Reimbursing telemedicine delivery: Lessons from the French market

The Covid-19 pandemic and resulting national lockdowns proved to be a springboard for telemedicine services in many countries.

These remote services played an essential role in reducing the transmission of this virus between patients and healthcare providers.

In October 2022, the World Health Organization (WHO) published a study that concluded telemedicine technologies are beneficial in the screening, diagnosis, management, treatment and long-term follow-up of a series of chronic diseases.

But financial and reimbursement barriers – i.e. how these services are financed and paid for – have been identified as being among the biggest challenges in adopting these technologies on a large scale.

Here, we look the approach taken in France, a country credited by MedTech Europe, the European trade association for the medical technology industry, as being a frontrunner in telemedicine roll-out in Europe, and consider what lessons other countries can learn to effectively deploy telemedicine.

How are telemedicine providers reimbursed in France?

Medical deserts

In response to concerns about its growing number of 'medical deserts', France first started partially reimbursing healthcare providers for teleconsultations and tele-expertise (collaborations between medical professionals to share opinions and deliver care) in 2018.

Medical deserts are generally defined as populated areas located more than 60 minutes away by road from the nearest acute care hospital.

This reimbursement was coordinated by the French Ministry of Health (Haute Autorité de santé (HAS)) pursuant to the 2018 Social Security Financing Bill.

As of 2020, virtual consultations are now fully reimbursed by the French Social Security department, compared to the 70% coverage previously provided.

Trialling telemonitoring

In tandem with the launch of government-funded telemedicine services, France launched a four-year pilot, known as the 'ETAPES' programme, to see whether this approach should be expanded to telemonitoring (where medical professionals monitor the health of patients remotely).

ETAPES provided funding for patients suffering from one or more of five medical conditions – heart failure, renal failure, respiratory failure, diabetes and implantable cardiac prostheses – to receive telemonitoring services.

Following the successful conclusion of this pilot, from July 2023 France will be the first EU country to allow reimbursement of telemonitoring for all citizens not limited to certain conditions.

Payment for this service will come from France's statutory health insurance (SHI) budget, which is financed through employee and employer contributions and taxes.

At the time of writing (April 2023), maximum reimbursement rates for telemonitoring have yet to be announced by HAS. These are due to be agreed before July 2023, will be condition-specific and based on a cost-benefit analysis of using telemonitoring versus conventional patient monitoring.

What can we learn from the French approach?

Reimbursement = investment

According to international healthcare consultancy Marwood Group in a report published in March 2023 (France Leads The Way – Expanding Telemedicine Reimbursement Creates New Market Opportunities), France's tried and tested reimbursement pathways for telemedicine make it a preferred investment destination for telemedicine compared to other countries in Europe that do not have established reimbursement models.

A route to care equality

France's efforts to expand telemedicine services by reimbursing providers indicate that the problem of patchy geographical healthcare coverage can be alleviated to some extent through publicly funded remote delivery.

With countries including the UK struggling to attract doctors and other healthcare professionals to work in some regions, telemedicine services could help bridge that gap and ensure more equal access to healthcare for everybody, regardless of geography.

No escape from administrative burdens

While France is highlighted by MedTech Europe as a 'best practice' example in the deployment of telemedicine services, both the trade association and Marwood's report acknowledge that administrative barriers have hampered the growth of telemedicine in France.

Even though pathways for reimbursement have been trialled and approved in France, the conditions under which telemedicine providers can be paid for services are regulated according to strict conditions, creating barriers to entry for some providers and slowing down deployment.

Need to grow patient awareness and enthusiasm

Notwithstanding the apparent success of telemedicine in France, MedTech Europe notes that patients still lack awareness of how to access telemedicine services.

Patient scepticism about the effectiveness of remote as opposed to face-to-face consultations also needs to be overcome.

This has been demonstrated by the rapid growth of telemedicine during the pandemic when in-person consultations were not always an option, and the subsequent backlash against remote consultations in countries including the UK once lockdown restrictions were eased.

What is happening elsewhere?

In the US, widespread use of telemedicine has only been possible due to the waiver of a huge number of federal regulations that have hampered telehealth adoption for decades. 

Those waivers are set to expire on 31 December 2024, so there is a window of opportunity for state and federal policymakers to rethink how telehealth is regulated and reimbursed. 

Meanwhile in the UK, where the NHS operates a very different reimbursement model to France's HAS, we have seen that under the NHS Long Term Plan, digital-first primary care will become a new option. Pursuant to this plan, every patient in England within the next five years will have a new right to choose an online or telephone consultation.

The NHS says it will deliver on this new commitment through three approaches:

• First, a new framework for digital suppliers to offer their platforms to primary care networks on standard NHS terms;
• Second, and in parallel, a review of current out-of-area arrangements and adjusting the GP payment formulae to ensure fair funding without inequitably favouring one type of GP provider over another; and
• Third, a review of GP regulation and terms and conditions to better support the return to practice and increased participation rates by GPs wanting to work in this way

Competition is key

As Marwood notes in its report, there will be competition to secure public funding contracts for telemedicine services where such opportunities are available.    

Demonstrating a clear clinical and/or organisational advantage over other existing telemedicine/telemonitoring solutions and conventional monitoring and healthcare delivery services will be key to obtaining public reimbursement.

In France, it is anticipated that the net benefit of a particular service, as assessed by HAS, will ultimately drive reimbursement levels. Digital solutions will be subject to an evaluation by a specialised commission of the HAS.

For advice and information on telemedicine services, please contact a member of Fieldfisher's digital health team.