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February 1, 2014

Telehealth Policy Reviews

It appears the emergence of a private company offering “Telehealth” services is an unintended consequence of a January 21, 2011 amendment to the preamble of the Medical Services Commission Payment Schedule allowing Telehealth services to include services performed outside of approved Health Authority sites. The Ministry of Health is now attempting to determine whether the development of private companies offering Telehealth services is a good or bad thing.

In September I submitted a freedom of information request for documents dealing with the government’s position with respect to Medeo. My interest in the company was sparked by a September 22, 2013 column in the Province which appeared to me to be akin to an advertisement. I subsequently discovered that the company has received a lot of uncritical media coverage. On January 28th I posted my article on a Doc for Me which concluded by observing that being able to see a physician on a smart phone or computer is probably not consistent with the government's attachment initiative. Three days later I received documents in response to my information request, four months after they were requested.

Part of the information release response package included a draft Ministry of Health briefing note prepared for an assistant deputy minister (ADM) titled "Third-party Telehealth Applications". It said: "At least one company (Medeo) is providing a third party mobile application to physicians and patients that allows them to connect via video conferencing through the internet, without either party being located at a secure Health Authority site." Much of the 43 pages in the response package dealt with the issue of data security and privacy. My interest is in the implications of the service for the cost of health care: will it increase billings to MSP and is it consistent with the attachment initiative that the General Practice Services Committee believes is cost saving and quality improving?

The ADM’s briefing note said:
"In a recent radio interview, Dr. William Cunningham, the current BCMA president, expressed concerns that the Medeo service not be used as a virtual walk-in clinic. The Medical Services Branch is concerned with quality (which is mainly the purview of the BC College of Physicians and Surgeons), as well as potential for increased utilization and misalignment with other initiatives such as Patient Attachment."

We can hope it’s not just the Medical Services Branch within government that thinks about quality issues in health care; we have to assume the author of the briefing note didn't intend to suggest that only the College concerns itself with such issues. The conclusion of the note said the Medical Services Branch will conduct a policy review of Telehealth with the involvement of the BC Medical Association, the BC College of Physicians and Surgeons, the Provincial Telehealth Office, the Billing Integrity Program and the Health Information Privacy, Security and Legislation Branch.

The information release package also included a "confidential issues note" dated June 4, 2013 giving advice to minister on "Medeo – Private website offering Telehealth videoconference service". It said "We understand the College of Physicians and Surgeons has asked the Ministry about the use of private websites like Medeo for Telehealth. The Ministry is investigating questions and concerns from BC physicians about this private website and its mobile application." A section of the issues note has a comment in the margin saying it is to be formatted: highlight, unfortunately that section is whited-out and stamped s.13 (Section 13 exempts advice to cabinet from release). It then stated: "We strongly support the use of Telehealth throughout B.C. We know it can help improve care to rural and remote locations." Despite the ADM's briefing note saying Medeo will charge participating physicians a 30% fee, the issues note for the Minister said: "Medeo claims it is free for physicians and an insured service for British Columbians covered under MSP. It is not known how this venture will receive income." Pity ministers who receive inaccurate notes like that!

The issues note reported: "The Ministry is in the final stages of delivering an evaluation document for a proof of concept pilot project. This document will outline a provincial approach to extend the Health Authority network to community based physicians vias the Physician private network for secure and private videoconferencing service delivery. The Provincial Telehealth Office has been included in the discussions asking for advice how to proceed regarding this company and their website and mobile applications." Again, the issues note for the minister is not consistent with the ADM's note which referred to a policy review involving key stakeholders. Either there are two reviews, or the left hand doesn't know what the right hand is doing.

The note to the minister includes an observation that might send a chill through physicians who might consider participation outside the Health Authority's secure system: "If the sending and/or receiving medical practitioner is not in a Health Authority approved site, the medical practitioner is responsible for the confidentially and security of all records and transmissions related to the Telehealth service."

Unless it was included in the whited-out sections of the issues note, I can see no reference to the attachment initiative, MSP costs or quality in the advice to the minister.

More questions than answers result from the release of information concerning Medeo. Hopefully the evaluations referenced in the issues note to the minister and in the ADM's note will be made public.

January 28, 2014

A GP for Me, Not

 GPSC videos Since 2003 BC's Ministry of Health has worked with the British Columbia Medical Association, through a joint committee called the General Practices Services Committee (GPSC), to co-operatively encourage more physicians to provide full-service family practice. The graphic on the right is from one of the Committee's YouTube videos which tell physicians how the changes it proposes work; click on the graphic to see all of the Committee's videos.

In June 2010 then Health Minister Kevin Falcon promised that anyone in British Columbia who wanted a family doctor would be able to find one by 2015. Like many government promises, it is unlikely that the family doctor one will be realized by its promised delivery date. Research reported in June 2009 by Hollander Analytical Services Ltd., working with the GPSC, provided economic rationale for the initiative. It presented data that showed most patients do not see a single general practitioner for more than 50% of their needed care in any year. That is part of the evidence the GPSC referred to when it said there is evidence that patients get better health outcomes and government saves money when they are "attached" to one family practitioner.

