Summary
The use of telemedicine, or remote clinical consultations, was limited in most OECD countries before the COVID-19 pandemic, slowed down by regulatory barriers and patient and professional hesitation. In early 2020, when COVID-19 severely disrupted face-to-face care, governments moved quickly to encourage the use of telemedicine. The number of teleconsultations skyrocketed and played a crucial role in maintaining access to care, but it only partially offset the decline in face-to-face visits. This briefing describes how governments have scaled up remote healthcare during the pandemic and examines the impact this massive shift to remote healthcare has had on health system performance.
important discoveries
Before the COVID-19 pandemic, nine countries (Estonia, Hungary, Iceland, Ireland, Korea, Luxembourg, Mexico, Turkiye and the United States) allowed medical consultations to be carried out only in the physical presence of the patient. While it was possible to use telemedicine services in other countries, many governments had specific telemedicine requirements that effectively discouraged their use. Although the number of consultations has increased, in countries such as Australia, Canada and Portugal, teleconsultations represented only between 0.1% and 0.2% of all consultations.
23 out of 31 countries1currently allow teleconsultation by non-medical health professionals, six more than before the COVID-19 pandemic (Estonia, Germany, Iceland, Luxembourg, Portugal and the United States).
Despite the rapid adoption of guidelines to encourage the use of telemedicine, only 17 countries report that the rules and regulations for providing telemedicine services are well established and clear.
During the pandemic, eight countries (Belgium, Czech Republic, England, Estonia, Hungary, Korea, Latvia and Luxembourg) started paying for teleconsultation through government/mandatory programs and eight countries (Belgium, England, Estonia, Germany, Hungary, Ireland , Latvia and Switzerland) started to pay for remote patient monitoring services through government/compulsory schemes.
Many of the changes that have enabled greater use of teleconsultation during the pandemic are temporary rather than permanent. In 16 OECD countries, changes in regulations are temporary and subject to ongoing or periodic review, while in 12 countries changes in funding have been or are temporary and may be subject to review.
The COVID-19 pandemic has massively disrupted personal health care
As health systems have focused on preventing and treating COVID-19 and populations have dramatically changed their behavior to limit infection, many essential personal health services have been delayed or simply suspended. In May 2020, the number of face-to-face consultations in primary care dropped dramatically, falling by 66% in Portugal, around 40% in Australia, 18% in Austria and 7% in Norway compared to the same month of 2019(OECD, 2021[1]). In-person visits per capita have dropped in seven of the eight countries reporting data for 2020 and by up to 30% in Chile and Spain. In Australia, average daily visits to hospital emergency departments dropped by 38% between early March and early April 2020 compared to the same period in 2019. In the UK, emergency department visits in March 2020 were 29% lower than in March 2019. In the Italian regions, visits to the pediatric emergency department decreased from 73% to 88% in March 2020 compared to March 2019.
This briefing describes how governments have scaled up remote healthcare during the pandemic and examines the impact this massive shift to remote healthcare has had on health system performance.2
Governments quickly adopted policies to encourage the use of telemedicine
Governments have encouraged remote care services by easing restrictions on their use
Prior to the COVID-19 pandemic, the number of telemedicine services was increasing, but still represented a very small proportion of the total volume of health services provided in OECD countries, between 0.1% and 0.2% of all face-to-face consultations in Australia, Canada and Portugal(Oliveira Hashiguchi, 2020[2]). While it was possible to use telemedicine services in most countries, many governments had specific telemedicine requirements that effectively discouraged their use.
According to an OECD survey on telemedicine and COVID-193before March 2020, nine countries4Medical consultations can only be carried out in the physical presence of the patient (illustration 1). In early 2020, governments and healthcare providers quickly moved to remote care services in response to the COVID-19 crisis.
After March 2020, all but one dropped this requirement. Austria, Türkiye and the United States dropped requirements that prescriptions can only be written in the patient's physical presence, and seven countries eased the condition that patients could only have teleconsultation with doctors they had consulted in person. Estonia and Türkiye introduced new laws and revised existing laws to authorize or regulate the use of telemedicine after the onset of the pandemic. In the United States, Medicare restrictions on telemedicine, which previously only allowed providers in rural areas to offer telemedicine, have been lifted. Korea allowed telemedicine services to be used temporarily at the height of the COVID-19 alert.
