Letter to the Editor: France Is the First Country to Reimburse Tele-Expertise at a National Level to All Medical Doctors

Tele-expertise is a type of telemedicine practice for health care professionals to request an expert medical opinion. It is an asynchronous telemedicine activity, which means that it does not need to rely on videoconferencing, and instead can be performed through a dedicated software or secured e-mail system. The activity requires a patient's informed consent and the medical report of the tele-expertise has to be included into the patient medical record after it is conducted. Tele-expertise is often seen as a way to reduce access time to a specialist opinion and to improve coordinated care as well as gradually improve the skills of the requesting doctor. Internationally, it is also referred to as e-Consult or store-and-forward. ¹

In France, tele-expertise was introduced into legislation in 2010, as a type of telemedicine activity, after the introduction of telemedicine as a remote medical practice into the Code of Public Health in 2009 (Table 1). ^2,3 The first financing experiment for tele-expertise started in nine regions in 2014 and extended to the whole country 3 years later. ^4,5 In 2018, negotiations between the National Health Insurance, Assurance Maladie, and the doctor's unions resulted in the reimbursement of video teleconsultations and tele-expertise (with two levels of complexity and funding, TE1 and TE2, respectively) and at a national level for all medical doctors on a fee-for-service (FFS) basis. The equipment is also funded of up to 525 Euros for the first year, for the telemedicine software and connected medical devices. ⁶ The scope, eligibility, and funding model are described in Table 2. As a result, France is the first country to reimburse tele-expertise at a national level for all doctors in all specialties and has been since February 10, 2019. Additionally, since March 9, 2020, tele-expertise for patients with suspected or confirmed cases of COVID-19 was eligible for public reimbursement, without any limitation of volume.

Although France is the first to reimburse tele-expertise nationally, it is not the first country to have a funding model of public reimbursement of tele-expertise. In the Unites States, Medicaid programs in 14 states initiated reimbursement of tele-expertise, with various conditions and eligibility criteria. ⁷ In the Ontario province, Canada, reimbursement of eConsult was possible since at least 2014. ⁸ In 2019, reimbursement was provided to an eConsult that was applied for physicians or nurse practitioners and billed if the answer could be provided within a maximum of 30 days after the request was given (Table 2). ⁹ It has not been permitted to bill an eConsult, if the purpose is only to discuss the results of a diagnostic test. In addition, it has not been applied to all doctors, as dermatologists and ophthalmologists have to apply e-assessments billing codes with four levels (initial, repeat, follow-up, and minor) of various reimbursement conditions (Table 3). After the activities in Ontario, eConsult expanded to some Canadian provinces, however were not always with dedicated fees. ¹⁰

In The Netherlands, tele-expertise has been funded at a national level since 2006 for both referring and expert doctors, but only in dermatology, and the condition relies on the gatekeeping role of primary care doctors. ¹¹

Reimbursement models have not been the only factor for the implementation of sustainable tele-expertise activities. In Brazil and Australia, successful tele-expertise activities in cardiology and dermatology, respectively, have been set up without dedicated FFS funding model. ^{12 –14} The national funding model in France, however, has been predicted to boost and structure the practice in various specialities beyond the initial projects implemented in the past 10 years since 2009. Those projects were mainly funded by the regional investment fund of the regional health agency in each region.

In regards to medical specialties, the main reported and evaluated tele-expertise activities in France were in dermatology and chronic wound care management. In teledermatology, there were reported activities between private dermatologists and general practitioners in the regions of Ile-de-France, ¹⁵ Hauts-de-France, ^{16 –19} and Corsica, ²⁰ and more specifically between two local hospitals, ^21,22 prisons, ^23,24 and university hospitals and geriatrics, ^25,26 and/or emergency departments. ²⁷ Wound care management with tele-expertise was evaluated in elderly home care, ²⁸ and for diabetic patients ²⁹ through large regional networks. ^30,31 One activity was also reported on the use of tele-expertise to improve burn care. ³² Other reported tele-expertise projects included support for improvement of drug prescription in elderly home care, ^33,34 for management of maxillofacial trauma in emergency departments, ³⁵ internal medicine, ³⁶ pneumology particularly for idiopathic pulmonary fibrosis, ³⁷ and in hematology. ³⁸

Despite the definition of a national funding model for tele-expertise in 2019, some challenges remain ahead for tele-expertise to be a daily routine practice for most doctors in France. The challenges include an update of the funding scope to increase patients' eligibility, the improvement of billing software to reduce technical barriers, education and training of health care professionals on the advantages of a secured structured tele-expertise in comparison with a nonsecured online or text-based chat with a colleague, ³⁹ and the organization of relevant networks through professional organizations or large-scale software implementation. ^40,41 Additionally, it may be worth considering to add a third level of complexity for more time-requiring tele-expertise and to allow and fund allied health professionals to perform tele-expertise in France.

In conclusion, as a structuring practice of medical collaboration, the authors encourage countries with no existing regulatory and funding frameworks for tele-expertise to define models adapted to their health care system structure and needs.