The 2009 Annual Report of the GPSC provided a good summary of incentive payments for general practitioners. It said:
"It appears that GPs who actively use incentive payments increase their proportion of majority source of care (MSOC) patients over time. A MSOC patient is one who receives at least three services in one year, and who receives at least 50% of their services from one GP. Thus, incentive payments may serve to increase the proportion of people who have a high attachment to practice, over time."

"Data extrapolation for complex, high-need patients with diabetes and congestive heart failure (CHF) for fiscal year 2007/08 indicated that an overall increase in attachment of unattached patients to a GP of just 5% could potentially result in cost avoidance of approximately $85 million."

"As of 2007/08, the overall uptake of incentive payments for GPs with at least 50 MSOC patients was 92%. The uptake for chronic disease management incentives was 87.5%.”

Notice the use of "may" and "could" in the report.

The 2012/13 annual report from the GPSC said: "The 2012 Government/BC Medical Association (BCMA) Physician Master Agreement increased the existing $190.5-million annual funding level for full-service family practitioners with an additional $10 million (effective April 1, 2012), and an additional $8 million (effective April 1, 2013)." Through MSP the government pays physicians of all types $4 billion per year; the GSPC payments are roughly 10% of the total payments made to family practitioners.

While BC's approach to improving access to family doctors can be criticized as an attempt to salvage the fee-for-service system in contrast to structural reforms in Ontario, it is impossible to fundamentally change health care delivery without substantial buy-in from physicians.

The 2012/13 Annual Report for GPSC also said:
The international literature indicates that patients who are attached to a particular family doctor receive: They also are:

In contrast to BC's marginal adjustment of some fee-for-service incentives, Ontario restructured how most of its physicians are paid. In the February 2012 Ontario Medical Review, the Ontario Medical Association (OMA) presented data supporting its argument that switching from enhanced fee for service to blended capitation reimbursement for Ontario physicians resulted in 2.1 million patients who previously had no family doctor being enrolled in a primary care model between 2003 and 2010. (There are 17 different alternative payment schemes in Ontario, but the three dominant ones are: the Family Health Groups (FHG), the Family Health Organizations (FHO), and the Family Health Networks (FHN)). The OMA is an enthusiastic supporter of Ontario’s alternative payment systems which it claims yield more services than comparable fee for service practices.

In a 2011 report Ontario’s Auditor General raised questions about the operation of blending funding for physicians. The Auditor upset the OMA by reporting: "…the Ministry has not tracked the full cost of each alternate funding arrangement since the 2007/08 fiscal year. At that time, most family physicians participating in these arrangements were being paid at least 25% more than their counterparts compensated on a fee-for-service basis." That prompted a harsh response from OMA in its 2012 Review in which it questioned the data used by the auditor. The OMA asserted: "Overall, the Auditor's analysis and commentary relating to family practice funding and performance is surprisingly unsophisticated, and plagued throughout with factoids. The Auditor has chosen to downplay, or totally ignore, a number of significant positive achievements and trends."

In a 2013 follow-up report, Ontario's Auditor made comments which were unlikely to calm the OMA; in particular, the report said: "By 2009/10, the 66% of family physicians who participated in alternate funding arrangements were receiving 76% of the total amount paid to family physicians. The Ministry had not tracked the full cost of each alternate funding arrangement since 2007/08, or analyzed whether the expected benefits of these more costly arrangements had materialized." The Auditor noted: "By the end of the 2009/10 fiscal year, more than 7,500 of the province's almost 12,000 family physicians were participating in alternate funding arrangements, and more than nine million Ontarians had enrolled with these physicians."

It is almost an article of faith among many health economists that replacing fee-for-service payment schemes will change incentives and be beneficial. Ontario’s Auditor raised a valid point that it's time to prove and quantify any benefits as well as any negative consequences that may have accompanied the changes. It is not surprising that the OMA would be pleased with the higher payments, neither is it surprising that the Ontario Ministry of Health had to pay much more in order to bring about substantial change. It is surprising that none of these questions have been raised in BC. BC's Minister of Health should require the same proof for benefits claimed for its fee-for-service incentive system which costs almost $200 million per year.

A private company may be shaking up BC's gradualist approach to fixing the physician shortage problem. A company called Medeo has received a lot of favourable media coverage on how it can make a physician available to anyone with MSP coverage via video over a smartphone or computer. Links to some of the coverage are available on Medeo's website. None of the stories include comments from the Ministry of Health or from anyone who might question the implications of providing such a service. Whoever is handling Medeo's public relations deserves a raise!

The home page for Medeo's website says: "See your doctor online. See a licenced BC doctor online with Medeo using your existing medical services coverage. You can connect from anywhere via secure video on computer, iPhone or iPad.” Next to those words is a link to a video that is essentially a 1 minute 45 second ad. It would be interesting to hear what the College of Physicians and Surgeons thinks of the video. In September I submitted a freedom of information request for the Ministry of Health's internal discussions about Medeo; as of January 28, 2014 I have not received any documents.

It could be that Medeo is the best thing since sliced bread, but when the approach of the Ministry of Health with respect to funding initiatives for the GPSC is compared to the largess of health reform in Ontario, it is hard to believe that the Ministry would welcome anything that increases MSP billings. It could be that Medeo is the route for satisfying government's promise to provide a physician by 2015 to anyone who wants one, but it doesn't look like that is the kind of relationship with a single physician that government’s costly attachment initiative is trying to foster.