Remove ‘blanket preference’ for video telehealth: Review

A blanket MBS recommendation to prefer video telehealth over phone should be dropped, according to the committee tasked with reviewing telehealth services in Australia.
 
The shift in tone, which the RACGP advocated in a submission earlier this year, is contained in a draft report into telehealth by the MBS Review Advisory Committee (MRAC).
 
It advises changing a current MBS Telehealth Principle – one of 10 put forward in 2020 – that states telehealth items ‘should prefer video over phone’.
 
Instead, the MRAC says existing evidence is not enough for the ‘blanket preference’ and recommends a change in wording that promotes GPs offering both phone and video consultations.
 
‘Video should be encouraged over phone where it will provide a better patient and/or clinician experience,’ the suggested revision reads.
 
Noting feedback that there is ‘no discernible difference in outcome’ in many types of consultation, the MRAC says variations in access to technology ‘can mean telephone offers a better experience for the patient and/or provider in some circumstances’.
 
It concludes the choice should come down to clinical judgement.
 
‘Therefore, the MRAC considered that clinicians should weigh factors and choose the most clinically appropriate modality for each consultation,’ it states.
 
In its submission to the review in July, the RACGP had cited a systematic review of evidence by Bond University, which reported that telehealth, either by phone or video, ‘appears to provide equivalent clinical outcomes for many types of clinical encounters, particularly for ongoing clinical care’.
 
An update to the Bond University analysis, which was commissioned by the Department of Health and Aged Care (DoH) and incorporates more recent studies, has also been published alongside the MRAC report.
 
‘This update has strengthened several of those conclusions, and not reversed any,’ the Bond University researchers state.
 
They also say analysis of 16 studies comparing telephone and video conferencing found ‘no major differences’ on clinical and cost effectiveness for a range of different conditions. However, they note the studies contain ‘moderate-to-high’ risks of bias and are only relevant for ongoing care of patients with chronic conditions.
 
Addressing the analysis as a whole, they said the reviews ‘provide a good basis for where telehealth is and is not clinically effective’ but highlight ‘significant gaps that warrant further primary research and synthesis’.
 
It is a conclusion echoed by the MRAC, which says more studies with extended follow-ups are needed before firm evidence-based recommendations can be reached.
 
‘Despite these research limitations, the MRAC considers it self-evident that video consultations more closely approximate face-to-face consultations than phone consultations, as they give clinicians access to both verbal and non-verbal information,’ their report states.
 
‘This makes video preferable or necessary in some circumstances, such as with paediatric patients, when diagnosing conditions with visual signs, and whenever observation of the patient is critical.’
 
Mental health telehealth services are one example where video consultations should be preferred, it says, noting it is ‘often important to be able to observe the patient’.
 
However, among its 10 recommendations is a push for some telephone services to be reintroduced for patients receiving continuing care, although the MRAC does not give more detail beyond citing ‘GP services with a known clinician and “subsequent” consultant clinician services’.
 
Longer phone consultations were stopped last year, with the college calling for their reinstatement as part of a permanent telehealth model.
 
More broadly, the MRAC analysis sums up the significant impact of telehealth since its widespread implementation, reporting that GPs account for the vast majority of telehealth consultations. The committee says the post-pandemic implementation has led to approximately a 10% increase in the use of general practice services, while noting that GPs on average tend to use video less than other clinicians.
 
Of the total telehealth consultations claimed by GPs in 2022–23, less than 5% were by video, the MRAC states.
 
Other MRAC-recommended changes include making permanent a temporary exemption to the 12-month rule for bloodborne virus and sexual and reproductive (BBVSR) telehealth, and doing the same for GP mental health treatment items. The committee cites access for vulnerable populations as the main factor behind their proposed change.
 
However, it recommends dropping a temporary exemption for GP non-directive pregnancy counselling services on the basis of the BBVSR change being put in place.
 
It also advises ending a similar exemption for nicotine cessation items. The MRAC cites MBS data suggesting the existence of that ‘appear to focus solely on telehealth nicotine cessation’, with a typical ‘episode of care’ for the MBS items being one consultation. This, it says, ‘did not align with expectations of clinical management of nicotine dependence’.
 
The MRAC also noted that PBS data did not reveal any change in the dispensing of PBS nicotine cessation therapies after the introduction of the specific GP telehealth items.
 
The MRAC comprises 17 members, including clinicians, academics, consumer representatives and health system experts, as well as a DoH medical adviser.
 
Its draft report on the implementation of telehealth is open for review until 6 November.
 
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