JULY 2020. A note on our market sizes. We are currently updating our telehealth report to take account of all digital health sectors in a given country. This process will alter and obscure the graphs at the top of the page. To understand the market size please look at the country, which will give an overview of where it has been updated and what is included. 

COVID-19 UPDATE - last updated July 20
The obvious headline is that use of telehealth skyrocketed to unprecedented levels during the COVID-19 pandemic. However, as most players pushed out free solutions and operators used informal solutions over formal ones, the effect on the actual telehealth market is mostly negligible. The pandemic has instead been a turning point for many policymakers and healthcare systems as many roll out new laws that either enable telehealth or facilitate easier scaling. While telehealth players themselves might still be seeing relatively small returns, COVID-19 has cemented foundations on which a robust market might finally grow. 

The stats look to speak for themselves. In France, a quarter of primary care was delivered digitally in the last two weeks in April compared to 1% in the beginning of March. In the UK, 48% of primary care was delivered remotely during April. New guidelines, codes and reimbursement mechanisms were introduced in Poland, the Czech Republic, Ireland, Austria and Belgium, among others while telehealth was allowed for the first time in Hungary and Lithuania. The 20% ceiling cap on remote consultations in Germany was lifted and a double-digit number of new solutions were launched within the space of a few weeks. 

To that end, spending on telehealth has increased. Based on tariffs and usage, HBI estimates that France has spent around €40m on remote consultations and other countries have spent multi-million amounts. This is a substantial market but most of it - we estimate 90% - has been collected by the practices and doctors fulfilling the remote consultation. For example, a doctor working in France may use a telehealth solution to see a patient but that doctor will collect the €25 tariff, paying a small commission to the provider on either a pay-per-use or subscription model. It’s therefore wrong to think of this as a new telehealth market when it is just the reappropriation of the existing primary care and outpatient spend. 

HBI’s market sizes account instead for the revenue collected by the telehealth suppliers. We understand that commission paid to the B2B suppliers on a pay-per-use model has been around 10% of the tariff or €2-5 per consultation where no tariff exists. Some also opt for a subscription model with Doctolib charging €79 pm for its solution on top of the €129 for the booking software. Other business models allow telehealth suppliers to collect the whole tariff as they behave like physical operators - what KRY has been doing in Sweden for years - but this is not a model that has excelled during the pandemic. 

Rather, this B2B model of selling telehealth and supporting solutions is where HBI has seen the greatest acceleration during the pandemic. The biggest operator in this space has become Doctolib, who added a telehealth solution to its appointment booking platform in Q3 2018. It went from providing 1k to 100k teleconsultations per day and had completed 2.5m video consultations through the pandemic. DocPlanner, Doctrin, Push Doctor, and other B2B solutions all tell HBI that they have seen consultations through their solutions increase upwards of 100%. 

There is, however, still a long way to go both in terms of monetisation and utilisation. A lot of the consultations delivered through the peak of the pandemic were actually delivered for free because most telehealth solutions enabled doctors to access the technology at no cost. A major challenge now will be converting free users into paying users. This, plus the fact that most telehealth providers collect only a fraction of a telehealth tariff, is where the dollar falls short and why the actual market remains relatively small. 

When we also dig down into the data, it’s becoming clear that many healthcare operators are opting for - or making do - with informal telehealth solutions like Skype, Zoom, WhatsApp or plain old simple telephone calls to conduct their remote consultations. The use of video consultations in the UK is actually at its lowest point since November 2018 (the oldest data available) with 44k in April compared to an average of 120k per month in 2019, according to data from NHS Digital. Telephone remains the most popular tool, meaning the biggest beneficiary of the pandemic here might just be landline providers. 

Last updated November 2018 
Increasingly in the healthcare industry, we all hear that digital is the future. But first, it needs to find a payor and a model that is profitable. The European teleprimary care market is a new and exciting market where success depends on any number of variables. However, it’s risky. Few telehealth providers are actually making a profit and markets remain small despite huge proceeds from funding rounds.

And yet - there are opportunities here. For telehealth providers looking to sell, for insurers and private healthcare providers looking to buy, and investors who want to get ahead of a market explosion. We predict a telehealth boom over the next three years.

Definitions

This report focuses on teleprimary care, where health providers deliver traditional primary care through telecommunications: whether that be chat, telephone call or video call. By traditional primary care, we mean when patients consult with a family doctor or nurse, receive a diagnosis, order a prescription and have access to sick notes. Not all of these functions are legal in each country - and none are legal in some.

Yet this definition is sometimes too simplistic as the major telehealth companies start to offer services outside of traditional primary care. Sweden-based KRY, for instance, is providing remote CBT therapy for patients living with mental health conditions and Medicheck is allowing patients with chronic conditions access to specialist doctors through telecommunications.

“I think we are seeing these barriers between primary and specialist care broken down,” says Samuel Danofsky, a spokesman for KRY. “In the long run, we will probably be able to do more tests in the patient’s home. We will see more self-examination, home monitoring and real-time data submission. Once the issue is diagnosed, more and more conditions can be dealt with at a primary care level.”

There is a market beyond traditional primary care but the market might be moving too fast: teleprimary care is not yet a fully developed market across Europe and the Middle East.

Impact

Teleprimary care can enable huge cost-savings for health care providers and insurers because doctors can treat higher volumes, patients are better signposted and there is less treatment wastage. Providers estimate that it is possible to deal with 70-80% of all primary care issues remotely. Doctrin has claimed that 30% of patients opt to use a path where they first consult a symptom checker, then text a doctor, then can meet face-to-face. 80% of these patients decide they don’t need a face-to-face consultation.

This can lead to huge efficiency savings for physicians which translate into cost-savings for insurers and healthcare providers. Medgate estimates that it has seen a 15-20% reduction in insurance costs through its teleconsultation service. This is only boosted once AI is added into the product. Medgate sees an efficiency saving of 40% when it is used as triage.

“Out of 100 patients 50% can be treated directly on the phone,” says Medgate’s Andy Fischer. “The rest have to be referred so we lose effectiveness on those. We’re using AI to decide which patients will profit most from telehealth. We’ve found that around 80% of patients can be treated telemedically if you use AI - without AI you only substitute 50% so you increase effectiveness by around 40%.”

