17 July 2020
BREAKING: government makes two good calls in one year
If there could be a silver lining to the disaster that is COVID-19 (there probably can’t) it is that with no place to hide the government is generally being smart, practical and efficient in how it is managing the crisis.
This approach has led it to make decisions that hint at a greatly improved care environment for patients and, perhaps, the working future for GPs.
If you think about it, it’s hardly a coincidence that when push comes to very hard shove, the government has made decisions that promote better operational efficiency and delivery of care in general practice – and which have been nowhere near as scary or seismically budget-busting as anticipated.
Of course, most of those decisions have been centred around telehealth, which isn’t an all-encompassing solution to better delivery of GP services into the future. But it’s a very big start and it certainly has GP advocates like the RACGP and AMA presidents into far more significant positions of influence and trust where it counts in Canberra.
Modern pyramids of healthcare
State governments remain almost wholly obsessed with monolithic, bright, shiny and digitally transformed – read horrendously expensive, low ROI and frequently dysfunctional – hospitals.
Hospitals for state governments have become a little like what pyramids were for the pharaohs: iconic megastructures that you can’t miss (particularly during elections), and which are meant to be a statement of wealth, power and prosperity, but which are political vanity projects, born of a system which is failing dismally to manage health upstream within the community. They too will take a long time to fall or be torn down so they will be studied with awe in the future. Not awe in the sense of wow, what a great idea; more wow, what a really dumb idea given the context of healthcare back then.
Acute care is and will always be a critical component of our healthcare system. And the people who work in acute care are as amazing, hard working and dedicated as any in primary and allied care. It’s just that the way hospitals are currently positioned, funded, structured and managed is hugely out of whack with where our system needs are heading and we are making almost no political headway into addressing the problem.
In fact, we are building hospitals the way Tassie’s Hydro Electric Commission kept maniacally building dams in that state in the mid 80s, even though there was clearly no return left on doing it. The HECT moved away from its core purpose of electricity distribution and generation as the organisation became stocked with more dam builders than electricity people. If it hadn’t been stopped when it eventually was, Tasmania would not be the major ecotourist destination it is today, and would be short its major source of state income after taxes. It would also be mostly under water.
This isn’t a problem that is going to go away soon. Healthcare needs are shifting sharply away from acute care towards longitudinal chronic care, but our federated health system is well out of whack in its funding priorities. GPs are the secret to the management of this rapidly evolving new world, but in the current setup, it’s been all hard yards trying to balance state versus federal funding signals to achieve any meaningful change.
State governments have virtually no political upside in spending their money on smaller, more agile establishments with close links to local primary health communities, rather than monolith hospitals. There are no meaningful funding signals between federally funded primary care and state-funded tertiary care. In that vacuum, hospitals almost occupy the status of pork-barrelling in election strategy terms.
With this said, COVID-19 has done a lot to put the spotlight on the general practice sector and just how effective it can be with even a few minor … OK, major tweaks such as introducing MBS rebated telehealth.
Two good decisions in a row?
The federal government doubled down this week in a spectacular run of good decisions and started restricting much of rebated telehealth to a patient’s own GP, as it clearly should be for good longitudinal health. For many the decision may have seemed reasonably obvious: there was an emerging swarm of telehealth companies, both pop-ups, and MBS jury-rigged existing outfits, which were mobilising in all sorts of ways to harvest low-hanging consults from a GP sector where many practices were not prepared or financially well enough off to defend themselves.
The decision prompted several of these outfits to come out and protest that the decision was bad for patients. There is what’s bad for patients, however, and what is merely less convenient for patients, and like home doctor services, some of these telehealth outfits were clearly offering convenience. In a stretched healthcare system, patient convenience is not a first priority, no matter how much the internet age seems to want to make consumers all-powerful.
In a slightly bizarre attempt to lobby against the changes, one particular telehealth outfit actually told Australian Doctor this week that the government’s move to restrict services was a “bricks-and-mortar protection model for GPs” and that her outfit wasn’t actually chasing revenue, they were chasing better patient outcomes. That’s despite this group declaring a 200% increase in their patient base this year (wonder why?) and the fact that the decision will immediately impact their numbers downwards by 20%.
If I’m a shareholder of that company, and the CEO is claiming publicly that the revenue implications of telehealth rebates is not a factor in her thinking, I’m selling.
The nice twist to this story is that for once, GPs are on the right side of the decision by government.
This isn’t to say that the CEO of this telehealth company doesn’t have some good points to make. Some established telehealth operations are good and probably an important part of the ongoing make up of a well balanced system into the future, including the ability to claim rebates for patients who aren’t calling their normal doctor. For one thing, lots of low-income patients often don’t have a normal doctor.
It’s just nice that for once, the government is on balance favouring GPs in their unfolding plans, not well funded interest groups or the tertiary or pharmacy sector. Perhaps that particular telehealth company will one day get some ability back to rebate telehealth, but in the meantime, favouring the general practice sector as you test and iterate is a good strategy for the government, and one they clearly recognise as effective.
