Lessons from billed telepsychiatry in Australia during the COVID-19 pandemic: rapid adaptation to increase specialist psychiatric care December 2022, Volume 32, Issue 4

Introduction

Australia has had a relatively successful public health response to the coronavirus disease 2019 (COVID-19) pandemic. In addition to social distancing and travel restrictions to prevent the spread of COVID-19, the Australian Federal Government promptly introduced new Medicare Benefits Schedule (MBS) telehealth funding in March 2020, for general practitioners, psychiatrists, other medical specialists and allied-health office-based consultations in metropolitan regions, to provide a rebate to patients accessing these services.¹ The new MBS telepsychiatry item numbers were introduced in March through early April 2020. This was in addition to an existing telehealth system for psychiatric care in rural regions.

Australia had far fewer cases of COVID-19 than the UK, US and Canada in the early stages of the pandemic. Australia had a first wave of COVID-19 infections from April to June 2020, and Victoria experienced a second wave from July to October 2020. Aside from these two waves, COVID-19 case rates remained low in Australia, with minimal community transmission, until the Delta variant of COVID-19 emerged in late June 2021, leading to lockdowns primarily in New South Wales (NSW), the Australian Capital Territory (ACT) and Victoria.

As part of this national response, telepsychiatry transformed the practice of psychiatry in Australia during the pandemic. Before COVID-19, telepsychiatry was mainly used across the vast distances covered by Australian rural psychiatric practice. However, during the pandemic, telepsychiatry became an essential part of mainstream practice. In particular, private practitioners rapidly expanded their use of telehealth during COVID-19. The adoption of telepsychiatry in Australia provides useful clinical practice information for other countries facing similar challenges for psychiatric care both during COVID-19 and more broadly.

Australia’s healthcare system is a hybrid of public and private services. Comprehensive acute hospital and community public health services are managed by states/territories and co-funded by state and territory governments and the Australian Federal Government. The Federal Government also funds private practice, fee-for-service, medical care, via the MBS. Psychiatrists working in private practice provide most (50–60%) of the specialist mental health care in Australia, including office-based outpatient consultations and private hospital inpatient care.² Office or practice-based consultations are partially reimbursed by the MBS, usually with an additional patient out-of-pocket fee paid to the psychiatrist, and data for these services are available from Services Australia.³ They are divided into face-to-face consultations (new or existing patients, interview of relatives/carers, group psychotherapy), MBS time-based items and the new video and telephone telehealth time-based equivalents.⁴

Given that a sizeable proportion of psychiatric consultations are reimbursed through a fee-per-item basis, as opposed to salaried or capitation models, it is possible to use de-identified Australia-wide billings data to track the uptake of telepsychiatry during the pandemic.

Methods

This paper draws on analyses of previously published papers.^5-9 MBS Item Service data were extracted from the Services Australia Medicare Item Reports for practice-based face-to-face consultations. Service data were also extracted for psychiatrist video and telephone telehealth MBS item numbers corresponding to the pre-existing face-to-face consultations.

Psychiatrist MBS Item Service data for April 2020-April 2021 in Microsoft Excel format were downloaded from Services Australia and transferred to and analysed using Excel. As a baseline comparator, we used face-to-face consultations from April 2018–2019 as described elsewhere.⁵ We also included data from a separate analysis of Victorian telepsychiatry data from April-September 2020 and compared it to face-to-face consultations in the same period of 2019 Victoria-wide.⁶ Totals and percentages were calculated for the various data.

This research involved fully deidentified, publicly available statistical data on mental health services subsidised by the Commonwealth of Australia, and accordingly, no ethics committee approval was sought.

