Response to the draft report of the Post-Implementation Review of Telehealth MBS Items
6 November 2023
Conjoint Professor Anne Duggan
Chair, Medicare Benefits Schedule Review Advisory Committee
Department of Health and Aged Care
GPO Box 9848, CANBERRA ACT 2601
Delivered by email to MBSContinuousReview@health.gov.au
Dear Professor Duggan
Thank you for the opportunity to comment on the Medicare Benefits Schedule (MBS) Review Advisory Committee’s Draft Report of the Post-Implementation Review of Telehealth MBS Telehealth Items (the ‘Telehealth Draft Report’).[1]
People With Disability Australia (PWDA) is Australia’s national peak disability organisation, representing the 1 in 6 Australians with disability. We are the leading disability rights advocacy and representative organisation and the only national cross-disability organisation representing the interests of people with all kinds of disability. We are a not-for-profit and non-government organisation, and our membership is comprised of people with disability and organisations primarily constituted by people with disability, including the PWDA Board and many members of our staff.
PWDA values the MBS Review Advisory Committee (MRAC) conducting a post-implementation review of telehealth services and welcomes the recommendations on the appropriateness of their future use. We agree that telehealth recommendations must strike the correct balance between access, quality and safety of medical care.
In particular, following the recent release of our COVID-19 Position Statement, we note that for some people with disability, telehealth is critical to avoiding COVID-19 infection and the recommendations need to reflect this.
PWDA broadly supports the Telehealth Draft Report recommendations, in particular the following: However, PWDA have the following comments regarding the implementation of the recommendations:
- Recommendation 1 – to adopt the revised MBS Telehealth Principles
- Recommendation 2 – re-introduce some telehealth as an option for patients receiving continuing care, such as for GP services with a known clinician and subsequent consultant clinician services’
- Recommendation 3 – explore using MyMedicare or options other than telehealth to remunerate clinicians for the additional administration required to manage complex cases
- Recommendations 5 and 7 – retain MBS eligibility for telehealth for mental health treatment items and bloodborne virus and sexual and reproductive health (BBVSR)
- Recommendation 8 – expand telehealth eligibility to nurse practitioner and midwifery MBS items; and
- Recommendation 9 – require initial GP consultations to be face-to-face and allow telehealth for subsequent GP consultations and specialist consultations.
However, PWDA have the following comments regarding the implementation of the recommendations:
Continuity of care and COVID-19 control
Recommendation 2, to reintroduce telehealth as an option for patients receiving continuing care, does not account for the needs of people with disability who use telehealth to reduce their chances of contracting COVID-19. In line with our COVID-19 Position Statement, PWDA recommends exempting people with disability, and/or those who are immunocompromised, from the ‘Existing Relationship Requirement’ so that people with disability can access telehealth appointments regardless of whether they have attended the medical practice in person in the past 12 months.[2]
Further, Recommendation 2 rests on the assumption that it is possible for people to secure and continue seeing the same health practitioner. However, the shortage of general practitioners,[3] the need for locum rotations, and fly-in-fly-out medical services may make this impossible in parts of Australia, especially rural and remote areas. Therefore, people with disability in these areas need to have an option to continue accessing telehealth as part of their healthcare.
Training
The Telehealth Draft Report acknowledges the need for technical user skills to use video conferencing for telehealth. However, health practitioners need training to develop their skills so they can use questioning to replace some of the much richer information they would gather in a face-to-face appointment.[4]
The rapid rollout of telehealth during the COVID-19 pandemic made it clear that patient history-taking skills are different in face-to-face versus telehealth methods. There is a risk that practitioners will have less opportunity to identify ‘red flags’ and signals they would ordinarily gather in other ways during a face-to-face appointment, and so training to overcome this is crucial in deploying telehealth.
The training must also support health practitioners to engage accessibly with patients with disability who need communication supports, to ensure that a high-quality history is taken, and the healthcare provided is not impacted by avoidable barriers.
Health workers with disability
Additionally, the Australian health workforce includes people with disability for whom telehealth may pose barriers to providing an adequate level of healthcare. For example, poor vision and sound quality are likely to disproportionally affect people with vision and hearing disabilities. Therefore, training is needed to ensure healthcare professionals with disability are not excluded from using telehealth methods with their patients. Examples include training healthcare professionals with disability on how to use live subtitles, or augmenting telehealth technology with other applications used for diagnostics or other health-related purpose.
