Teleconsultations have been refundable now by French national health insurance “Assurance Maladie” (First tier (compulsory) national health insurance (Assurance maladie) provides reimbursement of healthcare expenses in France) for over a year. A legal framework for telemedicine has existed for many years. Yet, until very recently, patients and clinicians were far from convinced. According to a January 2020 Odoxa survey only 6% of people in France were using use teleconsultations and 3 out of 4 were afraid this would remove the human element from the patient doctor relationship. But then, that was before Covid-19…in other words, light years away.

Teleconsultations have been encouraged by the government during the Covid-19 crisis.

A teleconsultation means a patient can be in contact with a doctor via a computer screen or a smartphone. After a remote consultation, the doctor completes a treatment form (In French – Feuille de soins) and sends this to Assurance maladie who then put in hand a reimbursement, subject to certain conditions. In particular, the consultation must take place as part of a “coordinated care pathway” (All patients must choose a primary care physician – médecin traitant. Reimbursements are at the standard rate when treatment is with, or recommended by, one’s primary care physician (family doctor) – the so-called coordinated care pathway – parcours de soins), i.e. conducted by the patient’s family doctor or by a specialist recommended by the family doctor. A physical visit to the practitioner in the 12 months previous to the teleconsultation has been a pre-condition for coverage. Government decrees have lifted this pre-condition for suspected Covid-19 cases and increased Assurance maladie reimbursements to 100% up till year end. A serious boost coming from the healthcare regulator.

Clinicians’ misgivings swept away by the emergency

As for carers, fears of congestion in hospital emergency rooms and the risk of infecting GPs have put paid to any remaining reluctance. Obviously, when conducting an examination on-screen there is always the risk of not detecting a medical condition. In many cases, the doctor cannot do without a physical examination of the patient. Nevertheless, the Covid-19 epidemic has lifted the covers off teleconsultations. They help carry out preventive medicine, remove doubts, reassure patients, monitor symptoms on an ongoing basis and, in a majority of cases, avoid unnecessary and potentially risky visits. Only yesterday, this was a practice held at arm’s length. Today, the teleconsultation seems to be an inescapable response for the treatment of Covid-19, but also for all other contagious illnesses, where every year doctors’ waiting rooms fill up with patients and their germs.

Telehealth platforms: start-ups ready for the off

For telemedicine to take off, we obviously need ready-made technical solutions. A large number of e-health companies are in the starting blocks. The company Doctolib (A company providing French practitioners with a consultation management platform on which patients can book appointments) already has a strong position in the patient / family doctor relationship and so just needs to promote this function. Doctolib has, therefore, trained doctors and provided the equipment for them to carry out remote video consultations using the Doctolib appointment platform. In April, the company confirmed they had multiplied the number of teleconsultations by 100, going from 1,000 to 100,000 per day at the height of the crisis! Qare and Hellocare, just like Doctolib, provide patients with the possibility of a remote consultation with their family doctor or another available doctor.

At Livi and Mededom, the method is totally different because the doctors are salaried employees of the teleconsultation platforms and may even be located at the other end of France. This way of operating does not comply with the criteria laid down by Assurance maladie, in particular the necessity to have met physically with the doctor in the previous twelve months. Consequently, these consultations are not reimbursed, except for Covid. Telemedicine companies are lobbying for a change in the regulations so as bring their services within Assurance maladie coverage.

Meanwhile, some policies issued by second tier health insurers (Supplementary cover to top up reimbursements or provide wider cover) offer coverage for telemedicine when through healthcare networks, in particular Santéclair and Itelis. Insured persons can therefore seek information, reassurance, consult a doctor remotely and download a prescription by using these specialised platforms.

What future for telehealth after Covid-19?

According to figures published in July by Cnam (the national health insurance regulator), 5.5 million teleconsultations were reimbursed in March and April. At the height of the crisis, these represented a quarter of all consultations. 56,000 doctors have now taken up telemedicine with barely a few thousand having tried it out up to January. Doctors under 50 have been the quickest to offer this service. On the contrary it is with older patients that the change in habits has been the most spectacular. During lockdown, the over-70s represented more than 20% of services invoiced.

Early July, the number of teleconsultations per week was still at over 300,000. During August the weekly figure dropped to below 200,000. There is no guarantee that the enthusiasm for telemedicine will continue after the crisis. Habits die hard. Even so, the Covid-19 crisis has removed a number of obstacles and highlighted the effectiveness and relevance of the system. Once the crisis is behind us, some concerns will reappear: emergency room overcrowding, epidemic risks, workforce gaps (So-called “medical deserts” i.e. areas of the country with an insufficient number of GPs). No doubt therefore that telemedicine will have a role to play in the future of our healthcare system.

Damien Vieillard-Baron

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