Since the onset of the COVID-19 pandemic, a major policy change has been introduced to allow non-medical healthcare professionals (e.g. nurses) to perform teleconsultation. Six countries (Estonia, Germany, Iceland, Luxembourg, Portugal and the United States) have changed guidelines under which healthcare professionals can conduct teleconsultations, with 23 countries currently allowing teleconsultation to be performed by healthcare professionals other than physicians. In 20 OECD countries, it is the sole responsibility of healthcare professionals to decide whether teleconsultation is appropriate. In 23 countries, patients must give their written or verbal consent to participate in the teleconsultation. 28 countries do not require in-person consultations after a teleconsultation and 23 countries allow teleconsultation between providers.
Despite the rapid adoption of guidelines to encourage the use of telemedicine, only 17 countries report that the rules and regulations for providing telemedicine services are well established and clear. While this may give providers some freedom, it also creates uncertainty among providers and may make it difficult for some providers to offer remote care services. In Canada, differences in licensing requirements for physicians providing virtual care, set by provincial and territorial regulators, make it difficult for healthcare professionals to care for patients across Canadian borders.
Illustration 1.In early 2020, pre-pandemic restrictions on the use of telemedicine were eased
Use of telemedicine before and after the onset of the COVID-19 pandemic
Note: * Applies to GPs and other GPs only, with limited exceptions. Agreement with statements is presented both for before March 2020 (i.e., before the start of the pandemic) and for after March 2020 (i.e., after the start of the pandemic).
What: OECD(2023[3]),The COVID-19 pandemic and the future of telemedicine,https://doi.org10.1787/ac8b0a27-en.
Countries used financial incentives to promote telemedicine
Governments have encouraged the use of telemedicine through changes to provider payment systems. Since the onset of the COVID-19 pandemic, eight countries (Belgium, Czech Republic, England, Estonia, Hungary, Korea, Latvia and Luxembourg) have started to cover real-time (synchronous) teleconsultations through government/mandatory schemes. Eight countries (Belgium, England, Estonia, Germany, Hungary, Ireland, Latvia and Switzerland) have started to offer remote patient monitoring services. In 16 OECD countries, the service fee is used by major purchasers to pay providers for each telemedicine service they provide, while in six countries telemedicine services are included in the capitalized payment to providers. In Belgium, Germany, Japan, Portugal and the United States, top buyers use billable and global budgets to pay telemedicine service providers.
In addition to government/mandatory schemes covering telemedicine services, several countries have also introduced financial incentives to encourage the use of telemedicine services. This included increasing payments for telemedicine services to match equivalent face-to-face services and payment margins to separately reimburse incidental expenses (e.g. technical support, equipment, connectivity) associated with providing telemedicine services (Figure 2).
Figure 2.Some countries used financial incentives to encourage telemedicine during COVID-19
Country agreements with declarations before and after the start of the COVID-19 pandemic
Note: Claims assertion is presented before March 2020 (that is, before the start of the pandemic) and after March 2020 (that is, after the start of the pandemic). Austria, Slovenia, Canada and Sweden did not respond to this section of the survey. Pay parity means that telemedicine and equivalent face-to-face services are paid at the same rates.
What: OECD(2023[3]),The COVID-19 pandemic and the future of telemedicine,https://doi.org10.1787/ac8b0a27-en.
After the start of the pandemic, the number of countries using payment parity to encourage providers to use telemedicine has doubled to 10. Portugal stands out because since 2013 the prices of teleconsultation in hospitals that operate nationally with hospitals of the national health services are 10% higher than face-to-face consultations. Eight countries already had payment surcharges for separate reimbursement of incidental costs related to the provision of telemedicine services prior to the COVID-19 pandemic. After the start of the pandemic, three other countries – Estonia, Ireland and the United States – started paying utility bills separately.
Telemedicine policies introduced with the pandemic are often temporary
In 16 OECD countries surveyed, changes in regulations are temporary and subject to ongoing or periodic review, while in 12 countries changes in funding were or are temporary and may be subject to review. In Austria, transitional regulations have been extended several times since the start of the pandemic. In Korea, the use of teleconsultation is strictly limited to exceptional situations such as pandemics, and it is a temporary service created to prevent the spread of infectious diseases in hospitals. Eight countries (Belgium, Costa Rica, Czech Republic, Hungary, Iceland, Lithuania, Mexico and the United States) are evaluating and developing frameworks for legislation and regulation of the use of telemedicine services. In six countries (Estonia, France, Israel, Luxembourg, Portugal and Türkiye), at least part of the regulations published after March 2020 have become permanent.
