What Broadband Giveth Health Taketh Away

I was a big fan of the government’s National Broadband Network when it was first announced as part of then Prime Minister Kevin Rudd’s election promise in 2007. I am not an engineer, so to be honest I wasn’t sure that the suggested architecture was the best option. I left that to the technical guys who understand those things. They seemed to agree that technically the model was a good one, even though it probably was the most expensive way to do it.

I was a simple doctor, who recognised the value of technology in improving the quality and efficiency of our healthcare system. I attended the big launch event in 2009 at the University of NSW that discussed the value of the new system to the various aspects of society. I even took part in the NBN launch in 2010, I was the doctor on the other end of the home telehealth service talking to the Prime Minister and selected dignitaries to demonstrate how the NBN could be used to deliver healthcare services straight into the home of older Australians.

My excitement was not because data could spew done the line at megabits per second, or that we could have crystal clear video at any location My excitement was because I believed that the government was producing a logical coherent strategy for collaboration across the various government sectors to combine and provide an integrated solution for healthcare that took advantage of the enhanced communications possibilities provided by the optic fibre in the ground to 93% of the Australian population, and the wireless and satellite services to the rest.

Today, much of that excitement has gone.

In 2010 the new Prime Minister, Julia Gillard announced that her government would make access to doctors easier by subsidising telehealth consultations. This was not a new idea. We had been talking about telehealth consultations for many years, and to be honest telehealth had actually moved on quite a bit from when we first started talking about the use of video conferencing as a way of extending the already strained healthcare workforce. However, it was a positive move, a small step forwards towards an integrated technology enabled healthcare system.

The Medicare items for telehealth consultations came into effect in July 2011. They were a bit disappointing, as they only subsidised specialist consultations, not the much more common, and often more important primary care or GP visits, and totally ignored allied health and nurses. My eternal optimism kept me positive. It’s a first step, and over the next couple of years, as they realise the benefit of linking people up with the technology they will continue to develop the reimbursement. The Department of Broadband Communications and Digital Economy (DBCDE) produced a great vision video which showed allied health workers and doctors speaking to their patients in their homes. This wasn’t what the new Medicare items paid for, but I assumed that the various departments must have spoken to each other, and this was a vision of where we were heading.

My excitement peaked on January 22 2012 when the minister for health and the minister for broadband were on stage together talking about how the NBN and modern medicine would work together to provide great new services to patients in their homes, and they would foster this with a $20 million grant to support such projects. It was nirvana to geek doctors like me, DBCDE and Department of Health and Ageing with the folk at NBN Co. working together to give Australia world class telehealth services which would make things better for us all.

Then reality set in. Within months of the launch of the well intentioned, but not perfectly designed telehealth consultation items, the folk at Medicare were working out how to make it a bit more difficult to bill them for such items. To be fair, their original incentives were a bit over the top. $6000 up front and a 50% bonus for using telehealth were pretty generous, and smart doctors decided that they were eligible for those benefits. Maybe some were a bit over zealous, but they met the requirements set out by the government, and they delivered a service to patients. Was it clinically useful. For most patients, it probably was. For some maybe not so useful, and for some it probably was not useful at all. However that is part of learning what works and what doesn’t in medicine. We learn that way during our early years as junior doctors, and hopefully there is a system in place to catch the things that slip through. The same occurs for early attempts at telehealth. They were not all going to be the most efficient and effective way to deliver care, because everyone involved was on a learning curve.

However, the folk at Medicare decided that it was to easy to use this new fangled video conferencing stuff, which in the consumer world many companies were offering for free, so they added some new clauses. The doctor and the patient had to be more than 15 kms away from each other, and the payments became staggered. Essentially it added a couple of new steps for the doctor to go through to use telehealth with their patients. We all know that doctors have lots of spare time, and the one thing they love is extra paper work, so it really shouldn’t be a problem. It seems some doctors were deemed to have abused the system, they provided the service to patients who should have been able to go and visit the specialist in person. Sitting in a waiting room full of sick people, and getting your children to take the day off work to take you to the specialist visit is definitely better than making the telehealth service available to all Australians.

Then it got worse. Come the Mid Year Economic and Fiscal Outlook on 21 October 2012 there were a slew of new restrictions added to the telehealth reimbursement from Medicare. First only Australians deemed to be remote, that is not live in major cities and outer metropolitan areas were now eligible. The problem is that is not where most Australians live, so the bulk of the Australian population cannot access these services. Even worse, those areas that were eligible were actually the least likely to be able to use the service at present, because the connectivity required to deliver the service doesn’t exist in those areas.  Just in case that wasn’t enough disincentive to stop the greedy doctors from billing the code, since their potential “customers” had now been decreased by a very significant percentage, they had to justify the new equipment, the required training, the required support services, and the associated disturbance to their workflow for the relatively rare rural patient who needs their service.