A customer-facing AI diagnostic tool could improve efficiency, but only once patients can perform home-based lab and diagnostic tests. “This will increase our input dramatically,” says Fischer.

When the AI is front-facing it can keep patients out of A&E, by signposting them towards adequate treatment and can help to diagnose, within minutes, rare conditions that might be missed by multiple doctors over extended periods of time. "I see huge saving potential when you apply AI in the right way," says Ada’s Nathrath. "I'm convinced that several % of overall health care spending can be saved." Hospital groups in Germany also perceive telehealth as a way of winning new patients.

All of this depends on penetration rates. In a country with universal reimbursement, we expect telehealth penetration to hover under 1% for a couple of years, before reaching 1% and then leaping to 3%.

Tele-primary care could ultimately mean that the NHS and public payors can focus more on chronic disease management programmes and have face-to-face consultations with the seriously ill. It is not difficult to see the attraction of all this for payors. Insurers can manage patient pathways whilst also developing a relationship with patients who will increasingly see the insurer badged service as the first friendly point of call. 

Business and payment models

The problem for many telehealth providers is finding the business model, it is not an easy product to monetise. We have divided the market between payors: public, insurance, private healthcare provider, occupational health, value-added service and B2C out-of-pocket. Below we explore each market...

Government: public payor and statutory insurers
This funding model is where telehealth has so far been successful and where we expect the market to grow significantly in the future. Here, we are looking at where governments who fund universal health care, or statutory insurers, have a reimbursement system pays for-profit companies for telehealth services. We do not include governmental 'innovation funds' that are sometimes set aside for health tech. We estimate that the 2018 public payor market is worth €58m, and predict it will grow to €133m in 2019, getting to at least €345m by 2020. We have assumed that most European countries will introduce telehealth reimbursement by 2020 and telehealth penetration will increase significantly where this reimbursement is nationwide and sufficient. We see this market growing fastest in France, Germany and the UK.

B2B

I. Private medical insurance

Private medical insurance (PMI) is one of the biggest and fastest growing markets for tele-primary care. We estimate that 80m-90m people across Europe and GCC have PMI or supplementary insurance and providers expect 3-10% of these to adopt telemedicine where it is provided. We expect 2.4m-8m people with PMI to be using telemedicine in the next 3-5 years.

France and Ireland are the biggest markets here, with 90% and 40% respectively having some kind of private medical insurance. 19% of the Spanish population, 11% of the German population and 10% of people in the UK have opted into PMI. Of these, France presents the greatest opportunity because the state has just introduced measures to reimburse telemedicine consultations at the same price as physical.

Insurers are keen to buy or build telemedicine services because it reduces costs, allows them to better control the patient pathway and changes the public perception of the insurer: they transform from being a gatekeeper of treatment to a provider of treatment. There’s an opportunity to sell both telehealth tech and service since insurers don’t tend to employ their own doctors.

The market could grow even faster if providers tackle the ‘adoption hump’. One international insurer tells HBI that adoption rates triple from 3% to 9% if it removes the excess charge when patients utilise the telemedicine services instead of visiting a physical primary care setting. Aetna International says that 76% of patients who use their telehealth services return.

Countries with highest levels of PMI:

France: 90% have Supplementary insurance. 60m people. Expected 1.8m-6m people.

Ireland: 40% have PMI. 1.92m people. Expected 57k-192k.

Spain: 19% (8.9m people). Expected 267k-890k.

Germany: 11% (8.8m). Expected 264k-880k.

UK: 8% (4m). Expected 120k-400k.

Ii. Private healthcare providers
It is possible to sell telehealth services to other private healthcare providers. Here we mean for-profit outpatient clinics and hospitals but also private general practices whose sole customer is the publicly funded healthcare system. B2B presents a good opportunity where the payor sees telehealth as complementary to existing physical primary care services and not competitive.

There is also the opportunity to sell into private acute care facilities. Sweden-based digital health company Doctrin sells telehealth solutions to private acute care provider Capio, which at the time of writing is yet to be incorporated into Ramsay. The technology is implemented into a tool for doctors and in a national online GP consultancy service. Those countries with high proportions of private hospital beds - Czech Republic (14%), Germany (30%), Spain (19%), Greece (33%), Poland (19%) - present a good market opportunity.

Iii. Occupational healthcare

Many telehealth providers sell services to Europe’s largest employers, who want to keep their staff healthy and at work. Here we would expect providers to sell tech and service. It means they also have more control over treatment and access to healthcare. The market is hard to gauge since deals are often confidential but we estimate that the 2018 market is worth €21.4m and could reach €69m in 2019 and €175m in 2020. Many providers tell HBI that these occupational health contracts form the majority of income while they wait for governments to introduce reimbursement or other models to become more profitable.

Iv. Add-on service

So how do you deliver telehealth to people whose governments don’t allow reimbursement, who don’t have private medical insurance, and who don’t work for a large company? Some telehealth providers are experimenting with adding remote consultations to more common types of insurance or services. DocDoc, in Russia, has a deal with the Sberbank, country’s largest bank that has 100m consumers to offer telehealth as a value-added service. One other large telehealth provider tells HBI that it is considering working with home and motor-based insurers. Providers could even target telecommunications or gym and wellness memberships. Again, we expect providers to sell both tech and service. We think this market is small and have predicted low forecasts because there are too many variables. However, we see a real opportunity to deliver telehealth to more people.

B2C - out-of-pocket

The B2C market is tough - we predict that just 5% of consultations are paid for OOP. The cost of patient acquisition is high since most patients can visit existing primary care facilities for free. We think the market is largest in big metropolitan cities and rural areas with low access to primary care and estimate that the 2018 market is worth €16.9m. We predict that the OOP market will decrease relative to the public payor and B2B markets.

Modes of delivery

Proponents of text-based chat argue that it is much more time efficient than video or telephone consultations. “You can only do four or five consultations an hour with video,” says Min Doktor CEO Laurens Leurink. “And there’s no data.” He explains that one doctor could treat between eight and 10 patients in an hour over text-based chat if their conditions fell into 50 health guides designed by the company.

