4. Policy priorities for promoting the best use of telemedicine
As OECD countries adapt to a new phase of the COVID-19 pandemic, this is an opportune moment for debate among citizens, health care providers and policy makers on whether to continue using telemedicine services, how to regulate their use, how to pay for them, and how to make sure that they constitute good value for money for all. This chapter puts forth three priorities for policy makers to promote the best use of remote care services. All three priorities rely heavily on data being collected, analysed, and reported. The first policy priority is key to identifying value-adding uses of remote care. The second priority ensures that providers are rewarded for adopting telemedicine services that are good value for money, and that patients have access to these services. The third priority builds on the previous two, appealing to health care workers and policy makers to keep learning and improving the performance of the health care system.
In the beginning of 2020, as governments, societies and economies grappled with the enormous uncertainty surrounding the spread of SARS-CoV-2 and the disease it caused, COVID-19, normal life came to a halt. With health systems focused on preventing and treating COVID-19, and with populations drastically altering their behaviours to limit infections, many in-person health services were postponed or simply cancelled, causing massive disruptions in the delivery of essential health care services, from prevention to curative to palliative care. More than two years after the first wave of COVID-19 cases, most countries are still grappling with the effects of the pandemic on health care delivery.
With the COVID-19 pandemic causing significant disruptions to in-person care, governments and health care providers moved quickly to simplify and promote the use of remote care services. Before March 2020, nine OECD countries allowed medical consultations to be performed only in the physical presence of the patient. After March 2020, all but Korea dropped this requirement (still, Korea made it possible to temporarily use telemedicine services at the highest alert level of COVID-19). After the start of the pandemic, three countries dropped requirements that prescriptions could only be written in the physical presence of the patient, and seven countries relaxed a prerequisite that patients were only allowed to have teleconsultations with physicians with whom they had already consulted in-person before. Countries – such as Estonia and Türkiye – introduced new legislation, or revised existing laws, to authorise or regulate the use of telemedicine after the start of the pandemic. In the United States, through the CARES Act provisions, Medicare telehealth restrictions that previously only allowed rural providers to offer telehealth were waived during the pandemic.
Governments also promoted the use of telemedicine through financing and provider payment. After the start of the COVID-19 pandemic, eight countries began covering real-time (synchronous) teleconsultations through government/compulsory schemes. In Belgium, while there were no significant legislative changes, in March 2020 a new legal base was adopted allowing reimbursement of telemedicine. In England, before the pandemic, telemedicine services for secondary care were mostly financed through voluntary schemes and out-of-pocket payments; after the start of the pandemic, they were covered by government/compulsory financing. In the United States, for the first time, audio-only telehealth services were allowed in fee-for-service Medicare during the pandemic. While there have been limited changes to the financing of asynchronous store-and-forward telemedicine services during the pandemic, seven countries (Belgium, Estonia, Germany, Hungary, Ireland, Latvia and Switzerland) began covering remote patient monitoring services after the start of the COVID-19 pandemic.
The number of teleconsultations skyrocketed in the early months of the pandemic, partly offsetting the reduction in in-person care services, and playing a vital role in maintaining access to, and continuity of, care in 2020. Provisional data from the 2022 OECD Health Statistics and ad-hoc data collection on teleconsultations show that, due to the boom in remote doctor consultations, the number of total doctor consultations increased in 2020 compared to 2019 in Australia, Denmark and Norway. If not for teleconsultations, in nine OECD countries, doctor consultations would have dropped on average by 14% in 2020 compared to 2019, and not by 3.1%, as was the case. In Estonia and Lithuania , doctor consultations could have dropped three to four times more if it were not for doctor teleconsultations.
While access to remote care services among older, poorer, and rural patients remains concerning, especially in some OECD countries, available evidence suggests that after the start of the pandemic access to remote care among subgroups has been mixed, and in some ways potentially positive. For example, regarding patient age, in the United States, use of telemedicine among people aged 51 and older went up and these patients now represent a larger share of all users of remote care, and in Canada (Ontario) the highest rates of use were reported among older adults aged 65 and older. Regarding income, 2021 data from the United States suggests that rates of telemedicine use were highest among patients on lower incomes. Based on a recent analysis in the United States, there are significant differences across groups of patients in the use of audio-only versus video telehealth, with lower rates of video use (and higher use of audio-only) found among patients with a high school diploma, adults ages 65 and older, patients with low incomes, and Latino, Asian and Black individuals.
