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How Primary Care Physicians Experience Telehealth: An International Comparison

Findings from the 2022 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
Doctor sits blurrily behind video monitor on top of computer

Internist Christoph Lembens conducts a video consultation from his office in Mainz, Germany. According to a Commonwealth Fund survey of primary care physicians 10 countries, telehealth platforms have been relatively easy to implement, and most clinicians are satisfied with the technology. Photo: Sebastian Gollnow/dpa via Getty Images

Internist Christoph Lembens conducts a video consultation from his office in Mainz, Germany. According to a Commonwealth Fund survey of primary care physicians 10 countries, telehealth platforms have been relatively easy to implement, and most clinicians are satisfied with the technology. Photo: Sebastian Gollnow/dpa via Getty Images

Toplines
  • According to a Commonwealth Fund survey of primary care physicians 10 countries, telehealth platforms have been relatively easy to implement, and most clinicians are satisfied with the technology

  • In at least half the countries surveyed, including the U.S., most physicians said telehealth improved timeliness of care, offset potential financial losses from COVID, and allowed them to assess mental and behavioral health needs

Toplines
  • According to a Commonwealth Fund survey of primary care physicians 10 countries, telehealth platforms have been relatively easy to implement, and most clinicians are satisfied with the technology

  • In at least half the countries surveyed, including the U.S., most physicians said telehealth improved timeliness of care, offset potential financial losses from COVID, and allowed them to assess mental and behavioral health needs

Introduction

In the early months of the COVID-19 pandemic, lockdowns and social-distancing rules caused in-person primary care consultations to plummet.1 Many clinicians opted for telehealth — the provision of clinical and other health-related care by video or telephone — as an alternative to face-to-face office visits. Governments in many countries, including the United States, facilitated this shift by loosening regulations and enhancing payment and reimbursement for telehealth services.2

Telehealth’s popularity with patients during COVID-19 suggests it will have continuing utility beyond the pandemic.3 With the global shortage of primary care physicians and exposed inequities in access to health care, telehealth may turn out to be a better way to deliver critical health services to underserved populations.4

While there is a rich body of research describing the benefits and challenges of telehealth for patients, providers’ perspectives have been far less explored. Their experiences are critical to future policy decisions about financing, regulating, and possibly restricting telehealth services.5 This brief presents findings from the 2022 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, conducted in 10 high-income countries from February through September 2022, to explore how primary care physicians view the ease of use and effectiveness of telehealth after the height of the COVID-19 pandemic. Our analysis is largely limited to those physicians who reported using telehealth, whether through telephone or video, at least some of the time.

Highlights

  • The majority of primary care physicians in all surveyed countries reported seeing some patients in a typical week through telehealth.
  • In most countries, including the United States, the majority of primary care physicians who used telehealth reported implementing their telehealth platform was “very” or “somewhat” easy.
  • In at least half the countries, including the U.S., the majority of primary care physicians reported telehealth improved timeliness of care, offset potential financial losses from COVID-19, and allowed their practice to assess mental and behavioral health needs to at least some extent.
  • In the U.S., a large majority of primary care physicians who used telehealth reported being “very” or “somewhat” satisfied with practicing telehealth.

Survey Findings

Gunja_primary_care_physicians_telehealth_international_survey_exhibit_01

Two years into the pandemic, the majority of primary care physicians in half of the countries we surveyed reported seeing more than a quarter of their patients through telehealth in a typical week via telephone or video calls (see Table 1 for percentages by country). In the United States, the majority of physicians saw fewer than a quarter of their patients through telehealth, and, consistent with prior research, nearly one in five U.S. physicians reported not using telehealth at all.6 In the United Kingdom, more than a quarter of physicians said that on a weekly basis, they see most of their patients via telehealth.

Gunja_primary_care_physicians_telehealth_international_survey_exhibit_02

The majority of primary care physicians in eight of the 10 countries we surveyed, including the United States, reported that implementing a telehealth platform was “somewhat” or “very” easy (see Table 2 for country breakdowns). But only three of 10 German physicians and four of 10 Swiss physicians reported the same.

Implementation challenges may be partly related to cost. Our survey shows that in Germany, physicians were also more likely to report the added expenses of implementing and maintaining their telehealth platforms as a “major” challenge (Table 1).

Gunja_primary_care_physicians_telehealth_international_survey_exhibit_03

In the U.S., Canada, the U.K., and Australia, the vast majority of primary care physicians reported telehealth improved the timeliness of care either “to a great extent” or “to some extent.” In contrast, less than half of physicians in Switzerland and Sweden, and only one of five in Germany, reported that telehealth improved the timeliness of care.