Magnus Liungman of Doctrin is also unconvinced by video consultations. “It’s not going to radically change or improve anything - it’s a telephone with an image,” he says, adding that he’s seen a 40-50% productivity increase with chat compared to 0-30% with video. Most of the major providers do still offer video consultations for necessary treatments, like dermatology, but it is not their first port-of-call. The video consultation space is filled more with smaller startups in markets where telemedicine is in its infancy or companies that have invested in luxury telehealth services for corporate clients.

Not everybody is convinced of the merits of AI. “To offer a safe instrument that is sensitive and specific you have to ask a lot of questions and you lose patients,” says Medgate’s Fischer. “That’s the main issue at the moment- the public doesn’t trust the instruments so we don’t believe it’s the right time to implement a fully diagnostic instrument.”

Market size
We have estimated each market size by looking at the number of primary care consultations that take place each year in a country and how much we would expect each telehealth consultation to be reimbursed at. This ranges from anywhere between €2 to €45 depending on what type of consultation is being purchased, who the payor is, and what country it operates in. The lower end of the scale would cover the cost of the software only and might be paid by healthcare providers that already have access to doctors. The higher end of the scale is the rate at which some public payors refund primary care consultations. 

The level of penetration typically hovers below 1% for a couple of years and reaches 1% normally within the first year of national reimbursement. We then expect to see penetration reach 2% the year after and 4% the year after that. This is why our growth rates are sometimes staggering - and we suggest that the number of consultations is perhaps a better indicator to measure the market. 

The future of the market / growth prospects

Telehealth has already disrupted the traditional primary care sector and this could be an opportunity to consolidate a very fractured primary care market. We think this will take time and depends if companies can find the business model that cracks challenging adoption rates and adequate funding.  

The big American tech firms could make a pivot to healthcare. Amazon has already bought into pharmaceuticals, is quietly employing a team of healthcare professionals and it has already patented technology where Alexa can recognise a cold and offer medication. Also let’s not forget the East’s large tech firms: one provider has said that Alibaba is interested in the market. “I think we’re going large existing players that are not today within the healthcare industry coming in and disrupting the sector,” says KRY’s Danofsky. “Also within the med-tech sector, I think we’ll see a huge development in medical devices, home testing and home monitoring that will become part of primary care.”

It’s also unlikely that teleconsultations will be restricted to primary care to such an extent for much longer. Indeed, we’re already seeing companies offer CBT and remote access to specialists for patients with chronic conditions. Babylon is already developing features like AI-powered health assessments, coaching, and monitoring, and CEO Ali Parsa signalled that the company is looking at online paediatrics and psychotherapy. This expansion will depend on the digitalisation of the whole patient journey. “For us, the patient journey is so much more complex than a doctor consultation,” says Doctrin’s CEO Liungman. “It involves primary care, triage, follow up visits, chronic patients. We need coordination between primary care, specialist care and even community care.”

This is all very ambitious. Large health authorities have been trying to implement integrated care for years and digitalisation on this level requires a huge expenditure in software and training. Like many large tech companies, the main players (and their small competitors) have huge burn rates while they wait for the market to develop. But investors do see potential in the market. Babylon has raised at least €75m through funding rounds, valuing the company at a reported €175m, KRY has raised €26m and Ada has raised €40m. Medgate, Europe’s largest player, is even profitable, we hear.

One potential risk to the market is that the groups purchasing telehealth services - public and private healthcare operators, insurers, etc - will start to develop their own capacity to deliver remote consultations. We know that one large insurer is already doing this and many possess the capital, if not the expertise, to invest in this. The insurer that HBI spoke to suggests the advantage of hosting its own telehealth services is that it can better control the patient pathway. This will obviously draw revenue away from the pureplay telehealth companies and perhaps even leave them obsolete. There's nothing to stop doctors just using Skype to contact their patients - and in fact many already do. 

Austria’s digital health economy is managed and delivered by the state with little input and few initiatives from the private sector. A recently launched government-run telehealth and triage platform links into a more developed electronic patient record system meaning we expect to see some population health, big data-led initiatives over the next couple of years 

Telehealth
As of early 2021, there is still no legal framework for the practice of telehealth in Austria although the country’s Medical Association released guidelines in March 2020 urging doctors to use Skype, a phone call or email to treat patients. It agreed with the statutory insurer (ÖGK) that such visits could be billed as if delivered in person.

We estimate that a maximum of €80m was billed for teleconsultations by doctors in 2020. They billed €94m total in 2018 (the last data available from ÖGK) growing year-on-year at 6-7% and visits including telemedicine are down 25%.  

The Austrian state is trialling its own telehealth solution, called ‘visite-e’, for seven months until June 2021. All medical professionals and hospitals will be forced to use this platform as the country doesn’t welcome private sector telehealth providers, believing that they fragment the market.

Private insurers have launched services using a handful of telehealth suppliers including 1health GmbH, Latido, and drd doctors. We expect this market to remain small compared to the state-led one. 

e-Prescriptions
Austria is expected to launch e-prescriptions in Spring 2021 starting with a three-month pilot, according to the Austrian Chamber of Pharmacists. 

Electronic patient records
The electronic patient record known as ‘ELGA’ was started as early as 2015 in an opt-out system: 97% of Austrians participate. It is completed by healthcare professionals but can be moderated by patients. It includes: discharge letters, laboratory and imaging results and medication information. Physicians, hospitals and pharmacies are already connected with care facilities joining through 2021. 

Digital therapeutics/health apps
The ÖGK has said it's in the very early stages of working on a plan for the reimbursement of health apps. It has said that compensation is possible if it forms patient treatment but there is no formal procedure for accreditation or reimbursement. 

Booking platforms
The largest player is DocFinder, which claims to have 6m patient inquiries a month. For context, there are around 53m primary care consultations a year in Austria.

The telehealth sector is still weak in Belgium but a framework set up at the beginning of 2019 has started to allow for a spectrum of digital health tools, from triage to digital therapeutics, to be reimbursed by the country’s public insurer. The country has an eHealth action plan running in its second phase from 2019-2021. A big theme is interoperability and data sharing.

Digital therapeutics/health apps 

Belgium is ahead of many of its European neighbours in that it has had an established framework for health app reimbursement since Jan 2019. However, none of the 20-30 apps currently working through the system yet have full reimbursement from Belgian statutory insurers (as of Feb 22, 2021). 

