18 September 2020

The Witch, the Lion and the Telephone

Clinical Telehealth

Mixed and cheesy metaphors for this week’s op ed will be Wizard of Oz, Alice and Wonderland and, see heading.

We definitely have left Kansas, we’re never going back, we’ve already taken a few steps down a deep and labyrinthine rabbit hole, we won’t be back out for some years to come probably, and no one has much of an idea of where this thing – telehealth – is taking us, or ends. That is at once exciting and scary. Just like a fairytale.

GPs, in particular will need to put their seatbelts on.

How you integrate telehealth moving forward into your workflows will determine both how much you get paid, and how much you improve the quality of your patient experience and care in the near term. For the next couple of years it could hardly be more important to pay attention to and engage with the machinations and politics of telehealth.

The only problem is, we are all flying pretty much blind at this stage.

Notwithstanding there are no roadmaps or precedents for us to work from – there is scant international evidence or data that compares to where we are – our starting point is a pretty good one politically.

On Thursday night Health Minister Greg Hunt said telehealth was “a revolution in healthcare delivery”. That sounds like it’s here to stay.

Let’s not reflect on the question, “If it’s so bloody revolutionary, why did the government steadfastly ignored it for the past decade?” and just appreciate that the Department of Health is on board and wants to make it work.

Having been forced to use telehealth for COVID, they – whoever “they” within the mysterious and dense organisation that is the DoH actually are – have established a very pragmatic starting position and a set of operating principles, so far.

If you aren’t quite clear what these are yet, it might be summarised as follows:

  • Having been forced to try telehealth because of COVID, and having cover of COVID emergency funding, we’ve got a lot of data now that indicates that it’s not the monster we thought it could be.
  • There is now enough data for us to commit to using it long term (i.e., hey this works pretty well actually and might even form the basis for a new way to do healthcare more efficiently) but nowhere near enough yet for us to yet understand what the most suitable settings should be.
  • We like it, we are understandably still very worried by it, we need more time, and more data so let’s press the “another six months for now” button, again under cover of COVID, to give us more time and data to think and analyse.
  • In the face of not understanding the levers and subtleties here, let’s keep doing what we’ve never been game to do before, and “iterate” … taking one small step forward at a time with an ability to pull back if it goes awry.

That’s an almost incomprehensibly sensible stance for a government department to take on such a major transformation in such a short time. But COVID has uncovered a lot of latent talent in government recently for being smart and pragmatic when it needs to be. It can happen.

But GPs will need to somehow work and engage with what is still a very opaque organisation.

Does anyone know just who inside the DoH is making any of these important decisions around telehealth? Is it a committee of experts? If so who is on it and why? Who gets veto and on what grounds? Do they take much outside counsel? How?

For a department contemplating the most important structural change in healthcare operation and funding for a generation, our understanding of how these decisions are being made inside DoH is surprisingly poor. It is just like that castle holding Sleeping Beauty hostage at the heart of the dark and impenetrable forest described in last week’s op ed.

If you want to get to whoever the druids are who make these decisions, you have to work hard around the edges talking to people who know people. That, or you know someone who you think might actually be one of those on the inside, if not actually on a committee (if there is a committee).

Like perhaps Dr Steve Hambleton, who was deputy chair of the MBS review, and must be a good insider candidate. Hambleton is very smart, open to discussion, but also very politic in what he actually says, understanding possibly that if you let too much go, you get cut from the team. It must be a hard balancing act.

A big part of being able influence the DoH on telehealth will be whether the new RACGP leadership can re-establish the sort of trust and working relationship that past president Dr Harry Nespolon managed to achieve in Canberra.

It will not be a matter of the new emissary from the RACGP, having been handed the presidential baton, picking up where the old one left off. The new president, and perhaps CEO, will need to spend much of their time re-establishing rapport and trust in Canberra to ensure GPs are properly at the table at perhaps the most important moment in the recent history of general practice.

At its heart, telehealth is about pay and care standards.

Dr Karen Price, and possibly the new RACGP CEO, will be going through the front door, which is the hardest way in – their connection to the committee in the castle in the forest that decides is via the Minister and the Secretary of Health, which isn’t the easiest avenue for getting your message across. Better to have links already into the insiders on the committee.

Regardless, all interested parties face the same issue. There is no data, time or ability to properly assess the likely effect of key settings like differential pricing signals, upgrading existing technology infrastructure, establishing proper standards, accreditation, training and so on.

All of this has been in place for face-to-face consults for decades. None of it is in place for telehealth.

So the first thing everyone is going to need to accept is that it’s going to be a long and complex journey over time.

So far our settings on telehealth are very basic and understandably pragmatic. Six months more of data on these settings won’t actually tell us much more than we already know. It will give everyone time to think, though.

We will need to be able to step out into, and at times quickly retreat from, things like pricing signal changes, technology standards and compliance demands, patient-doctor relationship protocols (when and where it has to be your own doctor), and so on.

Let’s take one element that is likely over time to be controversial yet very impactful if managed correctly – pricing signals.

Bulk-billing requirements for GPs will be dropped as of October 1 as a part of the six-month telehealth extension, but it’s unclear yet whether the increased bulk-billing incentive might be dropped in parallel with this move. That’s a simple pricing step that the DoH can test in the next six months.

The issue with this is likely to be that most GPs aren’t set up to easily add the workflow of taking a credit card payment on top of their telehealth consult, so many will not in the short term change. This is because most are not using a telehealth setup that is integrated with their patient management system (PMS) yet. Or even one that isn’t integrated but easy to use off the cloud such as Coviu or Medinet.