Overall the decision by the government to keep iterating on telehealth, under cover of COVID, is really smart. Even if things go woefully wrong, which they aren’t likely to, whoever makes that decision isn’t going to be crucified as they might have been in the past.
Under the cover of COVID, now is the time for the government to make hay: do all the testing and fine-tuning they can on the healthcare system to understand how best telehealth can work after COVID-19. They have several get-out-of-jail-free cards to play if they get themselves into any trouble.
Just as we aren’t about to turn on Scomo for spending too much money on protecting jobs across the country, the government isn’t likely to cop any flack for blowing out the MBS while attempting to make the system more efficient during this crisis.
The most complex issue is the structure of funding, in particular outcomes versus fee for service. Telehealth reaches into this complex area.
If telehealth continues to be fine-tuned to the point where the government is comfortable to keep rebated telehealth operating in general practice and in outpatient services for hospitals, are there any other funding signals they could test now that might lead to even greater efficiencies?
Maybe, for example, more efficient community-based healthcare, hubbed as it should be around our community GP network?
The RACGP and hay
It’s not just the government that should be taking advantage of COVID to make hay. The RACGP and its new CEO and president might take the reasonably large hint from the feds, grab the baton handed them by Dr Harry Nespolon, and get a little more pushy upstream while the decision makers are actually listening.
The next year is the best chance the RACGP might ever have had to be more influential in the future of the GP sector at a government level. We just need a new CEO and president with the ability and will to take a bit more risk.
More data on telehealth from the front line
While on telehealth (when aren’t we these days?) we have some interesting new data from the HealthEd Pulse Survey, conducted earlier this week by our partner HealthEd during one of their clinical webinars. We asked attendees for an updated view on income generated by telehealth, telehealth consult number trends and trends in the type of telehealth being conducted. The data is relatively good as it is based on responses from 661 healthcare professionals, 518 of whom were GPs.
Face-to-face consults aren’t picking up a lot yet with nearly 70% of survey respondents saying that they are seeing fewer or a lot fewer patients in person still compared to prior to the crisis.
But the overall number of telehealth consults has dropped quite a bit against April, when the crisis had most patients in lockdown.
Interestingly use of the telephone, at 85%, as the major means by which GPs are conduct their telehealth, hasn’t moved in any meaningful way from April where it was 90%.
Of the technologies most used for the remaining 15% of video based calls, by far the most used was Zoom, at 33% of all video-based calls. Skype and Facetime come in second and third, then there is a variety of, presumably, bespoke secure systems offered by vendors through the major booking engines and otherwise.
The takeaway here is that secure, built-for-purpose GP telehealth still has very low usage and penetration. That’s either because these systems aren’t agile or cheap enough to compete with the phone and products like Zoom, or they simply aren’t installed in enough practices with enough GPs trained on them.
That Zoom is so well used with no security issues so far (even though vulnerabilities exist) might say something about how our obsession with security can be sometimes misplaced and have very little return for risk mitigation.
That the phone is still being used so much is interesting for everyone and needs a deeper dive to see what lies beneath the statistic not moving much.
It’s not as clear cut as many video telehealth vendors are currently arguing. Obviously the phone is quick, effective and available as a technology. Intuitively most people believe video is a much better consult, but the high percentage of phone consultations might reflect how GPs can most efficiently (and still safely) deal with their patients. This is somewhere where the government needs to do more investigation and testing moving forward.
Some good news?
Incomes are recovering steadily and GPs are adapting reasonably well to the crisis, though most remain financially stressed.
There’s a long way to go in this crisis, but the trends in this data on incomes and use of telehealth are all pointing to general practice adapting to the new world in a manner which prior to the crisis, many would not have thought possible. And if telehealth keeps going the way it is at the moment, the future may actually be brighter.
Some other very surprising survey results from HealthEd Pulse: apparently GPs love working for corporates!
Postscript: A short note on the people who build dams and hospitals
In my non-illustrious journalistic career I once was the editor of an electrical engineering magazine and a spent a lot of time with people in the Hydro Electric Commission of Tasmania, most of whom were dam builders. I have very fond memories of those times as these people were highly motivated, dedicated and fun to spend time with. I watched underground spillways being built and was in awe of what they were creating. They were proud of what they did and they did it really well.
It wasn’t their fault that what they loved doing and wanted to keep doing was probably not the best way forward for Tasmania past a certain point in time.
In a not-too-dissimilar way I spend quite a bit of time these days with people who help build hospitals, particularly those involved with the digital side of building them. Like those dam engineers, some of the people planning and building our hospital networks are highly accomplished professionals who do admirable work, and, who, much like those dam builders, are pragmatic , intelligent and highly skilled professionals.
Nothing in this article is meant to detract in any way from these people’s skills, experience, character and accomplishments. They are some of the most skilful and dedicated professionals I have ever reported on. I’m just not entirely sure that those that direct them from above shouldn’t take those skilful and dedicated professionals and point them in a slightly more meaningful direction in terms of our future healthcare infrastructure needs.