The framework is organised as a three-tiered pyramid with apps able to claim reimbursement at tier 3, once it has proven “socio-economic added value”. The first stage is CE accreditation and the second is proof of interoperability with the Belgian healthcare system. 

The project, called mHealthBELGIUM, is joint-run by medtech representative body beMedTech, the tech industry body Agoria, plus three national authorities made up of insurer INAMI, regulator the Federal Agency for Medicines and Health Products FAMHP, and ‘eHealth’, which manages the interoperability tier of the pyramid (M2). 

Its scope is quite wide and permits any digital health tool to start the process. Some examples of the apps that have at least reached the first stage include: a remote diagnosis and monitoring tool for sleep apnea, an app that uses an EEG headset to automatically log seizures, a PACS solution for making images viewable on the web,  a handful of wider remote monitoring solutions. 

Telehealth

Belgium payor administrator INAMI issued temporary reimbursement for remote consultations early in the COVID-19 pandemic at an average cost of €22.50 depending on speciality. It started with COVID-19 treatment and remote psychiatry but has since expanded into chronic disease management, plus dentistry, speech therapy and occupational healthcare therapy. 

In 2020, 6m consultations were delivered remotely at a cost of €135m, accounting for 15% of the total, according to statistics from INAMI. 

In general, the for-profit sector has been much slower to catch on than in neighbouring countries and many of the consultations reimbursed through INAMI were delivered via tools like telephone or Skype. 

Early adopter, for-profit player ViVi Doctor, went bankrupt in Q4 2019 despite a €400,000 seed round and a pilot with Saint-Luc university clinics. We see some activity in the B2B space with teleconsultations tacked onto booking platforms, a model that has been successful for Doctolib in France, meaning that the bulk of, if not all, teleconsultations have been completed by traditional doctors. 

e-Prescriptions 

Electronic prescriptions have been compulsory since Jan 2020 and are widely used since 2018, as part of the 2013-2018 eHealth Action Plan. 

Electronic patient records

Belgium has not updated its EHR progress since early 2019 but at that time about 15% of hospitals had fully integrated EHRs, 75% used e-prescriptions and 60% had an electronic nursing file. Considering that e-prescriptions became mandatory at the beginning of 2020 we expect this to have increased substantially. 

It deploys summary EHRs, officially called Sumehrs, for doctors to share brief records with other doctors in a bid to improve integrated care. The system, which is opt-in and run by Vitalink, also has capabilities for different healthcare providers to see data on medication, vaccinations and screenings. The last two are the most popular with about two-fifths of the population signed up. 

Telemonitoring

Tools for telemonitoring are included under the new reimbursement mechanism mHealthBELGIUM, although INAMI also has a reimbursable pilot scheme for healthcare providers to remote monitor COVID-19 patients. 

As the pilot ends in Dec 2021 it will likely lead to a framework for paid telemonitoring of other chronic illnesses. Tariffs range from a €34 set up fee with €65-€100 per week depending on the amount of tech needed. Compare this to the inpatient day rate of €500-€1000 and it’s clear there are savings to be made. The private sector can plugin here, with start-up Byteflies and medtech group Philips, among others, supplying solutions to the market.

Czechia has made baby steps in the use of digital health with the public statutory insurers starting to reimburse both telemedicine and telemonitoring. The government approved a bill on electronic health at the beginning of 2021, which set up a framework for better data sharing. 

Telehealth

Czechia’s public insurers introduced temporary reimbursement for telehealth in March 2020, at the beginning of the COVID-19 pandemic with the largest, VZP, leading the charge. The fee is around 300 crowns (€11.60) with the consultation length set at a limit of 15 minutes. 

We estimate that there were 650,000-700,000 remote consultations in 2020, making the spend around €8m. We count 178,000 distant consultations for GPs at VZP between March-September (the latest data available) but we forecast around 400,000 for the whole year because of expected higher utilisation Oct-Dec due to the second wave and that billing for remote consultations was extended to the outpatient sector in October. We then assume that VZP has a market share in line with the share of the population it covers: 60%. 

Telemonitoring

Like telehealth, the public insurers have led initiatives in reimbursing telemonitoring. The country’s second-largest ZP MV ČR will reimburse up to CZK 1,500 (€58) for children and CZK 500 (€19) for adults for telemonitoring for cardiovascular illnesses, diabetes and sleep apnea alongside select medical devices. 

e-Prescriptions / sick notes 

Electronic prescriptions have been mandatory since January 2018 and are used widely. In 2020, more than 79m electronic prescriptions were dispensed and by the end of the year virtually all doctors and facilities are registered on the system. Doctors and pharmacists may view an electronic list of a patient’s prescribed medicines in an opt-out system. 

Electronic sick notes were introduced in Jan 2020. 

Electronic health records

The strategy for EHRs is not as developed or successful as e-Prescriptions. Czechia did have a patient data sharing system (IZIP), which was majority-owned by public insurer VZP running from 2001-2012, when the health minister deemed the project useless. IZIP was bought by Nordic Investors but the project does not appear to have prospered. 

Telehealth

The public sector has won control over the telehealth market in Denmark with a solution managed by the doctor’s union (PLO) taking a 90% market share of the 330,000 remote consultations run in 2020. It works by embedding into GPs’ practices and accounted for 2% of all primary care last year. For-profit player Hej Doktor continues to run in a handful of public partnerships and in a B2B positioning. 

A tariff for video consultations was introduced in Oct 2019 at 161.50 kr (around €20) and email consultations 45,72 kr (€6). Statistics from PLO show that video consultations went from four (not a typo) in the first week of March, to 15,700 in the last full week in April, to a peak of 22,900 at the end of March. Based on an average of 15k visits a week from mid-March we estimate that around €4.5m has been spent on video consultations although the bulk of this will be paid to the practices.

Telemonitoring 

The public sector has a couple of nationwide telemonitoring programmes for chronically ill patients on COPD and heart failure but there are no big initiatives from the private sector. A study found that the programme reduced costs by 35%. 