Australia, England, Estonia, Lithuania, Luxembourg, Poland and Turkey made permanent changes to provider funding and/or payment mechanisms, while in Switzerland some changes became permanent. In Australia, effective January 1, 2022, many of the COVID-19 telehealth services have been moved to permanent arrangements under a national telehealth scheme, including maintaining all video services made available during the pandemic, as well as allowing the full access to GP appointments for affected patients. by natural disasters. In Canada, provinces and territories have primary responsibility for administering and delivering health care, including funding, so changes and whether they are permanent or temporary vary by province and territory.
Telemedicine use skyrocketed during the COVID-19 pandemic, partially offsetting disruptions to face-to-face care services
The number of teleconsultations skyrocketed in the first months of the pandemic, to a certain extent offsetting the drop in face-to-face consultations. In Australia, in the quarter ended September 2020, 13.3% of all 15.5 million Medicare Benefits Schedule services were telemedicine appointments. In Belgium there were no teleconsultations in January and February 2020; As of April 2020, 44.4% of all consultations were via telemedicine and €238 million paid in related benefits. In Canada, 73.7% of all primary care visits and 63.9% of specialist visits were held virtually in Q2 2020, compared to 1.8% of all outpatient visits in Q4 2019. Costa Rica, a third of consultations in 2020 took place via teleconsultation(OECD, 2021[1]). In France, the number of billed teleconsultations increased in the first half of 2020Health insuranceincreased from 40,000 acts a month to 4.5 million in April, and during lockdown in 2020, every fourth consultation was a teleconsultation. At the In March and April 2020, Iceland increased by 69% the use of telephone consultations carried out in basic health units compared to this period of 2018/19, and remote services represented more than 80% of consultations carried out at that time. The number of telemedicine visits by Medicare beneficiaries in the United States increased 63-fold to nearly 52.7 million in 2020. In Denmark and Spain, nearly 50% of all physician visits in 2020 were teleconsultations (Figure 3).
Figure 3.Teleconsultation by physicians in OECD countries, 2020
Note: * Norway excludes specialist teleconsultation, Spain includes general practitioner and pediatrician consultations at primary health care centers of the national health system; Values for the Czech Republic are estimates. The data for Portugal comes from the "Portal da transparency", a data site of the National Health Service.
What: OECD(2023[3]),The COVID-19 pandemic and the future of telemedicine,https://doi.org10.1787/ac8b0a27-en.
Telemedicine has improved access to care and the patient experience, but impact on equity and efficiency needs further analysis
In the last OECD data collection on telemedicine taken before the COVID-19 pandemic(Oliveira Hashiguchi, 2020[2]), country experts overwhelmingly agreed that telemedicine services have the potential to have a positive impact on multiple aspects of health system performance (i.e., equity, efficiency, access, cost-effectiveness, and quality, including effectiveness, safety and patient-centeredness).
The COVID-19 pandemic has created a natural experiment that has created opportunities to empirically assess the impact of remote care services on various aspects of health systems performance, although not all countries have collected data and conducted studies. Ten countries (Belgium, Canada, England, Estonia, France, Israel, Mexico, Netherlands, Norway and the United States) collected indicators or metrics to assess the quality of telemedicine services, such as safety and outcomes. Administrative data on teleconsultation is very limited, with less than half of the 31 OECD countries having data on patient characteristics, type of telemedicine service, reasons for using telemedicine and subsequent care. Without this data, it is difficult to understand the impact of telemedicine on health system performance. Furthermore, only 12 countries make reference to telemedicine in national legislation or in the quality of care policy.
Access to telemedicine in rural areas remains a key concern; The use and satisfaction of the elderly increased over time
While telemedicine is generally improving patient access to care, there are concerns that the rapid uptake of remote care services during the pandemic may have exacerbated pre-pandemic inequalities in access to care. Available evidence suggests that the impact of telemedicine on access to health services among subsets of patients has been mixed since the start of the pandemic and may not be as clear as it was before the pandemic. However, access for older, poor and rural patients remains a concern, particularly in some OECD countries.
