face to face consults due lack of affordable telehealth from 20/7/20
There is increased risk of transmitting covid19 in medical clinics as not all patients mention have sore throat or cough
As a doctor with cardiac and immunity issues – the new regulations are impacting on my risks if I am not able to make enough money in telehealth and have to work face to face due to the amount of free work I will be doing.
I do not want to sign a contract with another medical clinic atm nor rent a medical clinic room which could put my health at risk and may also be financial risk due covid19 if in lockdown or people prefer telehealth
Regarding Telehealth – I am not going to refuse providing medical assistance – especially during covid19 pandemic even though I am not getting paid.
I expect to have to do much free work in telehealth from now on
(I have much telehealth training and experience having been trained and worked for Medibank Healthdirect Telehealth Solutions from 2011 to 2015 where there was continual telehealth education, assessments and experience and we took emergency calls and assessed and managed patients phoning from remote and metropolitan areas of Australia – from Rottnest island to Kakadu, Uluru and cities. I am aware of what telehealth can and cannot provide.)
These new telehealth restrictions will impact the public especially the vulnerable, isolated, people who have not seen a doctor recently and people who want to change their doctor
In my opinion these new restrictions in medicare not paying for many people’s telehealth will increase covid19 spreading through the community
If a medical practice is booked up days ahead with their patients’ telehealth appointments, people could miss out on essential medical care as none available via their clinic, if they cannot get free telehealth or cannot afford the paid telehealth.
The pop-up clinics are not particularly affected but will charge more money
I will have to work for no money for many telehealth consultations as I think it is unethical not to treat patients who request consultations (even if not covid19 and anaphylaxis as today started with)
Medicare has been influenced by AMA and RACGP with effects of increasing the income of many medical clinics but an adverse effect on many patients not being able to access the care that telehealth can provide (and some effect on doctors working for free telehealth who are not part of a medical clinic and have been advised to assist the public during covid19 pandemic via telehealth)
Medicare told me I can do telehealth with people in stage 3 lockdown in Melbourne. However as not able to advertise – I cannot see how this is useful to be advised of this
Today is first day of charity consultations as in my opinion is unethical for me to refuse patients who medicare chooses not to cover
While we all agree that the Telehealth “cowboys” need weeding out and that patients having a quality GP medical home is highly desirable, Andrew is right. As those commenting have pointed out, the restrictions will affect a wide variety of people. I would add people travelling, trucking and transport workers keeping deliveries going across the country, the elderly in residential aged care and access to after hours services where your GP is using a third party.
Patients can still attend a ‘Pop Up’ telehealth service for their medical care – or any GP or GP practice that they haven’t attended in the previous 12 months – it’s just that they won’t be eligible for a Medicare benefit for the consultation.
The patient can pay a fee. There will be no rebate. ‘The cost of convenience’ – no need to travel, no need to pay for parking, no need to wait, appointment when suits the patient (within reason), attend from the comfort of one’s home (which, in the present situation, could also be their workplace), and no risk of SARS-CoV-2 transmission,
Worth the $50-80 for the equivalent of a Level B consultation ? (that fee is based on what I have seen from trawling around the web for telehealth fees)
What proportion of ‘Pop Up’ patients would be willing to pay the full fee as an out-of-pocket cost? I guess we don’t know, but does anyone want to make a guess? Clearly not the vast majority of patients who are in financial distress, young people, unemployed, socially disadvantaged people, CALD patients, First Nations’ people, the list goes on. However, patients who can afford this will have this option. As patients who can afford this are likely to be socially advantaged and employed, the ‘Pop Up’ phenomenon in this context would be discriminatory for health care.
Hi Josef,
Thank you very much for your comments from the perspective of a so-called ‘Pop Up’ telehealth business.
You indicate that patients who would otherwise obtain medical care from a ‘Pop Up’ service may be displaced to emergency departments, ambulance services, and after hours GP services, with implications for use of service and cost. However, it’s also possible that they may be displaced back to their usual/regular GP …
It’s interesting that you comment that some of the patients who attend your service do so because they can’t get an appointment with their ‘regular’ GP. Where will they go now? Another traditional family general practice? But that compromises continuity of care.