The net effect according to the budget papers is a saving of $134 million over 4 years. There was not a lot of detail on how that saving is calculated, but the only way you can save money in Medicare is to not have doctors bill for the service. Well of course they won’t bill the telehealth consultation, it is too much work for too little return for them. So if the patient still wants to see a doctor, and remember in this case it is for a specialist consultation deemed to be necessary by their GP, they will just have to find a way to get to their practice. That the doctor can be reimbursed for, so Medicare still pays the doctor to deliver the service, just with a different billing code. The patient has to get there, spend a big chunk of their day, and probably that of a family member, because visiting a specialist is not something you want to do alone, to get there. Hopefully by then they are not too stressed out by the travel and associated anguish to spend some quality time with the doctor, and get back home. Assuming they get to do this in a reasonable time, there may not be any detrimental effect on their health. It may be a bit too hard, so they will postpone it, in the knowledge that if things get bad enough they can call an ambulance and go to the local hospital, who will arrange for a specialist to see them in the emergency department. That is probably a much better use of the budget money, and everyone enjoys a ride in an ambulance and a couple of days in a hospital bed.

In the mean time the roll out of the National Broadband Network continues unabated. The promise of broadband delivered video consultations with your healthcare workers remains a major benefit for the NBN. As long as you can pay for that service out of your pocket, and you can find a doctor who provides it then that probably still makes sense. Spending government money to lay the fibre to allow this to happen, and then saving the money you would spend to actually deliver a service over the fibre seems to make sense to some.

So my initial excitement that the government had a coordinated plan for the integration of technology into healthcare and other sectors of society has been significantly dampened. We seem to have two government departments at odds with each other about the value of telehealth. We have some innovation happening around the edges, but most of them have moved on to new things, because health and broadband, despite its promise doesn’t make business sense to anyone. The folk at NBN Co. tell us that new applications running on the network will revolutionise healthcare, and education, and many other things. However as many of these things are social benefits funded through our tax dollars through the government, it seems there has been a significant effort by the relevant departments to slow down its uptake, just in case people decide they like it and want to use it.

I still believe telehealth is a tool with great potential to improve the efficiency and effectiveness of our healthcare system. It has been shown to work when it is allowed to. However if it is not allowed to grow, if clinicians are not allowed to experiment to work out how to best use it, and if extra paper work is thrown in front of clinicians who want to use it, then it will fail. It will be another expensive failure, not because the technology doesn’t work, but because we have turned it into yet another silo in our already highly fragmented healthcare system. The NBN, the great communications tool which has the potential to integrate so much cannot defeat active disincentives which entrench policy that supports the fragmentation.

Yet another silo is not what healthcare needs, but if telehealth is only reimbursed for a small fraction of the community, only in certain circumstances, and only with certain providers, it becomes a very small not sustainable silo. At the same time we will invest billions to connect the whole nation to a network that has the potential to unite us, but not health, and probably not education, and the list goes on. We will have the world’s best network of non-connected silos in the world.

That is why I am no longer very excited by the National Broadband Network.

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10 Responses to “What Broadband Giveth Health Taketh Away”

  1. Kenny O'Neill Says:

    Seems very short sighted to me and they can’t see the wood for the trees, you need someone to quantify the cost of a ‘normal consultation for them’ but even then probably won’t make a difference. Is there use of telehealth in the non-Medicare sector?

  2. Greg Mundy Says:

    There is lots of use of telehealth in the non-Medicare sector (eg in Psychiatry and Geriatric Medicine) and in fact that is where it started, and will likely continue. I agree with George though that it won’t prosper in the fee-for-service sector, which is the core of our primary health system, without the right fee structure. That has been the history of health IT in Australia at least in the General Practice arena.

  3. Denis Tebbutt Says:

    The crux of the matter is not the technology, that only sustains the new process. What we are missing is a visible advocate for transforming the very core of the healthcare process upon which payment occurs; the ‘Consultation’. We also have an expectation that collaboration is occurring to ensure that value is realised at the point of care and delivered to the new health consumer, trying to modify the current model of payment to accommodate a new way of doing things is the big issue here. Too little trust going around at the moment resulting in the frustration that George is right to share.
    This does remind me of that great episode of ‘Yes Minister’ just take a look

    As for the reality, we are seeing great progress as a result of the maturing technology in this sector, but more importantly the excellent work of clinicians to change their processes for the benefit of all. Pity we don’t have anyone working out the Value Proposition and feeding it back to the Commonwealth, there were plenty of good examples of leadership in this regard at the Telehealth conference in Melbourne staged by HISA this year. We must collaborate on this and all keep up the pressure

  4. Lindsay Oates Says:

    I agree with Greg and I also see the use of telehealth a lot more in the aged and community care sector. I see staff using telehealth a lot more whether in the aged care facility or in a home. I also see a a greater number of older people taking to this particularly in towns where there are no doctors or where access and transport is difficult. Health IT will continue prosper, but only slowly in the current fee for service area.

