AMA submission on Connecting Health Services with the Future: Modernising Medicare by Providing Rebates for Online Consultations

The AMA has reviewed the Department’s discussion paper ‘Connecting Health Services with the Future: Modernising Medicare by Providing Rebates for Online Consultations.’ The AMA welcomes the Government’s decision to fund online consultations for referred specialist consultations and general practice support and infrastructure.

The AMA notes that the Government’s policy document ‘Connecting health services with the future’ also provides $50 million to ‘expand the GP after hours helpline and include the capacity for the helpline to provide online triage and basic medical advice via videoconferencing’. Given that the technology and training requirements for both these initiatives will be similar, the AMA would like to know the status of the implementation of the helpline initiative, and how it will be integrated with the online consultations initiative.

Online consultations have an important place in the delivery of health care for patients who have geographical difficulties in accessing referred specialist services where the doctor considers an in-person consultation is not clinically necessary. This type of consultation should not, however, replace care where the doctor considers an in person consultation is necessary in order to provide the best care for the patient.

Medicare items for online consultations should not be limited to video consultations; otherwise the patients most in need of these types of services may not receive them.

The discussion paper contemplates that there will be optimal specialties and practice models for online consultations. The AMA believes that the best use of online consultations will be determined over time through the exercise of medical practitioners’ clinical judgment. As with current MBS items, the treating doctor should determine when a particular type of service is clinically appropriate for the treatment of the patient.

The development of Medicare Benefits Schedule (MBS) items for online consultations should take into account that online consultations may:

• be utilised by all medical specialties to enhance the care they provide to patients to optimise patient convenience and timeliness of care;
• be clinically relevant in a very wide range of situations, not necessarily limited to rural, remote and outer metropolitan areas; and
• often constitute only one part of the episode of patient care that will also include telephone consultations between the local general practitioner and the specialist, and between the patient and the specialist.

To maximise the utilisation of online consultations in clinically appropriate circumstances it is important that the relevant MBS items do not artificially restrict the communications technology that medical practitioners may use to provide care to their patients. The MBS items should be drafted broadly to enable treating doctors to use their clinical judgment to determine when an online consultation is clinically relevant for their patient and the clinically appropriate technology to use to provide the service.

It is also important to recognise that technology is evolving rapidly, and may support a range of more advanced remote medical consultations that do not require a visual component. Accordingly, the MBS arrangements should be drafted as broadly as possible to avoid restricting the type of online consultations that will attract Medicare benefits.

Funding grants for computer hardware, software and an internet connection with sufficient speed and data allowance will be essential to increase take up of online consultations by specialists and general practitioners. The MBS fees for specialist online consultations and general practitioner attendances must also incorporate the costs of ongoing maintenance and necessary upgrade costs. Given these particular costs will be driven by the IT industry and not the health industry, MBS fees should be properly indexed to reflect this.

MBS Items

As noted above, there are many variables that will influence how and when a specialist will consider an online consultation clinically appropriate for their patient such as what type of physical examination might be necessary, the patient’s ability to travel and whether the patient will need a general practitioner or other health care provider to attend with them. There will likely be greater take up of MBS items for online consultations if the item descriptors are non-specific and allow the medical practitioner to use his or her clinical judgment about how and when online consultations are clinically appropriate. For example it would be an artificial barrier to take up if the item expressly required the attendance of a general practitioner.

Equally, the MBS items should take into account work done by both the specialist and the general practitioner to provide follow-up care arising from the online consultation. The online consultation model will introduce new workflow for medical practitioners. Prior to, or after an online consultation, specialists may be sent images, video or audio files relevant to the patient (eg, picture of eardrum, audio of heartbeat) that they will need to review. In many cases, after the online consultation the specialist may need to have further discussions, or email correspondence with the patient and/or the patient’s general practitioner. Both the specialist and the general practitioner may also need to make calls or emails to pathology and diagnostic imaging providers, allied health care workers, or pharmacists in order to manage patient care and treatment remotely. If patients require referral to a local health care provider, the specialist may not have a personal knowledge of providers within traveling distance of the patient and need to spend some time determining to whom to refer the patient. Patients may also respond to specialist and general practitioner emails with questions and observations that require a response and/or further action. These services could be accommodated by individual MBS items so that the Department can monitor utilisation.  Alternatively, these services could be included in the MBS item for the online consultation, with an appropriate loading in the fee, in the same way that aftercare for surgical procedures is included in the fees for surgical items.

Where there is no clinical need for the specialist to be able to see the patient, MBS items for non-visual online consultations and even telephone calls will avoid unnecessary additional costs of video consultations. These discussions will directly support the remote care model facilitated by online consultations and form an integral part of the episode of care, particularly for patients with chronic and complex conditions.

In the case of no-shows or late cancellations by the patient, specialists and general practitioners should be able to bill an item equal to 50 per cent of the MBS fee for the consultation to cover their lost opportunity costs and administration costs. Specialists and general practitioners will have incurred administrative costs in booking the consultation, and may also have to travel to another health facility to attend the consultation. Additionally, they will have lost the opportunity to see other patients or complete other work during this time.

In time, other online tools will support and enhance the level of care that can be provided remotely. To support online consultations and deliver an integrated eHealth system MBS items will need to be developed for reviewing history and notes on the personally controlled electronic health record.

