How funding impacts on telehealth and its role in health reform

15th Annual Health Congress - considering the challenges, implications

and future directions for health reform

Sydney, March 2014

Susan Jury Telehealth Program Manager

Royal Children's Hospital

Paulette Kelly State-wide Paediatric Telehealth

Program Manager (Victoria)

Overview

1. Costs, savings and revenue generation

(study results)

2. The role of telehealth in health reform

3. How current funding models both help and

hinders the use of telehealth

4. Possibilities for expanding telehealth use

without increasing costs?

Costs, savings and revenue generation

(study results)

Aim: To determine if telehealth follow-up to children with

highly complex nephrological disease was acceptable &

beneficial to stakeholders and if so, at what cost

compared to face-to-face.

The study:

• 50 telehealth video-consultations with 30 children over 16 months

• 3 nephrologists and all with a local GP or paediatrician (total of 25 regional

clinicians)

• All children also had face-to-face during this time

Findings

1. Telehealth offers convenience for families

2. Revenue generation for telehealth will drop

substantially but remains viable

3. Service funding and delivery models would benefit

review

4. Medicare boundary changes have excluded patient

groups in need

5. Telehealth can enable the local clinician to become

a true partner in care

6. A range of factors impact on ‘patient

appropriateness’ for telehealth

We know that telehealth

saves money and time (to the patient)

This cost is commonly carried by Travel Assistance Schemes.

• Average cost savings per consult $602

($525 including outer metro – original boundaries)

• Maximum $4,015 for one patient

across 10 consultations

• >$26,000 saved across 25 patients over 16 months

Cost savings (family or travel assistance scheme)

RCH end dr:

Est. cost per consultation $18

Additional revenue $40

Patient end dr:

Est. cost per consultation $40

Additional revenue $29

Patient / TAS:

Est. savings per consultation $525+

The role of telehealth in health reform

Telehealth offers much more than saved money for patients

Telehealth benefits the patient AND health services

1. Overcome barriers to access • (eg distance, disability, risks of infection, psycho-social, socio-economic)

2. Improve rural / regional access to specialist services

3. Help enable integration between 1°, 2° and 3° care

Improving rural / regional access to specialist services

• More convenient

• Promotes earlier intervention

• This should decrease # of appointments needed + decrease

emergencies (and use of emergency services)

• Convenience should reduce hospital FTA rates (non-

attendance)

The role of telehealth in health reform

Enabling integration between 1°, 2° and 3° care

• Encourages local care through partnership

• For this appointment

• For future and ongoing care

• Encourages use of local services (pathology, imaging)

• More cost effective

• More timely and convenient

• Increases local capacity through increased confidence and

competence in more complex care – regional workforce

The role of telehealth in health reform

Benefits of 1°-2°-3° care integration

Example: Joerg – history of allergy

• Child 4 hours drive away

• 1st appointment by telehealth includes local GP

• Due to allergy concerns has not received vaccinations

• Detailed consultation by allergist resulted in:

• Utilising local (cheaper) services & better use of tertiary

services – initial local allergy testing under guidance of allergist

before follow up appointment face-to-face at the RCH

• A more competent / confident regional GP – better ongoing

local care for for this and other families

• A vaccinated child – went to local hospital to receive vaccination

under controlled circumstances

• Three saved hospital visits

• Home based (eg sleep studies, EEG)

• Outreach

• Transition to adult care

• Preadmission clinic

• Discharge planning

• Palliative Care

• Allied health, nursing • (eg pain team, HITH physio)

• Screening clinics

Telehealth & health reform – telehealth offers

novel approaches to care

…from +ve impacts

of telehealth on

the cost picture….

to -ve impacts

Example: Oncology Geelong

• 6 children w leukaemia in Geelong region (1 hour from Melbourne)

• Each child 8 appointments pa could give chemo locally with RCH

input and avoid an RCH visit (48 apts pa)

THEN:

• Every month for 3.5 years – could do locally

• 5 years surveillance – every 6-8 weeks, then 4 pa then 3 pa then 1 pa

– a total of 16 appointments could manage locally

Additional benefits of using telehealth:

• Psycho-social, local involvement for other ongoing

• Use local services

• Avoid RCH……

The impact of geographical restrictions

How current Medicare funding both helps

and hinders telehealth provision

A current example: nephrology follow up by telehealth

• By the most expensive doctor

• Takes 30 minutes including set-up

• Excludes Allied Health

• No great financial incentive

for local paediatrician

• Excludes local allied health

participation

How current Medicare funding both helps

and hinders telehealth provision

Other examples

• Dermatology specialist end nurse practitioners

• Highly skilled, more cost effective

• Neurology multi-disciplinary clinics

• No scope for regional AH involvement – therefore care

remains at the RCH

• GP repeat referrals / scripts

known patients

• By telehealth, impact on family,

time off school / work

• Aged care

Non-MBS funding

Hospital to hospital telehealth activity

• Current arrangements:

• The health practitioner with the patient claims for a Tier 2

specialist clinic service item. The clinician at the remote end

cannot claim.

• July 1st IHPA changes:

• The remote service provider can claim – the health

practitioner at the patient end cannot claim

• NABF weightings are untested

• (Not introducing in Vic for 1 year+)

Unintended consequences of the July 1st

Tier 2 funding changes

• Unattractive for consultations including more than

one provider (eg multi-disciplinary or inter-specialty)

• Discourages engagement of local services

• Always problematic when funding one end or

participant only

Telehealth benefits the patient, State and

Federal governments – why limit it?

• Helps keep people out of hospital

• Supports patient self management and health literacy

• Avoiding admission

• Earlier discharge

• Enables a more supported primary care workforce

• Less need for referral

• More involved

• Knowledge & skills sharing

• Supports a more efficient health service

• Less duplication of tests

• Less delay in follow-up

• Better continuity of care

Summary: Telehealth simply offers another way

of accessing services… yet plays a significant

role in health reform. Why limit it?

Can we increase use without increasing costs?

• Remove geographical boundaries? (+/- added incentives

for metro)

• Offer telehealth for ANY activity as an alternative not

additional service option?

• Increase use local services and providers, multi-

disciplinary etc

• Support the most appropriate provider? (may not be the

most expensive)

• Allow providers at both ends to count the service item in

non-MBS telehealth? (hospital to hospital)

• Fund paediatricians appropriately when with the patient

during sub-specialist consults?

• Out-of-pocket billing guidelines?

Summary: Telehealth simply offers another way

of accessing services… yet plays a significant

role in health reform. Why limit it?

Can we increase use without increasing costs?

• Review funding for travel, eg outreach programs & patient

travel assistance schemes? – including ambulance transport in

aged care

• Improve proactive rather than reactive access to GPs

through use of telehealth

• Ensure telehealth is a countable activity through other

funding sources (NABF etc) – including other telehealth (eg

store & forward etc) – can be an effective and efficient way of

providing quality healthcare.

Summary: Telehealth simply offers another way

of accessing services… yet plays a significant

role in health reform. Why limit it?

Can we increase use without increasing costs?

Susan Jury

Telehealth Program Manager

Royal Children's Hospital

www.rch.org.au/telehealth

susan.jury@rch.org.au

Tel (03) 9345 4645

Paulette Kelly

State-wide Paediatric Telehealth

Program Manager (Victoria)

paulette.kelly@rch.org.au

Tel (03) 9345 5644