Best Practice has three integrations available and Medical Director has its own integration, so it’s not like the applications aren’t there. GPs and their practice managers have just not got around to using them. This is despite Medicare numbers showing that several non-GP specialist groups and allied healthcare groups are embracing purpose-built systems, especially video, at relatively high rates so far.

Having a system that integrates with your PMS or other workflow is going to be fundamental to the telehealth revolution in the short to mid term.

The DoH will likely have to look very quickly at incentivising GPs with something like ePIP to install and start using such a system. If it doesn’t want to spend more on ePIP it should shift all that My Health Record (MHR) ePIP incentive into helping practices establish good telehealth systems as the sector productivity gains would be enormous.

Using a purpose-built system, that can schedule patients, opt between audio and video, track calls for audits and billing, talk to the PMS system for summaries and notes, and most importantly, perform differential payments, will open the door to all sorts of productivity gains for patients and doctors, and allow the government to collect data and analyse the utility of telehealth far better.

Leaving pricing aside, the underuse of available technology by GPs so far, is the biggest sleeper for the DoH at the moment for impact on system safety and efficiency.

Among GPs, currently only 3-5% of all telehealth is video, the rest phone, 99% is bulk-billed by phone, and most phone is not operated via a purpose-built telehealth system but via the doctor’s hard line or mobile.

The situation is a result of subsidised telehealth being introduced completely unexpectedly.

But if you stop and think about how inefficient and potentially unsafe manually processing most of your consults using your own phone is, you start to realise how important it is that GPs and the government ensure that available purpose-built systems are installed and used.

Think about how much time is wasted by GPs, who might be doing up to 60% of their consults over the phone (more in Victoria), and having to process everything important about the consult manually in parallel to the call – notes into the PMS, script writing, Medicare processing and so on.

Now that bulk-billing has gone you can add gap payments via credit card, manually. That adds up to a lot of time being wasted, which defeats a lot of the upside of telehealth for many GPs in the short term. It’s money they can’t afford to waste. It even threatens to turn some GPs against the idea of universal subsidised telehealth.

Without integrated purpose-built technology that complements the doctor workflow and allows data to be generated for the DoH to regulate and iterate on policy settings, telehealth could easily get itself down a dead end in the rabbit hole that it would be hard to get out of. It would also prevent more sophisticated and important attempts at pricing.

Pricing in business and service delivery “is the exchange rate you put on all the tangible and intangible assets of your business”, according Patrick Campbell, CEO of a major subscription software and pricing consultancy in the US. Of course, that’s looking at it from the perspective of a GP in this system. The government looks at pricing with different intent and motivation of course. It will almost certainly use pricing as one of its major tools to mould the trajectory of telehealth over time.

One pricing issue already on the DoH radar is differential pricing between phone, video and face-to-face consults.

The position of the AMA and the RACGP has always been that a GP’s time is worth the same no matter what they are doing. So five minutes on a phone needs to be paid at the same rate as on a video call or in person.

At first this makes sense. Why should we value a GP’s time differently depending on what activity they are undertaking? We don’t do that anywhere else in health.

But there is logic.

Perhaps because 20 minutes on a video call, in many situations, is fundamentally going to be a lot better for everyone, than spending the same 20 minutes on the phone. Or, as the DoH secret decision-making committee (druids?) might easily conclude, because phone is so much more open to abuse and overuse, so a different price to video, set at the right level (lower obviously), might send a sensible signal for phone versus video usage. After all, before COVID, GPs took a lot of phone calls and communicated digitally in a whole lot of other ways, and got paid nothing for it.

A scale of some sort, maybe with attached circumstances, doesn’t seem an unreasonable way to think about how they use phone. Or for that matter if we start extending the use of telehealth into other technologies, such as real-time or part-time virtual care, or the simple use of text-based technologies, or even intelligent learning bots.

You can see just how many twists and turns we are already looking at here. The potential for efficiency and patient care is oh so high, but so is the complexity and possibility of stuff-up. And we are going to start to do all of this without any meaningful data or precedent to understand the likely effect.

What else could be on the table early on?

  • Time-based payment of video calls like we have for face-to-face consults?
  • A simple differential between a video call and a phone call?
  • Even, differential payment on phone calls?
  • Geo restrictions on phone and video

It is understood that the druids inside DoH are keen to explore differential pricing between video and phone as a starting point to controlling cost, the easy abuse of phone, and promoting the almost certainly better quality of consult that comes with using video.

You can’t blame them.

But how this is likely to pan out between the DoH and the various colleges will be telling.

It’s going to be hard for the RACGP and AMA to argue against a strong signal that promotes video consults over phone consults. They may argue for some sort of edge incentive through PIP instead to keep their “time costs the same” position, but you know that a transactional pricing signal will change behaviour with a lot of certainty. You just don’t quite know what that behaviour will end up looking like.

Which is why all parties in this brave new adventure (down a rabbit hole, through a cupboard, into and out of a tornado into a different land, whatever) are going to have to take a very deep breath, stand back, and consider very carefully how they engage with each other in the coming months and how, as a professional group, GPs are going to lead, and approach, change.

Telehealth is a technology opportunity into which COVID has fortuitously driven us.

The rewards for getting it right over time here are almost incalculable for government, patients and GPs. But the risk in complexity of change and politics are very high given how we got here, which has been wholly unplanned.

Mistakes are inevitable.

The old rules of negotiating, engagement and risk management are no longer in play.

As state and federal governments realised for a just a little while during COVID, normal operating procedures aren’t an option.

We’re not in Kansas any more.

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