Digital therapeutics 

There is yet no widespread reimbursement framework for digital therapeutics, although providers can apply to the Danish Medicines Agency on a case-by-case basis. 

e-Prescriptions 

Electronic prescriptions have been used widely for at least a decade in Denmark and have been mandatory for around three years. 

Electronic patient records

Denmark has a digital health portal called sundhed.dk where patients can see their data from the public sector like treatments, medicines, drug allergies, laboratory tests as well as register for things like organ donation and give power of attorney.  

A digital health market exists in Finland but it is largely embedded in the existing private and public healthcare sectors with little disruption from B2C players. The country’s university hospitals are leading a push on telemonitoring and digital therapeutics by launching tenders for solutions for their patients. Healthcare reform, known as SOTE, will move procurement from around 300 bodies to 21 regions over the next few years, presenting the opportunity for region-wide contracts.  

Telehealth

Finland has not had to undergo the same deregulation as most other markets as telehealth has always been permissible. In the private sector, the large occupational healthcare players dominate the market by offering an on-demand, digital front door to their services built largely inhouse. The public sector also offers telehealth services for people without employer coverage, where they mostly partner with external suppliers. 

The for-profit market is about €5m in 2020. This is made up of external telehealth suppliers to the public and private sectors: the main player VideoVisit Oy has an 85% market share. We have not included any revenue from Terveystalo or Mehilainen into the market size as it is a free add-on service to its corporate and public services and is therefore indistinguishable. 

    Occupational healthcare market - Digital health was a core strategy for Terveystalo and Mehilainen before the pandemic, although it did hugely boost utilisation. Both have been building digital front doors - Terveystalo claims its waiting time for an online appointment is seven seconds - for corporate and out of pocket patients. In 2020, around a quarter of Terveystalo’s 7m visits were digital, a quadrupling of volumes although it increased its IT spending by 20%. Mehilainein, which has formed a new company to export its digital health services, says users of its remote services grew fivefold to one million, representing 90% of its total base. Both companies invested about €30m in digital health over the year. 

For patients without employer coverage, Mehilainen charges €33.90. 

B2B/G market - B2B/G sales are mostly to Finland’s 310 municipalities, who offer varying levels of remote consultations all the way from primary care to follow up as part of the normal patient pathway. Most use external suppliers for the tech with the biggest being VideoVisit Oy, which serves two-thirds of the municipalities and has an 85% market share. As part of SOTE reforms procurement will move to 21 bigger regions, central Finland has already launched a platform called OmaKS that has a chatbot, symptom checker, online consultations among other stuff. 

”People who don’t have employer coverage will almost always use these services rather than pay out of pocket, that’s why we don’t have a big B2C player in the market,” says the CEO of one digital health provider in the market.

Telemonitoring 

The telemonitoring market is mostly driven by university hospitals tendering for solutions to monitor chronically ill patients at a regional level. The handful of B2B suppliers (Medixine, Forsante) build solutions that can be wrapped around any use case, mostly paid on a per-use basis. “Our partners provide the content and we provide the solutions to deliver it,” the CEO of Medixine tells HBI. Most projects started in 2018/19 and are still in the pilot stage, having been paused during the pandemic. 

We are also starting to see the for-profits take notice of such tools. Pihlajalinna has a new project with Medixine to monitor its diabetes patients, with hopes that it will later cover more chronic diseases. 

The market is worth about €6m in 2020. 

E-prescriptions / electronic patient records 

The two are common and often paired together in Finland. At least half of its citizens use Omakanta, which is managed by social security body Kela, to organise prescriptions, see laboratory results, check wellness information, among other capabilities. Helsinki University Hospital (HUS) also has its own project called Apotti. It is primarily an EHR system built on Epic that combines health and social data but does have a patient-facing portal to book appointments, fill in health questionnaires, submit social care applications, and even includes video consultations. 

Digital therapeutics 

The DTx market is a little bit behind the telemonitoring one, HBI is told, but is starting to develop with new companies in the market. Orla launched in January 2020, acquiring rival Elisa in September. Finnish pharma group Orion is also building solutions in partnership with universities. Policymakers, who have started to regulate DTx, say the goal is to build digital health apps into Kanta (described above). There has been no public talk of building a separate reimbursement and approval model similar to that in Germany or Belgium. 

France is relatively ahead on reimbursement for digital health tools: telehealth consultations have been reimbursed since September 2018, a scheme for telemonitoring is likely to be introduced in 2022 and a new amendment allows faster reimbursement for digital therapeutics.

We have increased our market size because we now add in all digital health tools, including doctor booking, which is a large market and in many instances indistinguishable from telehealth. 

Telehealth / booking platforms

Remote consultations swelled in France under the pandemic, with over 17m reimbursements in 2020 and the French payor CNAM spending €430m in the process. At the peak of the first lockdown, it was reimbursing 1m teleconsultations a week, compared to just a few thousand before, with teleconsultations representing just over a quarter of all consultations. 

It is reimbursed at the same rate as physical consultations of between €23-€58.50 depending on the speciality. Before the pandemic, CNAM paid 70% with the mutuelles paying the remainder but has since become fully reimbursable and will stay that way at least until the end of 2021.

The B2B model of providing the software to doctors has largely won over any B2C models as the tariff structure hugely favours a patient’s own or local GP. Doctolib has become the clear frontrunner in adoption among doctors: it started as a booking platform, later adding telehealth once reimbursement started in 2018 and sells to 150,000 out of 200,000 doctors and 90,000 physiotherapists in France. The reimbursement model has left B2C players like Livi/Kry scrambling to scale. 

We have categorised the €430m as the ‘total market’ because the majority is retained by liberal doctors and telehealth is provided as a software-as-a-service (Saas). The for-profit market size is made up of revenues from SaaS sales and where the supplier can retain the reimbursement.  As an example, Doctolib charges practitioners €129 per month for its booking software and with an additional €79 per month for telehealth tools, giving it estimated revenues of around €370m for 2020. 

France is also the market that has been targeted by consolidators. America’s largest telehealth player Teladoc Health bought MédicinDirect in 2019, which works primarily with employers and insurers while HealthHero has bought top-five player Qare. 