Across the OECD, patients who have used telemedicine services are overwhelmingly satisfied, with broad agreement on the value of remote care services among patients across and within countries. There is also plenty of evidence that telemedicine services save patients money and time. From a patient’s perspective, the evidence seems to indicate clearly that telemedicine services represent good value for money. Unsurprisingly, around two in five patients who used remote care services during the pandemic prefer remote to in-person appointments.
Compared to patients, physicians have more mixed views of the role of remote care services in a new phase of the pandemic in which most people are vaccinated and in-person services have mostly resumed. There is concern among health care professionals that scaling-up remote care services so quickly during the pandemic may have led to unnecessary and substandard care. Some physicians expect to reduce their provision of telemedicine services or even stop providing them altogether following a period of increased use in 2020. Moreover, in some OECD countries, telemedicine policies introduced at the start of the pandemic are temporary and may end up being reversed. Changes to regulations in 16 countries, and to financing in 12 countries, are temporary and subject to ongoing or periodic review. Temporary changes have so far been extended multiple times since the onset of the pandemic, but it is possible that despite significant demand from patients for remote care services, these may soon become unavailable or, as before the pandemic, subject to strict regulations.
A key underlying uncertainty for policy makers and health care providers is whether telemedicine services substitute for or complement in-person care, and if they are complements then whether they are cost-effective services. From the perspective of health systems, it is still debated whether remote care is good value for money or wasteful. On the one hand, there is a good deal of data suggesting that telemedicine services reduce subsequent (and more costly) health care utilisation and lower the chances that patients will miss appointments. On the other hand, teleconsultations can lead to subsequent (duplicative) in-person care and, under certain provider payment schemes, may lead to higher spending at no extra value for health systems and patients. Beyond the question of whether telemedicine services are substitutes or complements to in-person care, there is evidence to suggest that the use of remote care services can be beneficial for climate-related policies, by reducing travel and, during the pandemic, avoiding the use of personal protective equipment.
Data are needed to understand whether telemedicine services represent good value for money for health care systems, yet there is a lack of data collection in OECD countries on the reasons why patients use teleconsultations and on subsequent use of health care services following a teleconsultation. Indeed, the COVID-19 pandemic has provided a great natural experiment in the use of telemedicine services, creating opportunities to explore the impact of remote care services on different aspects of health system performance, but not all countries have taken advantage of these opportunities to collect data and conduct studies. Only ten countries reported that there are data collections on quality indicators such as safety, health outcomes and avoidable admissions.
As governments, societies and economies adapt to a new phase of the pandemic, this is an opportune moment for debate among citizens, health care providers and policy makers regarding whether to continue using telemedicine services, how to regulate their use, how to pay for them, and how to make sure that they constitute good value for money for all.
Before the COVID-19 pandemic, policies on remote care varied widely both across and within countries, for example regarding the types of telemedicine allowed, the funding and provider payment schemes used, requirements in terms of distance between participants, eligibility of health workers and patients to participate, patient consent, and integration with traditional in-person health care services. After the start of the pandemic, telemedicine services became more widely available due to swift government actions across the OECD, but this does not mean that there was a homogenisation of regulations concerning care delivered via telemedicine. There are still meaningful differences in how remote care is organised, regulated, and financed across the OECD, and large differences in the importance of telemedicine services as a share of all health care provided in countries and subnational areas. In other words, countries are starting from very different places, needs and preferences.