Some after hours GP services (eg ‘Family Home Doctor’ in SA) provide video consultations after hours – so with effect from today, this will not be eligible for Medicare benefits, unless the patient has had a face-to-face (home visit) consultation with the same after hours service within the previous 12 months. I wonder if the video consultation would be eligible for Medicare benefits if the patient had attended a traditional ‘in hours’ general practice that recommends this particular service for after hours care for its patients? This hasn’t been defined in the new rules. FWIW, I think it would be fair for Medicare benefits to apply to an after hours video consultation provided by an after hours service that’s recommended by a particular general practice, where the patient has attended that particular general practice for F2F consultation(s) within the previous 12 months.
I have no evidence to support this claim, but I suspect that there is at least some good general practice provided in the ‘Pop Up’ domain. It’s not exclusively about ‘on demand’, low-value, ‘fast food’ care, as implied by pejorative remarks and stereotypes.
I don’t work for a ‘Pop Up’, and I have neither the intention nor desire to work for a ‘Pop Up’. That’s just a personal decision. I work at a GP-owned traditional family general practice. It’s non-procedural. I like the practice’s philosophy and the way it works.
Do you have any formal audits or evaluations of the care provided by 1300HEALTH ?
It will definitely have big impact on patients who can’t get proper care . Since COVID situation lots of people working at home and they might have been regular patients of Gp near work for convenience and never seen Gp where they live ( home ) . Sooo they cant access services close to where they are working now even on phone .
Poorly thought through policy. As Dr Goldbaum says, throwing the baby out with the bathwater. Easy to imagine a long term patient of a practice who is fairly healthy and not on any prescription medication and so hasn’t needed a consultation in last 12 months – what is the SINGLE MOST LIKELY thing they’re going to seek medical attention for at present? COVID symptoms. And you’re going to force a face to face consultation under those circumstances????
Well put Andrew Baird. Thorough and subtle. There is valuable information in the popups’ presentations.
Thank you very much for your comments, Ahad, Anon, Rod, and V. I agree with your points.
Just some comments in response.
1. I agree. Pop-up telehealth businesses are a challenge and a threat to the traditional general practice model. However they are providing something that our patients are want. We can at least look at what’s going on in the Pop-up phenomenon, and see if we are interested in accommodating those ‘wants’ in the way we provide care
2. Telehealth – in particular video – is a relatively new paradigm in patient-doctor communication in Australian general practice, and like any new paradigm, there is some uncertainty and uneasiness about how it works, and where it fits. This will evolve with experience.
3. The phone call as a form of telehealth has been embedded in traditional general practice since the phone was invented. We know when it’s appropriate to use the phone for patient care (as you say, results, preventive reminders, triage, minor illness, and so on). We know the limitations of phone consultations.
4. Indirect physical examination is possible with a video consultation: general appearance (the ‘eyeball’ diagnosis), posture, movement, facial expression, mental state, cognitive state, work of breathing, respiratory rate, pulse rate (patients can be shown how to check their pulse, and to call out the pulsations (the GP does the counting)), limb movement, swellings, rashes, spots,…
Some patients have BP machines – even oximeters. Some have pregnancy testing kits. Diabetic patients have glucose meters. Most patients have a tape measure and many have scales and a thermometer.
For example, the combination of work of breathing, respiratory rate, and fever (which can be assessed by video) is more sensitive and specific as an indicator of pneumonia in a child than auscultation of the chest.
You can assess the site of pain – the patient indicates where it is. You can even make an assessment of local peritonism (ask the patient to press the area, and to release the pressure). You can make an assessment of general peritonism (ask the patient to get on the bed, and to sit up). Of course, these are only assessments and indicators, they’re absolutely not diagnostic. I once diagnosed a peritonsillar abscess in a patient by video (slightly muffled speech, swelling around the tonsil, deviated uvula).