Digital therapeutics 

Digital therapeutics can be reimbursed under the framework used for medical devices, the LPPR (Liste des Produits et Prestations Remboursables). There is only one solution eligible so far - a telemonitoring solution for lung cancer - but a process introduced in June 2021 should accelerate access to the market. Health authority HAS will allow solutions to be reimbursed for one year while waiting for official approval under the scheme, which in effect gives 12 months to collect clinical evidence for the later claim under the LPPR. Looking at pricing, the lung cancer solution Moovcare costs €500 quarterly.

Telemonitoring 

The LPPR reimbursement mechanism will be a route to market for most telemonitoring solutions. However, France has said it will introduce a specific framework at the beginning of 2022. It has been running a four-year pilot called ETAPES for five chronic diseases that reimburses the doctors and industry solutions. Some kind of model is expected to be included in the health budget to be discussed in autumn 2021. 

The supply remains very fragmented: there are over 100 approved solutions on the pilot scheme that includes medtech, pharma and start-ups. 

e-Prescriptions 

Prescriptions are mostly still paper in France but it has an objective to make all prescriptions electronic by 2022. A bill signed at the end of 2020 sets out a framework for the adoption, which will start with experiments for certain kinds of prescriptions. Patients will be able to see the prescriptions on a shared medical file (dossiér médical partagé [DMP]) hosted by statutory insurer l’assurance maladie, which are themselves transitioning to a new platform by the beginning of 2022 called Mon Espace Santé. 

Electronic patient records 

About a tenth of France’s population used the version of electronic patient records (dossiér médical partagé) that is being phased out. It gave patients access to their test results, allergies, and treatments. That information will be included in the new version - Mon Espace Santé - but it also adds secure messaging, a health diary and a catalogue of mhealth applications approved by the state. 

Thanks to exuberant health minister Jens Spahn, Germany has passed a raft of legislation over the last three years to make the country a leader in digital health. It has pioneered a new reimbursement model for digital therapeutics, is set to reimburse telemonitoring solutions, and has given German hospitals €3bn to digitalise. 

A note on market size. Our ‘public market’ size looks at how much traditional public healthcare operators have billed for digital health minus the cost of the digital health software they use to provide the service. Our for-profit market size looks at the earning of the digital health operators. 

Telehealth 

The de-regulation of telehealth kicked off with the German Medical Association lifting a ban in mid-2018 but regional implementation, alongside restrictions on digital prescriptions and sicknotes, left the market limping. 

Before the pandemic, the only reimbursable type of telehealth was existing practices seeing their own patients digitally. Even this was under the restriction that no more than a fifth of consultations could be remote. However, 2020 saw that cap removed and the first suppliers approved in the on-demand B2C market. 

Since 2019, physiotherapists and psychiatrists, among other ancillary services, have been allowed to deliver telehealth. Ancillary services like midwifery were temporarily allowed through the pandemic. 

Different types of markets

There are two main markets in German telehealth. The first is selling SaaS (software as a solution) to the practices, the second is providing on-demand online appointments. Suppliers in the former have no need to employ doctors, whereas the latter often do: either as full-time employees or on a freelance basis for a few hours a week. 

1. The practice market 

There are around 102k practices in Germany, with around 40% offering video consultations and 44% using digital for at least half of touchpoints with their patients, often email. Reimbursement is complicated but doctors bill for their normal rate plus various surcharges that comes to around €30-€50 a visit. 

1.4m video visits were billed in the first half of 2020 (the most recent data available) by family doctors and psychotherapists compared to 3,000 for the whole of 2019. This gives a market of €120m-€150m (our total market size), assuming around 3m consultations across the whole year. This is still a very low penetration rate considering there are around 1bn doctor visits a year in Germany. 

The practices fulfil the video consultations through approved suppliers, so informal tools like Skype and Zoom are not allowed. The biggest players are Doctolib and CLICKDOC (which also offer on-demand services for patients) and RED medical and Deutsche Artz (which don’t) priced at €9-€50 per user per month for varying levels of capability. Here we see the commoditisation of telehealth, one investor tells HBI that it’s a “race to the bottom” and Fresenius Helios, Europe’s largest hospital group, says that it decides supplier on price. 

An annual survey of doctors by association KBV found that four in ten medical practices offered video consultations in 2020, two in ten offered online booking, and one in ten offered online prescription ordering. A further four in ten offered no digital services at all!

Based on the KBV data we estimate there are 70k doctors using telehealth software at a cost of €240 a year, making a total for-profit market of around €17m.

2. The on-demand market 

Since mid-2020, patients have been able to see an online doctor on-demand and have it reimbursed. Here, the providers employ doctors full-time or part-time and take a cut of the fee or charge for a subscription to the solution. There is invariably overlap with the practice market described above and it is often practice doctors employed by the suppliers, using the route to earn extra income. The important differentiation is in who initiates the contact: it is a B2B market but at the demand of the customer. 

The biggest players here are TeleClinic, bought by Zur Rose in 2020 to slot into its online pharmacy ecosystem, Kry/Livi, and Zava. The tariff is only covered if the suppliers have contracts with the patient’s statutory insurer. This market is so far smaller as most players are still in the early stages of commercialisation: TeleClinic hoped to hit 100k consultations by the end of 2020 and is monetised by an undisclosed cut of the €30-€50 tariff. We therefore estimate that this market is worth less than €5m in 2020. 

The suppliers here will increasingly face competition from statutory insurers. Techniker Krankenkasse, the largest with 10m covered, was the first to launch video consultations combined with e-prescriptions and sick notes. As TeleClinic CEO Katharina Juenger tells HBI: “It’s only really TK that has in-sourced digital know-how, all of the others don’t have any technical knowledge. That means we probably won’t have a partnership with TK and if you are insured with them then you will probably use their service but there are over 100 public insurers in Germany who we are ready to work with.”

3. Referral streams for hospital groups 

This market has not taken off at all. A joint-venture between Switzerland’s largest player Medgate and hospital group Rhoen ended as the Rhoen-Asklepios merger slowed the project. A separate joint-venture between Fresenius Helios and Canadian telehealth company Dialogue to build telehealth/digital occupational health services has also quietly disappeared. The strength of patient choice laws likely impacted both of those decisions. 

