The shift to virtual care in response to COVID-19

By Damien Angus, Maureen Connolly, Mariella Salita & Per Firor

Updated: 8 September, 2020

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COVID-19 is driving significant changes in society and challenging healthcare systems across the globe. Digital technology has enabled Australians to stay connected during the pandemic and is both facilitating and disrupting our healthcare. The cycles of outbreak and containment are highlighting the benefits and challenges to virtual care including the following: 

  • Adapting Australia’s activity-based funding schemes to meet care needs
  • Providing both clinical and social/welfare support for COVID-19 positive patients
  • Developing digital solutions faster than our ability to adopt them 

Adapting Medicare Benefits Activity-based funding scheme

Prior to COVID-19, Medicare Benefits Scheme (MBS) funding was restricted to the following:

  • People outside major cities and who were at least more than 15km away from the specialist; 

  • Residents of aged care facilities; 

  • People receiving care from Aboriginal Medical Services or Aboriginal Community Controlled Health Services.

As such, virtual care attendances accounted for only 0.1% of all MBS funded attendances.1

In response to the pandemic, the Federal Government established temporary MBS funding arrangements for virtual care. These, in their initial form, were short-lived.


Service delivery arbitrage - our structural problem

Australia’s Primary and General Practice care model is based on GPs offering a range of services required by their communities. Medicare compensates them on a fee for service basis. From these fees they must cover overheads including rent for their ‘shop front’ surgeries. These practices, many of them small, incur these overheads regardless of whether a service is delivered virtually or in-surgery and of course many services cannot be offered virtually.

Enter the ‘virtual surgery’. We recognise the advent of pure virtual practices. They will offer greater access and convenience. However, because they are virtual, they cannot offer a full range of general practice care services. Instead, they are lower cost business models that selectively offer only profitable services. The net effect is the traditional GP practice will experience market erosion as they lose profitable services to a low-cost competitor while retaining low margin or loss-making services from which they must cover their physical overheads.

Australians will continue needing liver palpations, PAP smears, ear irrigations, and a plethora of other diagnostic and therapeutic services. For this, we require a viable full-service general practice which in turn requires GPs to retain physical premises for which they are not currently directly compensated.

Australia’s is a structural problem. Virtual care should be another tool for the GP and not a threat to the full-service general practitioner. However, a funding model that compensates for activity rather than service places the full-service general practice at an economic disadvantage.

Activity-based funding is also problematic in our public hospital system. Many states fund their health districts, services, and/or hospitals on an activity basis. In the initial outbreak, hospitals cut back on elective procedures (activity) and in doing so cut their funding. Like their community GPs, they largely retained their fixed overheads including public sector staff. We now have public hospitals facing deficits, case backlogs, growing waiting lists and an increasing burden of disease.

Protecting the full-service General Practitioner

On 10 July 2020 the Federal Minister for Health Greg Hunt announced changes to telehealth arrangements recommended by the Australian Medical Association and Royal Australian College of General Practitioners to “promote patients receiving continuous care from a patient’s regular GP or medical practice… From July 20, telehealth GP providers will be required to have an existing and continuous relationship with a patient in order to provide telehealth services.”

This requires patients to have had a face-to-face relationship with the GP or their practice in the last 12 months in order to be eligible for a Medicare-funded telehealth session. This measure affords some protection to full service general practice. A notable exemption was for areas under Stage 3 /4 restrictions (e.g. Victoria at the time of writing). This turned out to be crucial as approximately 20% of positive cases report they did not have a GP at the time of notification much the less having had a prior face-to-face relationship. 

During the outbreak in August 2020, community health workers in outbreak areas reported approximately 20% of COVID-19 positive patients did not have a GP at the time of contact. This presents an obstacle to immediately linking these patients to primary care and highlights the need for closer integration of primary, community, and acute care sectors.


Health outcomes require more than clinical inputs

Research suggests that clinical care can address only 20% of a person’s overall health and wellbeing; the greatest gains, especially for those at highest risk of poor health, come from action on their social determinants of health.

Feedback from community health workers during recent community outbreaks of COVID-19 indicate approximately half of COVID-19 positive patients require some form of social support to convalesce at home. This support could range from having 14 days’ worth of food on hand, medical supplies or money, to housing insecurity.

Approximately half of COVID-19 positive patients require some form of social support to enable a safe and effective home isolation and recovery.

Public sanitation, antibiotics, and genome mapping stand as major achievements in public health. There is a huge opportunity to improve societal health and wellness by treating the whole patient and not just their disease. This requires understanding a person’s social circumstances and understanding how to address them. This understanding cannot be gleaned from a medical record alone (electronic or otherwise).

This is not about broad-brush social programs but being able to identify at the individual level what forms of assistance and intervention are helpful. The technologies to support this future vision already exist. Client insight and relationship management software, artificial intelligence, and machine learning stand at the ready. Useful data exists, but it is fragmented over multiple organisations and systems both public and private.

The challenges are organisational, legislative, and cultural. We value our privacy which is why so much of our information is fragmented across government departments and agencies and locked away. Policy, procedure, and legislation often prevent it from being used even for the purpose it was collected.

At the same, we show a willingness to share our information on social media in exchange for the value we perceive we get from these platforms.

Australian organisations and governments in particular, need to provide our population with greater control and flexibility in how our information is used. We should be able to direct the government to share our information with those we wish rather than the government dictating what they allow to be done with our information.

Adoption lags innovation

Up until 2020, it was an accepted part of Australian culture to receive healthcare in a face-to-face setting in the provider’s rooms or clinic. The COVID-19 pandemic is an unforeseen culture interloper. While our younger generations are ‘digital first’ by nature, COVID-19 is shifting this preference across the generations out of necessity.

In Victoria, the state with the largest outbreak which is predominantly community-based, we observed many pockets of significant technical innovation. These include:

  • Austin Health in partnership with Arden Street Labs deploying a ‘digital first’ solution in which every COVID-19 test patient (positive or negative) can enrol in an online monitoring program with an app to detect and escalate clinical deterioration while they convalesce at home,

  • University of Melbourne in partnership with Two Bulls recruited respiratory clinics and eligible primary care organisations to participate in a study which is based on a patient app targeted at those in isolation,

  • Monash Health and The Alfred in partnership with Deakin University are trialling artificial intelligence for patient triage with ongoing monitoring using medical grade monitoring equipment via an app in the home.

We see other forms of innovation within hospitals and health services. South Australia has adopted Microsoft Teams across its health department in response to COVID-19. The Royal Prince Alfred Hospital in Sydney opened the first virtual ward in Australia. However, we have yet to see these innovations translate to systemic change at the whole of state or national level.

Our capacity to innovate is clear. However, we must move beyond trials, single hospitals or districts, and innovate across the healthcare spectrum. To do so we must create the policy, economic, and cultural foundations that will enable it.


References

1. Virtual care is defined as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximising the quality and effectiveness of patient care.” - Shaw J, Jamieson T, Agarwal P, et al., Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique, J Telemed Telecare 2018;24(9):608-15

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