Notwithstanding, indeed because of, the significant heterogeneity in telemedicine use in the OECD, there are three priorities that policy makers in all countries could consider:
Learn more about which patients are using remote care services, why they are using, or not using, these services and what happens after they use them. This is essential to inform discussions of the impact of telemedicine services on health care system performance. Without data and analysis, it is not possible to determine whether remote care services are reducing or compounding inequalities in access and outcomes, whether they are duplicating care or replacing more costly services, whether they are improving patient experience and health outcomes or risking patient safety. Relevant data include patient characteristics (e.g. employment, location), the reason for a teleconsultation (e.g. requesting a repeat prescription, presenting a new health problem), the outcome of the teleconsultation (e.g. end of episode, referral to in-person appointment), and what would have happened if the patient had not received a teleconsultation (e.g. unmet need, use of emergency department). All these data are crucial to determine whether spending on telemedicine services is improving access, quality (including safety, effectiveness and patient-centredness), equity and cost-effectiveness. Implementing the OECD Recommendation on Health Data Governance would be an important first step in fostering the use of data while protecting privacy and data security (OECD, 2022[1]). The use of electronic health records to share data across providers and allow patients access to their own data is improving (Oderkirk, 2017[2]), but as mentioned data on important indicators is not collected, analysed, or shared.
Investigate whether payment for provision of telemedicine services and prices, are creating economic signals and incentives that promote good value for money. After the start of the pandemic, governments used financial incentives to successfully promote the use of telemedicine services, from introducing payment parity with equivalent in-person care, to additional fees for teleconsultations, and separate payment for ancillary costs. Yet, it is far from clear that current prices (e.g. payment parity) and provider payment mechanisms (e.g. fee-for-service) for remote care services are incentivising and promoting cost-effective uses of telemedicine. Setting prices at an appropriate level involves factoring in the unit costs of providing services, economies of scale and scope, high entry and capital costs, as well as marginal benefits of quality (Lorenzoni, Bunyan and Milstein, 2022[3]). The base for payment should contribute to, rather than detract from, health system objectives: while fee-for-service may be a good model to promote use of telemedicine in early stages of adoption, it may not be the best model to promote efficiency once telemedicine has been scaled up. Presently, there are limited data on costs (e.g. what is the unit cost of a teleconsultation) and utilisation (see previous point) to inform decisions concerning provider payment arrangements and prices.
Foster integration between remote and in-person care services so that these are fully co-ordinated and part of a seamless care pathway. In-person care and telemedicine services are currently fragmented, with some providers going digital-only and others deciding to stop using remote care altogether. This fragmented model of care is not evidence-based and does not serve the interests of patients who must navigate health care services that are not centred on their needs. Integrating remote and in-person care services relies on a strong information system to ensure information sharing between providers and patients across levels of care, financial incentives and payment mechanisms that incentivise sharing of information, and local level involvement from the community, with participation from all stakeholders, to ensure sustainable change.
All three priorities rely heavily on data being collected, analysed, and reported. Presently, the discourse around remote care services is dominated by limited anecdotal evidence and concerns about risks that cannot be quantified due to a lack of data. Every day, throughout the OECD, thousands of patients consult with health workers both in-person and remotely, but most information about these encounters is not collected, not linked, or not analysed. In the case of telemedicine, this lack of data collection and analysis is even more glaring given the medical act itself is only possible due to the use of information and communication technologies.
Telemedicine is only a tool, and, like any other tool, it can be well used or misused. When well used it can be beneficial for patients and health systems. The first policy priority is key to identifying what are value-adding uses of remote care. The second priority ensures that providers are rewarded for adopting remote care services that constitute good value for money, and that patients have access to these services. The third priority builds on the previous two, ensuring that health care workers and policy makers keep learning and improving the performance of the health system. It is worth remembering that the COVID-19 pandemic is not over, and it could become yet again an acute public health crisis. The progress made in the last years should not be wasted.
References
[3] Lorenzoni, L., R. Bunyan and R. Milstein (2022), Value-based providers’ payment models: understanding where and under which conditions they work, OECD, Paris, https://www.g20hub.org/files/OECD_HUB_final%20report_BUNDLED%20PAYMENTS.pdf (accessed on 5 October 2022).
[2] Oderkirk, J. (2017), “Readiness of electronic health record systems to contribute to national health information and research”, OECD Health Working Papers, No. 99, OECD Publishing, Paris, https://doi.org/10.1787/9e296bf3-en.
[1] OECD (2022), Health Data Governance for the Digital Age: Implementing the OECD Recommendation on Health Data Governance, OECD Publishing, Paris, https://doi.org/10.1787/68b60796-en.