Timeliness of care, however, does not necessarily translate to improved quality of care. Among providers in all countries who reported telehealth improved timeliness, fewer than one of five also said they saw an improvement in the quality of patient care they were able to deliver since the start of the COVID-19 pandemic (data not shown).

Gunja_primary_care_physicians_telehealth_international_survey_exhibit_04

The use of telehealth made it possible for a large majority of physicians in the U.S. and Australia who use it to offset financial losses related to the pandemic. Few physicians in Germany reported the same.

While the majority of primary care physicians who use telehealth in the U.S. and Australia reported that it offset potential losses, nearly one of three physicians in the U.S., and nearly half in Australia, said low or no insurance reimbursement for telehealth visits was a major challenge for their practice (Table 1).

Gunja_primary_care_physicians_telehealth_international_survey_exhibit_05

With the onset of the pandemic, mental health needs spiked globally.7 Physicians in the U.K., Australia, Canada, and the U.S. most often reported that telehealth allowed their practice to assess mental and behavioral health needs of their patients to either “a great extent” or “to some extent.” In contrast, less than one-third of physicians in Germany and France considered telehealth to be an effective tool for assessing mental and behavioral health needs.

Gunja_primary_care_physicians_telehealth_international_survey_exhibit_06

Except for Germany and Switzerland, more than half of primary care physicians who use telehealth — including three of four in the United States — reported they were satisfied with practicing it.

Discussion

According to primary care physicians in most of the countries we surveyed, telehealth has had important benefits: offsetting financial losses during the pandemic, improving the timeliness of care, and allowing doctors to assess patients’ mental and behavioral health needs more effectively. Still, telehealth uptake has varied from country to country.

In the Commonwealth Fund survey, one in three U.S. primary care physicians reported that low or no reimbursement for telehealth visits is a major challenge in their practice — additional evidence that the United States underinvests in primary care, particularly compared to other high-income countries. With the health care system already facing a primary care shortage and a burned-out workforce, it will be critical to ensure that primary care physicians are adequately paid to meet the health care demands of a growing population.8

For telehealth use to make further gains, policymakers and health system leaders will need to understand which telehealth services, and which forms of telehealth, are most frequently used by providers and patients.9 In the United States, for example, higher-income, younger, and white adults are more likely to use video services when they use telehealth care, while lower-income and Black and Hispanic adults are more likely to use audio services.10 Research also showed continuous growth in telehealth visits for treatment of mental health and substance use issues during the pandemic, particularly among rural Americans.11 Evidence from the United Kingdom similarly suggests telehealth has improved access to mental health care for people in rural regions, which constitute much of the country.12 In all nations, concerted data collection efforts that track these measures could help policymakers maximize telehealth’s benefits and reduce health disparities.

In several countries, recent shifts in government financing and regulations have created uncertainty about the future of telehealth. While the U.S. Congress has extended several pandemic-era rules to make telehealth visits more accessible for both providers and patients — like allowing Medicare beneficiaries to receive primary care telehealth services without geographic restrictions — not all changes are permanent, and the decision to extend other longer-term policies may be left up to individual states.13 Policymakers in other countries may face similar challenges, potentially affecting the “new normal” of blended in-person and telehealth visits.14

Finally, it should be noted that we were unable to identify the reasons for variations between countries, if physicians’ telehealth experiences improved the quality of care they delivered, or if telehealth is being delivered in the most appropriate and efficient ways. More qualitative research will be needed in each of these areas to properly assess the benefits and drawbacks of increased telehealth use.15

HOW WE CONDUCTED THIS STUDY

The 2022 Commonwealth Fund International Health Policy Survey of Primary Care Physicians was administered to nationally representative samples of practicing primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. These samples were drawn at random from government or private lists of primary care doctors in each country except France, where they were selected from publicly available lists of primary care physicians. Within each country, experts defined the physician specialties responsible for primary care, recognizing that roles, training, and scopes of practice vary across countries. In all countries, general practitioners (GPs) and family physicians were included, with internists and pediatricians also sampled in Switzerland and the United States.

The questionnaire was designed with input from country experts and pretested in most countries. Pretest respondents provided feedback about question interpretation via semistructured cognitive interviews. SSRS, a survey research firm, worked with contractors in each country to survey doctors from February through September 2022; the field period ranged from 8 to 31 weeks. Survey modes (mail, online, and telephone) were tailored based on each country’s best practices for reaching physicians and maximizing response rates. Sample sizes ranged from 321 to 2,092, and response rates ranged from 6 percent to 40 percent. For analyses that are limited to primary care physicians who use telehealth, sample sizes ranged from 317 to 2,056. Across all countries, response rates were lower than in 2019. Final data were weighted to align with country benchmarks along key geographic and demographic dimensions.