The age distribution of telemedicine users varies from country to country and appears to be changing with the pandemic. In Canada, the highest rates of telemedicine use were reported in adults aged 65 and over, while in England patients aged over 74 were up to 28% more likely to seek face-to-face consultations than patients aged 25 to 44. Data from the United States suggest that younger patient populations were the most likely to use telemedicine in 2020, but from April to October 2021, rates of telemedicine use were similar across all age subgroups except the age group from 18 to 24 years old. Elderly patients seem to be satisfied with remote care. In survey data from Austria and Belgium, older respondents were more likely to be satisfied than younger patients. Concerns that older adults would not be able to cope with telemedicine were confirmed in Poland.
Patients living in rural areas still seem to use telemedicine services less than other patients. Available data from the United States and Canada show a sharper increase in telemedicine use among urban populations.
Patient income remains an important correlate of telemedicine use, although recent data from the United States suggest that the association between income and telemedicine use may be changing. In Canada, patients in the highest income quintile had a higher proportion of telemedicine use during the first wave of the pandemic. In the United States, the increase in telehealth use in 2020 was greatest among patients in low-poverty counties, but more recent data for 2021 suggest that telehealth use was greatest in patients earning less than $25,000. The US analysis also shows that there are significant differences between patient groups in the use of audio-only versus video telemedicine.
Patient experiences with telemedicine are positive and satisfaction is very high
There is much more consensus among patients within and within countries than among physicians about the value of telemedicine services. In Australia, 77% of fellows at the Royal Australasian College of Surgeons believed that satisfactory care could be provided by telemedicine in half or more of consultations, but only 38% of respondents felt that the quality of care could be improved. In the United States, among respondents to multiple waves of McKinsey surveys conducted in 2020 and 2021, two-thirds of physicians and 60% of patients agreed that eHealth is more convenient for patients than face-to-face care, but only 36% their Physicians agreed that remote care was more convenient for them.
In Canada, 78% of physicians agree that virtual care allows them to provide quality care to their patients, with over two-thirds of physicians satisfied with video visits and 71% with telephone consultations. A national survey of 1,800 people, conducted May 14-17, 2020, found that 91% of patients who connected virtually with their doctor during COVID-19 are satisfied, which is 17 percentage points higher than the satisfaction rate. for face-to-face service. emergency room visits. In another Canadian survey of over 12,000 people, conducted between July 14 and August 6, 2021, 89% of respondents felt involved in making decisions about their care and 88% felt the visit was effective in addressing their health they were inquiring about. Among patients using e-mental health services, a staggering 74% of e-mental health service users agreed that remote care helped them navigate a time of crisis and grief that would have resulted in physical harm or suicide.
About two in five patients who used remote care services during the pandemic prefer them to face-to-face services, while physicians have more divergent opinions.
Surveys across all OECD countries continue to show patient preferences for using remote care services. In Australia, 41% of patients who attended surgical telemedicine consultations said they would prefer telemedicine to face-to-face consultations in the future. In Canada, 46% of respondents who used virtual care after the start of the pandemic said they would prefer a virtual consultation as their first point of contact with their doctor. In Israel, approximately 82% of men, 73% of women and 80% of patients with chronic illnesses agreed that they would continue to use telemedicine. In Poland, 43% of respondents believe that telemedicine should be one of the main ways of contacting their GP. In the United States, in November 2021, 55% of consumers said they were more satisfied with telemedicine appointments than with in-person appointments.
Compared to patients, physicians have more mixed views on the role of remote care services in a new phase of the pandemic, when most people are vaccinated and face-to-face services have resumed. For example, in Australia, 85% of surgeons surveyed recently expressed a desire to continue providing access to telemedicine, and in Canada, nearly 25% of physicians expect to increase their use of virtual care in the future. In Norway, GPs estimate that they will have around one in five consultations via video in the future, and in England 88% of 2,000 GPs believe that greater use of remote consultations should be maintained in the long term. However, in Sweden, approximately four in 10 physicians no longer want to use digital care consultations, and in the United States, 62% of physicians say they would recommend in-person care over remote care for patients.
Research also shows that patients often save time and money by using remote care, making telemedicine services very valuable to them. In an Australian survey, 60% of patients reported cost savings from teleconsultation and 77% felt their telemedicine consultation was cost effective. In Canada, patients who used teleconsultation instead of face-to-face consultations reported saving an average of $144 by not needing to care for a loved one, taking time off work, and avoiding travel and related expenses. In England, between 1 April 2020 and 31 March 2021, video consultations saved patients a total of 530 years in travel and waiting time and £40 million in travel expenses.
It is unclear whether remote care replaces or complements face-to-face care and whether telemedicine adds value to health systems or is wasted.