  5. Peter Hitchiner Says:

    The NBN solution to affordable, ubiquitous broadband has been to spend the money on the pipes and forget about the funding of the bits on the end. Yes, NBN is an expensive and technically sound solution but it does have similarities with the hospital with no patients (substitute Broadband for Hospital). The problem has been that NBN expenditure has been disproportionate without recognition of the big picture. George, don’t give up!!

  6. Steve Says:

    I saw a great example of how telehealth can lower costs of medicine.
    In this case the examinations were done by a community nurse, via an auroscope linked to a laptop recording the exam. The exam was then sent to a specialist (via DVD/snail mail) and any required treatment was documented.
    The specialist did not need to be flown to a remote community.
    The community was attended to by one of their own.
    Examinations were performed much more quickly, resulting in many more seen/day. Diagnosis was performed at a hugely increased rate.
    Cost was much lower, as in this format, most cannot be billed to medicare!
    In this case, NBN would have allowed uploading of the video and more immediate viewing. Real time viewing would both not be required, increase costs (infrastructure and time) and produce a less desirable outcome for the patient.(in this case, Aboriginal children)

    The main thing I learned was that not all telemedicine means a different thing to different people.

  7. Pete Says:

    Great article George, I think you’ve hit the nail right on the head and I agree with you 100%.

    Without the intention to make this comment sound like a Cliché or politically motivated, I can tell you that unfortunately this is what you get with a socialist (pseudo communist) government that wants to look like they are doing something for the population/country by giving with one hand (giveth), and then at the same time taking back with the other (taketh away). The people in the know (the minority – Doctors, Specialists, the people who will actually be using the technology) know exactly what is happening but the majority (everyone else) have no idea and just believe the Gillard government’s BS propaganda, totally unawares of the reality of the situation. Unfortunately this is the reality in Australia with the current Labour government (socialist/communist) that don’t really care about the population per say, they just want to look like they are doing sometihng in order to get more votes. This may sound harsh but it is the reality.

    Additionally this is also the result of the wrong people assigned to positions of decision making. How can one explain the reasons for applying the handbrake on such a superior technology (and extremely costly) and idea? Its simple. The people that make the decisions, don’t have one single constructive idea in their head about what they are doing. Thus they make an absolute mess in the process by applying rules and regulation that will null/void any benefits of this technology.

    What is the solution? Its simple (but not easy).

    - Find the right people (several, not one or two) who have experience (not just a uni degree), but real experience and use them as consultants.
    - Look at what and how other countries have implemented similar telemedicine technologies so we can either copy a working version or make it even better after critical analysis.
    - Listen to Doctors and specialists who will actually be using this technology, ask them for their ideas and input so that the best possible outcome is obtained.

    One might say that this scenario might be pipe dreams because we have a socialist/communist Labour government that is only interested in votes and retaining power, not in the interest of the country. But at least if a discussion is out in the open like this one, and more Doctors and Specialists apply pressure to the government (as they are the ones who will be using the technology, not some dimwit politician) we might get somewhere, eventually.

    • georgemargelis Says:

      Thanks Pete
      I don’t think it is evil intention as much as poor understanding of the consequences of poor implementation.
      Closer collaboration with the healthcare sector and the vendors would have helped.
      It is not too late to correct the problem, but the first step is in admitting that they got it wrong.

  8. jannaass Says:

    I enjoyed this take on telehealth and whatever. I was “lucky” to go and learn how to use the video equip intended for the rural hospitals to connect up with the specialists at the main tertiary one.. yes we found a power socket, chair, desk etc and said our end [rural] was ready to go……………woops seemed no one had spoken to the specialists up in the big ivory tower, and no one told the IT team that when a waiting room has 30 patient to be seen in the OPD noone was going to run a few hundred metres to the IT dept to see a patient on a screen. So no one had spoken to the consultants, no area put aside close to clinics so it could be done in clinic time etc etc.. a big flop and a few $$ down the drain. BUT the CEO did have their smiling [right side of face please that has the dimple] in the newspaper to say how they really really cared about rural health, and what had been spent. So shut up and be forever grateful. !!!

    • georgemargelis Says:

      The issue is we need to move telehealth from being a cute technology demo for our of the ordinary situations to a tool that can be used by all clinicians to deliver better care. That requires some planning, the example you give of the telehealth equipment being set up away from the normal clinical areas demonstrates this.

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