Telehealth billing restrictions cause financial pain

4 minute read

The government's announcement that gap payments could be charged for telehealth provided cold comfort for rheumatologists

Earlier this week, the federal government announced that gap payments could be charged for telehealth appointments – but that patients with chronic health conditions would still have to be bulk billed.

The announcement has brought relief to many practices that have seen face-to-face appointments all but evaporate during the COVID-19 pandemic.

But it provided cold comfort for rheumatologists who are struggling with the sudden loss of income.

“As it currently stands, the lifting of restrictions to bulk-bill the COVID-19 telehealth item numbers are not going to be very helpful for rheumatologists, because it comes with huge caveats,” said Dr Irwin Lim, a Sydney-based rheumatologist, director of BJC Health and the editor of Rheumatology Republic.

“I still have to bulk bill commonwealth concession card holders (this is fair and would be what we would do) and patients who are more ‘vulnerable’ to COVID-19.

“The definition used for ‘vulnerable’ is so broad and includes persons at least 70 years old, parents who have a child aged under 12 months, people who are being treated for a chronic health condition and those who are immune compromised.

“When you look at this, with the strictest interpretation, it would mean rheumatologists might have to bulk bill every single patient we see!”

Associate Professor Helen Keen, a rheumatologist at Royal Perth Hospital and Fiona Stanley Hospitals, said the telehealth item number was a great initiative, as it allowed people with chronic health issues (who might be at risk of poor outcomes, or of catching COVID due to advanced age or immunosuppression) to access health care.

“It prevents unnecessary movement, of people on public transport through medical facilities, and sitting in waiting rooms,” she said.

However, telehealth was bulk billed, so it represented a significant reduction in remuneration for many specialists, she said.

“I am not spending less time with a patient on the telephone/telehealth than I did in person,” said Professor Keen.

“The consultations are often long, as we can’t access non-verbal clues in conversation, that aid in the gathering of the history,” she said.

“Trying to get a person to explain where their pain is for example, is quite difficult if they can’t point to it. The descriptor ‘fingers’ is quite vague to a rheumatologist trying to work out what structure us actually hurting.”

Professor Keen said she prefers not to see new patients by telehealth.

“We may do a telehealth visit, and then decided an in-person review is needed, which is not ideal and creates some duplication of work,” she said.

“In all honestly, there is not much I like about telehealth,” said Professor Keen.

“It creates an artificial barrier limiting the patient doctor interaction, It makes history taking more difficult, and clinical examination essentially impossible. The simplest task, such as getting a document signed becomes onerous.

“It does allow us to get our patients their drugs, and whilst enabling some sense of safety to many of our patients. However, I don’t think telehealth is generally good medicine, and should be reserved for extra-ordinary situations, but that is where we find ourselves.”

Steve Hall, a rheumatologist and adjunct professor at Monash University in Melbourne, said he is now using telehealth for 97% of his appointments.

“My conclusions/concerns include:

1. We are going through a period where rheumatology training is likely to be rather compromised. I doubt if the registrar experience in rheumatology at this time is equivalent to usual training. The College and the ARA needs to give some attention to this and supplementation beyond the theoretical may need to be developed.

2. Consumers often like this pattern of health care delivery. It saves a lot of time for patients. No travel. No long waits in clinics or doctors’ offices.

3. Moving to extensive bulk billing may well change how patients expect to be billed moving forward. Learned behaviour is very powerful

4. Agree that consultations move to a different skill set. Some consultation simply cannot be done “tele” and there will have to be a limited number of face-to-face consultations available for injections, more examination etc.

The adaptations are highly unlikely to be temporary and I expect that many aspects will become our new norm.”

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