Results

We summarise our previous analyses of these data and their broader implications for telepsychiatry during the first year of the COVID-19 pandemic in Australia⁵, as well as through Victoria’s second wave of COVID-19 from April to September 2020.⁶

Australia-wide, psychiatrist telehealth and face-to-face consultations were 13% higher during the first year of the pandemic (April 2020-April 2021) compared with face-to-face consultations for the corresponding period in 2018–2019. Telehealth comprised 40% of total consultations (face-to-face and telehealth combined) for April 2020-April 2021.⁵ Face-to-face consultations for April 2020-April 2021 were 65% of the comparative face-to-face consultation levels for 2018–2019 (using 2018-2019 as a baseline percentage of 100%).⁵ The majority of telehealth involved short telephone consultations of ≤15–30 minutes, while video was used more in longer consultations.⁵

Victoria experienced a prolonged lockdown from July to October 2020, due to the second wave of COVID-19 infections. There was a corresponding relative increase in combined psychiatrist face-to-face and telehealth consultations by 19% in July-September 2020 compared to the same 6 months in 2019. This exceeded the nationwide increase of 14% for the respective period.⁶ Face-to-face consultations in Victoria in July-September 2020 were only 46% of the respective 2019 level, and psychiatric consultation via telehealth became predominant, representing 73% of the overall face-to-face and telehealth consultations combined.⁶ In the same period, there was a relative tripling of short (less than 15 minute) consultations in Victoria compared to 2019, with 87% of these consults delivered via telephone, as described in more detail elsewhere.⁶

Discussion

This unprecedented transformation in MBS-subsidised psychiatric care has demonstrated that psychiatrists adapted swiftly, overcame barriers to face-to-face care, and responded to increased demand through the expansion of telehealth during COVID-19. This was especially so during the Victorian second wave of COVID-19. The relative flexibility of the regulatory implementation of telehealth in Australia compared to other countries likely contributed to their uptake by both patients and psychiatrists¹⁰, despite some initial restrictions on use, such as specific patient groups and constrained billing, that limited uptake.¹¹

It is important to acknowledge that our research on private outpatient telepsychiatry does not encompass patients and carers who would not be able to access internet-based technology – particularly video telehealth. However, telephone telehealth is potentially accessible across rural and remote regions and may be more practical than patients or psychiatrists travelling for consultations. Our results showed that there was significant uptake of psychiatrist telephone telehealth, which provides some accessibility. Patients and carers may not have the financial means to access private psychiatric care due to out-of-pocket costs, which warrants further research.

A recent study of patient satisfaction with telepsychiatry found that the majority (64.2%) wished to continue using it after the pandemic, citing the lack of a need to commute and increased flexibility as advantages, offset against feeling less connected to their practitioner and the practice.¹² There are patients and circumstances for which telehealth is not suitable for psychiatric care: acute care, some new patients, and patients with sensory and related disabilities.¹³

Telepsychiatry remains a useful component of Australia’s public health response to COVID-19. Since telepsychiatry has shown itself to be a widely acceptable approach, it presents a permanent care option that may be useful beyond the pandemic period¹⁴, complementary to, but not replacing, face-to-face care.¹³ Given its potential, further research is needed regarding the quality of psychiatric care provided, outcomes, patient and practitioner satisfaction, and further analysis of demographics and health economic implications. Research is similarly needed into the uptake and outcomes for telepsychiatry in public – state or territory-funded – mental health services, especially regarding the implications of differential patient populations and acuity levels.

Conclusion

Telehealth has been an integral component of Australia’s relatively successful public health response to COVID-19. The public availability of MBS data makes it possible to accurately assess change in psychiatric practice. These data make it easier to assess telepsychiatry’s effects than in salaried or capitation funding models such as those in the UK and Canada. The rapid and substantial provision of telepsychiatry in Australia indicates that it may be a useful substitute or adjunct to face-to-face care in other countries during COVID-19 lockdowns or similar emergencies where travel is restricted, such as other pandemics and natural disasters. The Australian Federal Government subsidises MBS telepsychiatry care with a patient rebate per consultation, illustrating that government-subsidised services can rapidly provide additional care. In addition, as patients directly provide out-of-pocket payments for telepsychiatry, this indicates that they find this service worthwhile. Our results on the success of this Australian Federal Government initiative may inform and provide support for the national adoption of telepsychiatry and digital technologies both during COVID-19 and beyond, along with guidelines for their appropriate use. Further study of the uptake of telepsychiatry is needed for the subsequent outbreaks of COVID-19 and lockdowns since June 2021.

Peer review and provenance

Externally peer reviewed, not commissioned.

Copyright:

© 2022 Looi et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.