Continuing professional education
PWDA recommends the development of a Continuing Professional Development unit of competence, that builds skills in the provision of accessible telehealth appointments and use of accessibility features, specific instruction on communicating accessibly with people with disability when gathering health information and providing health care services via telehealth, and to address barriers that telehealth may pose for both consumers and healthcare professionals with disability. PWDA recommends this unit of competence is codesigned with people with disability.
Appointment duration
PWDA also recommends making funding available for longer telehealth appointments for people with disability. This will support people with disability who have complex health needs and/or access requirements sufficient time to meet their needs. PWDA recommends allowing access to an MBS item for longer duration consultations once the provider has completed the telehealth training recommended above. This would provide an incentive to deliver quality healthcare that better suits the needs of people with disability.
Patient-end support
PWDA supports Recommendation 10, to reintroduce GP patient-end support, where the patient is provided supports to enable patient participation in a telehealth appointment.
People with disability who use communication aids, translation programs, and/or support for decision-making, may need patient-end support from an appropriately trained nurse or allied health worker. Therefore, PWDA calls for Recommendation 10 to include this type of telehealth support.
In addition, while we broadly support telehealth, COVID-safe home visits continue to offer an opportunity to ensure high quality healthcare for people with disability especially for those who do not leave their homes. Therefore, we recommend the MBS include an enhanced appointment payment to ensure commercial viability of home visits, especially for new diagnoses, to complement telehealth measures.
Call for further study
Lastly, PWDA is particularly concerned by the identified shortcomings of the current available data as identified at page 14 of the Telehealth Draft Report.[5] More research is needed to examine the impact of telephone, or video-based telehealth, on the accessibility, quality, patient experience and healthcare outcomes for people with disability.
We recommend that a study be undertaken with the health workforce (allied health, primary care nurses and general practitioners, and specialists) and people with disability to:
- gather experiences of those who have used telehealth, or who have attempted to do so but for whom this has not worked. This should include challenges, benefits, impacts, cost, and accessibility issues (in the broadest sense, including but not limited to software, access to the internet, costs incurred and avoided, and the use of adaptive communication tools)
- examine any differences between the use of telehealth and video conferencing
- compare the use of telehealth for diagnosis or initiating new treatment, with use in follow-up care
- quantify and examine adverse events, and compare these with face-to-face care
- ensure that the perspectives of health workers with disability are included; and
- examine the use (or decision not to use) telehealth by health workers and patients for whom English is not the primary language.
If you wish to discuss this letter, please contact my Senior Manager of Policy, Mx Giancarlo de Vera, at giancarlod@pwd.org.au or via telephone on 0413 135 731.
Yours sincerely
Sebastian Zagarella
Chief Executive Officer People with Disability Australia
[1] MBS Review Advisory Committee, Telehealth Post-Implementation Review Draft Report, September 2023, last accessed 24 October 2023 https://consultations.health.gov.au/medicare-reviews-unit/mrac-draft-report-post-implementation-review-of-te/consultation/download/
[2] People With Disability Australia, COVID-19 Position Statement, 21 September 2023, last accessed 1 November 2023, https://pwd.org.au/covid-19-position-statement/
[3] Australian Government, Strengthening Medicare Taskforce Review Report, December 2022, last accessed 30 October 2023, https://www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf and the Australian Medical Association, AMA Report projects “staggering” GP shortage, 25 November 2022, last accessed 24 October 2023, https://www.ama.com.au/ama-rounds/25-november-2022/articles/ama-report-projects-staggering-gp-shortage
[4] Benziger CP, Huffman MD, Sweis RN, Stone NJ. The Telehealth Ten: A Guide for a Patient-Assisted Virtual Physical Examination. Am J Med. 2021 Jan;134(1):48-51. doi: 10.1016/j.amjmed.2020.06.015. Epub 2020 Jul 18. PMID: 32687813; PMCID: PMC7368154. Last accessed 24 October, 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368154/?utm_source=makeanapplike
[5] MBS Review Advisory Committee, Telehealth Post-Implementation Review Draft Report, September 2023, last accessed 24 October 2023 https://consultations.health.gov.au/medicare-reviews-unit/mrac-draft-report-post-implementation-review-of-te/consultation/download/