Digital therapeutics

The jewel of Germany’s digital health progression is its specific reimbursement programme (know widely as DiGA) for health apps and digital therapeutics. From a commercialisation perspective it’s still early days, the first apps qualified for reimbursement in October 2020 and based on statutory insurer data HBI estimates that 0.02% of all prescriptions were apps. This makes a market of less than €2m in 2020 but sources are optimistic about growth as doctors get used to prescribing. 

Apps on the DiGA catalogue must be approved by the Federal Institute for Drugs and Medical Devices (BfArM). The supplier decides a price then have one year to collect outcomes evidence (real-world or clinical), after which it negotiates a final price with the GKV (represents all statutory insurers). There are 19 approved apps as of July 13th 2021, normally priced at €250-€500 for a 90-day prescription. Most are the only solutions owned by their parent companies but GAIA is a notable exception. It has a portfolio of DTx apps and has been selling B2B already for over a decade. 

The biggest challenge remains adoption. Most suppliers have partnerships with pharma companies to use their sales distribution channels but there is no extra incentive for doctors to prescribe their use. 

Telemonitoring 

Acute care telemonitoring apps would be reimbursed under the DiGA framework but a new scheme specifically for care apps is due in 2022. The DiPA will allow reimbursement for a broad range of use cases that help in long-term care from supervision, to brain and body exercise, to organisation. The budget is a little bit tighter than the DiGA with carers able to reimburse two solutions at €50 a month. The long-term care insurances expect to pay €30m in its first year and €65m in its second. 

The Hospital Future Act (Krankenhauszukunftsgesetz für die Digitalisierung von Krankenhäusern)

From 2021, Germany’s hospitals will be able to access a €4.3bn fund for digitalisation made up of €3bn from the central government and the remainder from federal states. Health minister Jens Spahn wants it to be spent on modern emergency capacities, digitalisation and IT security. Available use cases include patient portals, electronic health and care records, digital medication management. The fund covers necessary personnel costs. 

E-prescriptions will be mandatory from 2022. Gematik, jointly owned by Germany’s healthcare bodies, is developing a standard app for its implementation and in July 2021 started a trial in pharmacies in Berlin. Over the rest of the year, it will be rolled out into clinics, hospitals and pharmacies nationally. 

Electronic patient records.

All statutory insurers must offer an electronic patient record from 2021. Its rollout was slightly muted as many are minimum viable projects and most patients don’t even know they exist. EPRs are given as a use case for Hospital Future Act spending.

Greece has a national digital health strategy focused on digitalising hospitals and medical records. Much of the transformation is being funded by the EU’s recovery fund. It has a nascent telehealth sector dominated by one player with government contracts and a few pilot projects in telemonitoring. 

Telehealth

Greece has not had to deregulate as current law allows remote consultations at the doctor’s discretion. The main player in the market is Dr Button, which delivers free at the point of use consultations to about half of the country’s 11m population through partnerships with 6 of its 13 regions. These were kick-started due to the pandemic but Greece has made the expansion of telehealth central to its digitalisation strategy so there is hope that PPPs will remain and grow. The market is nascent with Dr Button and rival Telemedico in the early years of revenue and is still worth less than €1m. 

Electronic health records / electronic prescriptions 

This is another pillar under the country’s digitalisation plan. The government is expected to have an early version operational in August 2021 that will allow patients to see data from both the public and private sectors, referrals, tests and medical certificates. 

Digitalisation of hospitals 

The government is keen to digitalise its public sector hospitals, making this another key priority under its national digitalisation plan, but has not expanded on what this will look like. 

Booking platforms 

There are a couple of early adopters with the most established being Go2doctor but the sector is nowhere near as well established as markets like France. 

Telemonitoring 

There are a small handful of telemonitoring public-private partnerships, including medtech company Biotronic building Greece’s first specialised remote monitoring centre, but the sector remains underdeveloped.

Telehealth

Telehealth has been reimbursable in Hungary since the government deregulated it in April 2020 to allow assessment, diagnosis, ordering of tests and monitoring at a distance. That led to a market of about €3.5m in 2020, which is 94% owned by international player Teladoc. The bill allows doctors to treat both bodily and psychological conditions. 

Teladoc sells B2C and B2B to corporate clients, recording €3.3m sales in 2020. It has been in the market since 2006 so the practice did exist before but the new decree formalised the market. Other players do sell B2B to practice doctors but these are much smaller. Medicorp, the owner of B2B brand Medio, made €300,000 in sales in 2020 despite having Triton, Swiss Clinic and others as clients. The platform says it has booked 19,000 appointments and made 6,000 video consultations. 

e-Prescriptions/health records

The Hungarian government has a health cloud called Elektronikus Egészségügyi Szolgáltatási Térből (EESZT) that allows patients to manage refill e-prescriptions and look at health data, among other capabilities. From June 2020, private operators have been able to access and add to the data. It is well used: 22,000 institutions, 28,000 doctors and 13,000 pharmacists use it on a daily basis. The proportion of electronic prescriptions rose from 70% to 95% in 2020. Remote prescriptions were temporarily allowed in the first pandemic but ended when an emergency decree expired in September. 

Telehealth

Ireland’s telehealth players sell B2B to the country’s private health insurers and GP practices but the market is still relatively small: worth less than €5m a year. 

All of Ireland’s major private insurers offer remote consultations to the half of Irish people that have PMI. The largest, VHI, and the second largest, Irish Life Health, both contract with MyClinic. 

A survey of Ireland’s GPs found that 60% of remote consultations were delivered by phone, video and email through the pandemic compared to 10% before. The HSE separately reimbursed non-COVID remote consultations for seven months from March 2020 at €25 but these now must be funded from the capitation fee. A €30 tariff for potential COVID patients and €75 for respiratory patients continues to hold. 

The market has seen some interesting M&A. Pan-EU consolidator HealthHero bought MyClinic in Jan 2021 and VideoDoc was bought out of administration from UK care home group Advinia for £40,000 in February 2020. Accounts show it had sales of just £99,000 in the first half of 2019. Advinia CEO Sanjeev Kanoria said that he has overhauled the group’s business model and is working on a strategy for the next few years. 

Electronic health records

Through eHealth Ireland, the country laid out an €875m business case for an electronic health record system back in 2016/17. Progress has been slow as these have only just entered into the pilot stage, Ireland continues to point to it as a key digitalisation strategy.