Spending on telemedicine services is a waste when they do not bring any benefit and can be replaced by cheaper alternatives with identical or better results. On the one hand, there is a lot of data to suggest that telemedicine services reduce subsequent health care utilization (especially more expensive services such as emergency care and hospitalizations) and decrease the likelihood that patients will miss appointments. On the other hand, teleconsultation can lead to subsequent face-to-face visits and – under certain provider payment schemes – lead to higher expenditures with no added value for health systems and patients.
In a 2021 Canadian survey, 81% of people using video consultations and 77.1% of mental health patients said that remote care saved them from at least one in-person visit to a doctor or emergency room. In the same survey, 11% of virtual visits resulted in the patient being referred for an in-person appointment with a specialist and 10% in advising the patient to schedule an in-person appointment with their GP. In a study in England, 18% of patients were discharged after telephone or telemedicine consultation in April 2020, compared to 25% in February 2020, while the proportion of patients discharged after face-to-face consultations remained constant at around 22% . The same analysis also shows an increase in prescriptions and referrals after a teleconsultation. The reasons for these trends are not clear.
Analysis from Sweden shows that remote care users had lower primary care utilization rates than personal care users prior to 2018, but the opposite was true in 2018. Although remote care services have replaced some face-to-face care , they resulted in a higher number of queries overall. However, it is unclear whether the increase in occupancy was due to previously unmet demand or if it was due to unreasonable demand.
Policy priorities for telemedicine
As governments, societies and economies adapt to a virus that will become endemic, this is an opportune time for healthcare professionals, policymakers and citizens to discuss whether they should continue to use telemedicine services, how their use will be regulated and how they will be paid for the wort. and how to ensure they offer good value for everyone. There are important differences in the organization, regulation and funding of remote care across the OECD and major differences in the extent to which telemedicine services are used. There are three priorities that policymakers need to consider moving forward, and all three rely heavily on the data collected, analyzed and reported:
First, more information about which patients use remote care services, why they use these services, and what happens after they use them is essential to support discussions about the impact of telemedicine services on health system performance.
Second, it is necessary to better analyze whether the payment arrangements and organization of telemedicine service provision encourage adequate and effective use of services. Some patients seem to want to use telemedicine more and there is potential for cost savings. Therefore, the challenge is to adapt payment systems so that this is possible and of high quality, accepting that, for some conditions and some patients, face-to-face consultations are preferable. There is little cost and usage data and analysis to inform vendor pricing and payment decisions.
Third, remote and face-to-face care services need to be integrated so that they are fully coordinated and form part of a seamless care path. Face-to-face and telemedicine services are currently fragmented, with significant divergence among providers on the merits of telemedicine services. This is not ideal and does not serve the best interests of patients.
(Video) Is Telemedicine The Future Of Health Care?
Telemedicine is just a tool and like any other tool, it can be used well or misused. When used correctly, it can be beneficial for patients and health systems, as long as we keep working to overcome some of the pitfalls.
references
[3] OECD (2023),The COVID-19 pandemic and the future of telemedicine, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/ac8b0a27-en.
[1] OECD (2021),Health Overview 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
[2] Oliveira Hashiguchi, T. (2020), “Bringing healthcare to the patient: an overview of telemedicine use in OECD countries”, OECD Health Working Papers, nº. 116, OECD Publishing, Paris, https://doi.org/10.1787/8e56ede7-en.
Contact
Francesca COLOMBO (✉francesca.colombo@oecd.org)
Tiago CRAVO OLIVEIRA HASHIGUCHI
Luca LINDNER (✉luca.lindner@oecd.org)
Luca LORENZONI (✉)luca.lorenzoni@oecd.org)
Comments
31 OECD countries participating in the December 2021 OECD survey on telemedicine and COVID-19.
For a more in-depth analysis, see OECD(2023[3]), on which this Policy Brief is based.
The OECD survey on telemedicine and COVID-19 was sent to OECD countries in December 2021 and responses were received by the end of April 2022. A total of 31 OECD countries participated in the survey. Telemedicine has been defined as the use of information and communication technologies to provide healthcare remotely.(Oliveira Hashiguchi, 2020[2]). Three categories are considered, which can be sensibly combined: Telemonitoring, Store and Forward and Interactive Telemedicine.
Estonia, Hungary, Iceland, Ireland, Korea, Luxembourg, Mexico, Turkey and the United States.