5. We may need to rethink the role of physical examination – how the indirect video examination can complement (or even enhance) the direct physical examination in an in-patient consultation
6. Rapport is enabled with a video consultation – GP and patient can see one another, and their facial expressions, movement, posture, gestures, and the ‘non-verbals’.
7. Interestingly, rapport is compromised in an in-person consultation with both GP and patient wearing masks, concealing their lower faces. No masks required (currently) for a video consultation.
In the present pandemic situation with the need for social distancing, we need to be minimising our direct physical contact with patients – obviously, there are situations where this is essential, but there are also situations where there are alternatives (eg via video – see point 4 above)
8. We can look to the UK for some guidance on the use and role of telehealth – where it’s well established. In the UK, general practice also uses asynchronous ‘e-consults’, and webchat.
9. There are some examinations that can only be done in-person: cervical screening test, assessment of lumps, dermoscopy (although wait for an app and device for that), eye examination (also, no good way of checking VA remotely), ear examination, testing sensation and reflexes (although a neurological screening exam is possible via video), and others.
Physical treatments can obviously only be done in person: vaccinations, wound management, etc
As a provider of Telehealth GP triage through my 1300HEALTH Telehealth platform ,I can categorically state that the profession and the Government have thrown out the Baby with the Bathwater.
This cruel and unconscionable decision will not only negatively impact a large number of Australians from all sectors of the community, but also place more pressures on our already crowded Emergency departments and busy ambulance services.
There will be further cost blowouts due to the increase in home visiting doctor visits for those who cannot leave their homes and do not meet the eligibility criteria for medicare telehealth.
Numerous telehealth patients report that they have called the service because they have not been able to access their GPs within a reasonable time, have been referred by their GPs because of Covid security risks, or have been referred by hospital departments to call prior to them attending the A&E.
The new restrictions will particularly affect those Australians who need medical advice and attention in the after hours period when the majority of GP clinics are closed.
I challenge the naysayers to personally experience a session or two ,of providing telehealth GP triage ; not only for the Medical challenges presented ,but also for the patient gratitudes experienced.
This suggestion by the Author, is very concerning :
” 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.”
It will be a sad day if a Traditional GP – i.e. a ” FAMILY DOCTOR ” resorts to ‘ making Changes ‘ in order to come down to the Standards of these Opportunistic POP-UP CLINICS !
The core of a good GP practice is the biomedical side of the biopsychosocial of the consultation.[We are Drs not psychologists, although the counseling side is also very important, especially if a patient goes to a psychologist for a visit and comes back and says,”No doctor,I would rather talk to you and let you help me sort out my life….” Soooo much more can be observed when seeing a patient, walk, talk, carriage of the body, facial expressions, how easy they can get out of a chair in the waiting room, who brought them in and why, not even talking of the patient who is standing, either because he is anxious, there are no seats in the waiting room [bad organisation] or he has a thrombosed hemorrhoid etc etc.
We as GPs have the most incredible ‘computer’ with our hands for examination and our senses for observation. Why would we not use those? I had hoped the days of GPs saying they see if they can consult the whole day without getting out of their chairs, was a thing of the past. I really think these are a good middle road to the telehealth consultation, now that the genie is out of the bottle. I have always phoned patients to tell them their normal results myself, as it is a golden opportunity for health promotion disease prevention.
It is a sad day indeed for our profession when the HUMAN touch which is sooo important, gets lost completely because of the fast pace of living. A family doctor needs to touch, comfort, relieve pain and uncertainty as well as our agenda for treating biomedical disease, please don’t phase that out.
Forcing a face to face contact when we are encouraging social distancing
Unfortunately I think the AMA & RACGP have taken a paternalistic approach appearing to act on behalf of the “patient” without have the proper conversation with the Australian people about the issues Including continuity of care. I am a GP & obviously prefer patients to keep their care within the one practice but also understand that accessibility & convenience can play a part. The restrictions will be problematic for some of our patients (examples consistent with ones listed by Dr Baird) as well as our shared after hours service across our region. We could assume this is an unintended consequence though I feel it represents a lack of vision & striving for effective partnerships between doctors & their community.