To facilitate the provision of a comprehensive eHealth system to rural and remote patients, Government will need to take strong leadership and ensure that adjunct measures to support the effective provision of care are put in place:

• many patients will require a prescription for medication as a result of an online consultation. It may be inappropriate for the specialist to direct a general practitioner to write a prescription for the patient. Accordingly, online medical consultations will need to be supported by technological and legislative frameworks that provide for electronic prescription transfer.
• the referral of a patient to another medical practitioner as a result of an online consultation needs to be supported by a nationwide health provider registry. This will ensure the specialist and/or general practitioner can identify the best practitioner for the patient’s needs in a location with which they may not be familiar.

Specialist Consultation

The MBS fees for the initial consultation and the subsequent attendance for online specialist consultations will need to cover the following costs of providing the service:

• follow-up telephone consultation between the specialist and the patient
• follow-up telephone consultation between the specialist and the general practitioner
• follow-up telephone or email correspondence related to the management of the patient
• travel to an online consultation hosted by another health facility, eg a hospital.
• extra time to conduct consultations necessitated by the online format
• set up time
• hi-speed and large data usage allowance broadband costs
• hardware and software maintenance and upgrade costs
• ongoing ‘help desk’ support from an IT service provider
• staff training to operate equipment and manage online consultations
• administrative costs of scheduling online consultations

As mentioned earlier, follow-up telephone and email services could be covered by individual MBS items so that the Department can monitor utilisation.

As specialists will be at a remote distance from the patient, new arrangements will be required for specialist billing.

Given that the patient will not be attending the specialist in person, practices will have to make greater use of electronic Medicare billing and payment facilities. As part of this, legislative requirements will need to be amended to allow patients to use an electronic signature to assign their benefit to a medical practitioner.

Where a specialist chooses to charge the patient a fee that is higher than the Medicare rebate, the most efficient and convenient arrangement would be to allow patients to assign their Medicare benefit to the specialist by electronic means, which would enable the patient to pay the difference between the doctor’s fee and the Medicare rebate by electronic transfer to the specialist.

General Practitioner Attendance

The MBS items for the service at the patient ‘end’ of the consultation should be available for an attendance by a general practitioner or where that doctor has delegated the attendance to a practice nurse or aboriginal health worker if he or she considers it is clinically appropriate.

If a general practitioner attends an online consultation, and the specialist directs the patient to seek, or patients seek themselves, a follow-up consultation with that general practitioner, in many cases the most practical arrangement may be to conduct that consultation straight away. Accordingly, the MBS arrangements should allow this consultation to be billed on the same occasion as the item for the general practitioner’s attendance during the online consultation.

We envisage that the general practitioner’s participation in the online consultation may be fractured, and include periods where the general practitioner is either asked to leave the room or not required to be in the room. Therefore, the MBS items for the general practitioner attendance should accommodate the total aggregate time they spent on the consultation.

Accordingly, the AMA proposes that MBS items for online attendance by a general practitioner should be time-tiered.  Because it is hard at this stage to predict the amount of time general practitioners will spend with patients during online consultations with specialists, we foreshadow that time-tiered items will need review in the future. 

In addition, the Medicare arrangements will need to cover the following fixed costs of providing the online facility (regardless of the time the general practitioner attends the online consultation):

• follow-up telephone consultation between the general practitioner and the patient
• follow-up telephone consultation between the specialist and the general practitioner
• follow-up telephone or email correspondence related to the management of the patient
• general practitioner or other staff travel to an online consultation hosted by another health facility, eg a hospital.
• additional administrative workload to co-ordinate and book patients, general practitioners, and specialists for online consultations.
• set up and shut down of the online consultation by the medical practice providing the service;
• hi-speed and large data usage allowance broadband costs
• hardware and software maintenance and upgrade costs
• ongoing ‘help desk’ support from an IT service provider
• staff training to operate equipment and manage online consultations

Alternatively follow-up telephone and email services could be captured with individual MBS items so that the Department can monitor utilisation.

Infrastructure

Medical practices that choose to provide patients with facilities for online medical consultations will incur significant start-up infrastructure costs. Funding grants for these upfront costs will make the business decision to offer online medical consultations financially viable.

The AMA is of the view that costs for the hardware and software required to enable online consultations should be provided through funding grants to specialist and general practices and other health facilities such as hospitals that provide video-link facilities as envisaged in the discussion paper.

While many general practitioners already have computers and internet access in their consulting rooms, it is unlikely that many online medical consultations will take place at the general practitioner’s desk. Many practitioners will also need to upgrade their internet plan to a higher speed with a larger data usage allowance. To accommodate the range of online consultations, most practices will need to set up a dedicated area and computer for video-link up. General practitioners, and specialists who already have computers for clinical practice will also need to invest in additional technology to enable effective online consultations, including appropriate web cameras, remote camera control, software, microphones and faster internet connection.

The capital costs that should be funded through grants for participants in online consultations include:

• computers
• web cameras
• microphones
• headsets
• digital cameras
• software
• Information Technology services to maintain the equipment
• fit out of a dedicated equipment room at the patient end
• room hire or purchase

Fee Setting Process

The Department has not made clear how it will approach the task of setting the MBS fees for the online consultation items. The AMA looks forward to further information about and involvement in the fee setting process for the online consultation MBS items as getting this right will be critical to acceptance and take-up by the profession.  The AMA would be happy to work with the Department to identify the contemporaneous costs of providing online consultations for medical practices.

Online consultations should be used only as an adjunct to normal medical practice. We look forward to the Government’s close consultation with the AMA and the medical profession, especially rural doctors, to ensure that this initiative provide the maximum benefit to patients living in rural and remote communities. The AMA would also like to see a corresponding commitment to attracting and retaining doctors in rural and remote communities to complement these important measures.