How the health crisis resulting from the Covid-19 pandemic has affected telehealth practices in France
The lockdown, implemented as of mid-March 2020 in France to respond to the Covid-19 pandemic, has led to an important increase of telehealth – a practice that brings together activities (care, consultation, etc.) performed between healthcare professionals and their patients using digital technology and which includes, on the one hand, telemedicine – for activities carried out remotely by a medical healthcare professional (doctor, midwife, dental surgeon) and in particular teleconsultation (teleconsultation), and, on the other hand, telecare – for activities carried out remotely by a non-medical healthcare professional (e.g., dietitians, nurses, speech therapists) or by a pharmacist.
Since then, and in order to allow the deployment of these practices, the French government has eased the rules applicable to teleconsultation and has set up specific exceptional authorizations for the telecare practice.
- Quick reminder of the French legal framework of telemedicine and telecare
Telemedicine
The regulatory framework for teleconsultations is based on two principles that must be met in order to be entitled to trigger reimbursement from the French social security: firstly, the teleconsultation has to be part of the coordinated healthcare circuit, with an initial referral by the referring physician when the teleconsultation is not carried out by the latter, and secondly, the referring physician (or another specialist) performing the teleconsultation has to know the patient beforehand, i.e., the patient must have had at least one consultation with the remote physician, in person, over the previous twelve months.
It should also be noted that, since 2018, teleconsultations performed by healthcare professionals are covered by the French social security schemes in the same way as physical consultations, for all patients and all over the country, subject to specific legal, regulatory and deontological conditions, such as the assessment by the physician on whether the use of teleconsultation is appropriate and the obligation to use a video-transmission system.
Telecare
Unlike teleconsultation, telecare was not allowed before the current health crisis, as the decrees providing for the conditions for carrying out telecare in order to guarantee their quality and safety, as well as the authorized categories of professionals, had not been published.
Telecare, which is the counterpart of teleconsultation and remote monitoring for non-medical healthcare professionals, is a type of remote care practice that connects a patient with one or more pharmacists or non-medical healthcare professionals in the course of their skills. Its legal framework has been established by the law relating to the organization and transformation of the French health system (Law No. 2019-774 of July 24th, 2019), which provides for the practice of telecare by non-medical healthcare professionals (medical auxiliaries).
- Regulatory changes during 2020
The health crisis has led the French Health Minister to authorize some non-medical healthcare professionals, by way of derogation, to practice telecare. The following non-medical healthcare professionals have thus been authorized to use telecare: dietitians, occupational therapists, nurses (for the monitoring of Covid-19 patients), masseur-physiotherapists, speech therapists, orthoptists, chiropodists, podiatrists, pharmacists and psychomotor specialists.
The regulations governing the practice of telecare for different authorized professionals were specified in the ‘Arrêté’ dated March 23rd, 2020 prescribing the measures for the organization and operation of the health system necessary to deal with the covid-19 pandemic within the context of the health emergency and are now specified in the ‘Arrêté’ dated July 10th, 2020 with the same name, which repealed the Arrêté dated March 23rd.
They have in common, in particular, to limit the use of telecare to certain defined intervention/care, as well as to impose to the non-medical healthcare professionals to assess the relevance of using telecare and also that he/she has previously carried out an initial intervention/care in the presence of the patient. In addition, among these rules, we can note the obligation to use a video-transmission system, with a particularity for nurses who can carry out telecare over the phone if the patient's and/or nurse's equipment does not support the video-transmission.
These particular provisions, allowing specific professionals to use telecare, are applicable as long as the health emergency remains in force, and will therefore no longer be applicable, in theory, beyond this health emergency.
As for the teleconsultation, in the context of the health emergency established by the law dated March 23, 2020 (emergency law to respond to the Covid-19 pandemic), the regulations governing the performance of interventions have been softened, in order to protect patients and physicians from the risks of infection, allowing its deployment. Since then, patients can benefit from teleconsultations conducted by a doctor not known to them, without needing to be referred by their referring physician (i.e., outside the coordinated healthcare circuit) and with no requirement for a physical consultation with the remote physician within the twelve months beforehand. In addition, to reduce disparities in access to digital technology, consultation over the phone has been authorized for pregnant women and certain patients (e.g.., without access to a video system, in long-term care, over 70 years of age).
With regard to reimbursement of teleconsultations, the French social security schemes reimburse 100% of the consultation costs until December 31st, 2021, whereas in principle (i.e., outside times of crisis), French social security schemes reimburse 70% and complementary health insurance reimburses 30%, this being similar to what applies to physical consultations.
As with teleconsultations, telecare via video-transmission (and in certain cases by telephone) is entirely reimbursed by the French social security for professionals having an agreement with the French social security system.
- How will these remote health practices evolve in the future?
The use of teleconsultation and telecare has increased considerably since the beginning of the French lockdown on March 15th, 2020, as a result of regulatory flexibility, making these technologies essential for medical and paramedical assistance and monitoring of patients.
Will these flexibilities, related to the Covid-19 pandemic, become permanent once the health emergency has ended?
The government has announced its aim to pursue the deployment of telehealth while maintaining the high quality of care, and has taken commitments to these practices in the context of the Accords du Ségur de la santé.
With regard to teleconsultation, the intention to maintain more flexibility regarding the principle according to which the remote physician has to know the patient beforehand, has been stated. As concerns the practice of telecare, the objective is to make it sustainable for several professionals, and to open it up to other areas of their activity – as illustrated by the recent documents[1] published by the French Haute Autorité de Santé (National Authority for Health) on the eligibility criteria for telecare and the good practice recommendations for its implementation, so as to support the long-term use of telecare by non-medical healthcare professionals.
[1] Quality and safety of telecare - French Haute Autorité de Santé - February 2021.