ACKNOWLEDGMENTS

The authors thank the following for their assistance in producing this brief: from SSRS — Robyn Rapoport, Rob Manley, Christian Kline, and Molly Fisch-Friedman; from the Organisation for Economic Co-operation and Development — Tiago Hashiguchi; and from the Commonwealth Fund — Chris Hollander, Aishu Balaji, Melinda Abrams, Gretchen Jacobson, Rachel Nuzum, Corinne Lewis, Paul Frame, Jen Wilson, Jesse Baumgartner, and Paige Huffman.

NOTES
  1. Michael Mueller et al., “The Health Impact of COVID-19,” in Health at a Glance 2021 (Organisation for Economic Co-operation and Development, 2021).
  2. Organisation for Economic Co-operation and Development, The COVID-19 Pandemic and the Future of Telemedicine (OECD Health Policy Studies, 2023).
  3. Shira H. Fischer et al., “Use of and Willingness to Use Video Telehealth Through the COVID-19 Pandemic,” Health Affairs 41, no. 11 (Nov. 2022): 1645–51; and Jacqueline W. Lucas and Maria A. Villarroel, Telemedicine Use Among Adults: United States, 2021 (National Center for Health Statistics, Oct. 2022).
  4. Munira Z. Gunja et al., Stressed Out and Burned Out: The Global Primary Care Crisis — Findings from the 2022 International Health Policy Survey of Primary Care Physicians (Commonwealth Fund, Nov. 2022); and Jesse C. Baumgartner, Sara R. Collins, and David C. Radley, Inequities in Health Insurance Coverage and Access for Black and Hispanic Adults: The Impact of Medicaid Expansion and the Pandemic (Commonwealth Fund, Mar. 2023).
  5. OECD, COVID-19 Pandemic and Future of Telemedicine, 2023.
  6. American Medical Association, 2021 Telehealth Survey Report (AMA, 2022).
  7. World Health Organization, “COVID-19 Pandemic Triggers 25% Increase in Prevalence of Anxiety and Depression Worldwide,” news release, Mar. 2, 2022.
  8. Molly FitzGerald, Munira Z. Gunja, and Roosa Tikkanen, Primary Care in High-Income Countries: How the United States Compares (Commonwealth Fund, Mar. 2022); and Gunja et al., Stressed Out and Burned Out, 2022.
  9. OECD, COVID-19 Pandemic and Future of Telemedicine, 2023; U.S. Government Accountability Office, “Medicare Telehealth: Actions Needed to Strengthen Oversight and Help Providers Educate Patients on Privacy and Security Risks,” (GAO, Sept. 26, 2022); and Rebecca Fisher, Urmimala Sarkar, and Julia Adler-Milstein, “Audio-Only Telemedicine in Primary Care: Embraced in the NHS, Second Rate in the U.S.,” Health Affairs Forefront (blog), Dec. 5, 2022.
  10. Madjid Karimi et al., National Survey Trends in Telehealth Use in 2021: Disparities in Utilization and Audio vs. Video Services (ASPE Office of Health Policy, Feb. 1, 2022).
  11. Justin Lo et al., “Telehealth Has Played an Outsized Role Meeting Mental Health Needs During the COVID-19 Pandemic,” Henry J. Kaiser Family Foundation, Mar. 15, 2022.
  12. David Nelson et al., “Mental Health Professionals and Telehealth in a Rural Setting: A Cross-Sectional Survey,” BMC Health Services Research 23, no. 1 (Feb. 27, 2023): 200.
  13. American Hospital Association, “Congress Passes Omnibus Spending Bill with Health Provisions,” special bulletin, Dec. 23, 2022; and JoAnn Volk, Madeline O’Brien, and Christina L. Goe, “State Telemedicine Coverage Requirements Continue to Evolve,” To the Point (blog), Commonwealth Fund, Dec. 20, 2022.
  14. OECD, COVID-19 Pandemic and Future of Telemedicine, 2023.
  15. Ateev Mehrotra and Lori Uscher-Pines, “Informing the Debate About Telemedicine Reimbursement — What Do We Need to Know?,” New England Journal of Medicine 387, no. 20 (Nov. 17, 2022): 1821–23.

Publication Details

Date

Contact

Munira Z. Gunja, Senior Researcher, International Program in Health Policy and Practice Innovations, The Commonwealth Fund

[email protected]

Citation

Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, How Primary Care Physicians Experience Telehealth: An International Comparison — Findings from the 2022 International Health Policy Survey of Primary Care Physicians (Commonwealth Fund, Apr. 2023). https://doi.org/10.26099/0q4z-rg92