Electronic prescriptions 

A new law allowed pharmacies to accept electronic prescriptions in April 2020, to encourage remote care. Most prescriptions are still paper.

Italy has been the sloth of Europe in its approach to digital health but a huge €16bn plan to transform the entire healthcare sector is counting on digitalisation. The state is going to throw billions of euros at telemedicine, telemonitoring and new electronic patient records to try and rebuild one of the worst pandemic-hit healthcare systems globally. 

Telehealth

Italy has been rather late in deregulating telehealth. The Ministry of Health proposed guidelines back in 2014 but the regions did not approve these until December 2021, stifling the emergence of a telehealth market. The market is now attracting a lot of attention due to its size - Doctolib had rushed to set up a team within a month - but it is still at a very early stage. Virtually all B2B and B2C players are in the early stages of going to market as of August 2021. As elsewhere, many traditional healthcare providers are using informal telehealth tools. For example, big imaging and diagnostics polyclinic Centro Diagnostico Italiano (CDI) says its remote consultations are all on Zoom. 

There is hope for quick market expansion. Italy wants to strengthen telemedicine as part of its recovery plan and will build a national platform of accredited providers. That will give confidence to providers like CDI to use more formal solutions. 

Booking platforms 

The booking platform market is slightly more established and is likely to be the business model that a successful telehealth strategy hinges off, as seen in France. The biggest national player, Dottori, had €2.7m sales in 2019 and acquired digital health solution builder Appocrate in Q3 2021. Smaller rival iDoctors had €700,000 in sales in 2020. Both are now offering video consultations and Europe’s biggest booking platform Doctolib is not far behind, having launched at the beginning of 2021. Combined with telehealth, we expect this market to grow fast over the next few years as Italy’s outpatient market consolidates and the state builds more local health and care facilities as part of its recovery plan. 

Telemonitoring

The market is extremely fragmented and there is no specific scheme for reimbursement. However, the regions will be able to collectively access €1bn for projects that support the digitalisation of homecare as part of its recovery plan. The state wants to explore new models of homecare based around digital technologies to ensure it can offer one in ten over 65s homecare services by 2026. Lombardy has already dedicated €166m to the cause and we expect to see some region-wide tenders for chronic disease and elderly care management. Projects must meet state guidelines, which includes interoperability with electronic health records. 

Digital therapeutics

Italy has not made moves on digital therapeutics strategy or reimbursement in the same way as its European neighbours. 

e-Prescriptions

Since 2016, Italy has had electronic prescriptions for what it calls ‘Class A’ medicines, which are drugs essential to manage chronic illness and are fully reimbursable from the state. In May 2020, it extended e-prescriptions to cover all other medicines. Nearly all prescriptions are now electronic. 

Electronic patient records

Italy will spend €1.4bn transforming its badly-used electronic patient records, known as Fascicolo Sanitario Elettronico (FSE), into a portal to deliver digital health services. As it stands, each region manages its own record system leading to unequal and often poor quality systems. 

One in five people have so far activated their profile and the majority don’t even know it exists. 

The transformation is a strategy under the recovery plan, where the state wants to improve and harmonise the service. The goals for it are: to be a point of access for health services for patients, to contain the patient’s entire medical history for the use of healthcare professionals, and to allow local healthcare authorities to capture data to improve services

Telehealth 

The two biggest players in Norway’s telehealth market are Eyr and Confrere. The former is an on-demand service that sells B2C and B2B, having partnerships with Norway’s largest pharmacy groups Farmasiet and Apotek 1, healthcare provider Falck and a handful of insurers. It had just shy of €1.3m sales in 2020 and also raised NOK50m €4m led by state-owned Investinor. Confrere had €1.5m sales in selling directly to small practice GPs (a growth rate of 1,000%!). 

Telehealth has been allowed since 2016 and authorities set out specific tariffs at the beginning of the pandemic. It pays NOK107 (€10) in the day and NOK304 (€29) in the evening. 

Telemonitoring

The government has extended a telemonitoring scheme that centralises procurement until 2024.  Up until now, the Welfare Technology programme has given safety, coping and diagnostic technologies to the chronically ill and elderly and the new remit will extend to disabled children and young people. Nearly all of Norway’s municipalities participate. 

To give an idea of budgets. The programme is giving municipalities NOK49.6m (€5m) on homecare tech, NOK 6m (€0.5m) on tackling loneliness, and NOK7.4m (€0.7m) on tech for disabled children. 

E-prescriptions

Norway has had electronic prescriptions since 2013 that are widely used today. 

Booking platforms 

This is not a sector that has taken off in Norway. One site, Legelisten.no, is embroiled in a five year legal battle with the Norwegian Medical Association over reviews and recorded just €75k in sales. We can find no other competitor

COVID-19 UPDATE - June 19, 2020
During the COVID-19 crisis, the Polish healthcare system introduced reimbursement for doctor and nurse consultations for video, phonecall or chat. Any entity that has a contract with the NFZ can provide remote services. This has been introduced not just at a primary care level but going into specialist care. E-prescriptions are also allowed. This has so far mostly been delivered by a state-led infrastructure. We don't expect much of the new reimbursement funding to fall into the hands of any private telemedicine suppliers. 

Overview. Last updated Nov 2018. 
Poland has a national health-based public sector that has not traditionally worked well with the private sector. For that reason, it’s unlikely that companies can sell B2B to the state but we still see Poland as one of the most exciting markets, due to significant out-patient and occupational health markets. 

Healthcare provider-come-insurer Medicover tells HBI it runs around 350k remote consultations a year and expects this to grow 20-30% every year among corporate clients who pay for employees to have access to primary care and diagnostics. We have decided to include our estimation of Medicover's telehealth expenses in our market share, despite it not directly contributing to revenue, so as to not give a false impression of telehealth activity in the for-profit market. 

We estimate that the 2018 market is worth €4.7m and that towards the end of 2019, telehealth will reach 1% penetration in 2019 due to the growth of occupational healthcare providers and the insurance market. Medicover at the beginning of 2019 covers around 3% of Poland's population and the country's largest insurer has another 4% (although there is bound to be some overlap) and both companies are pivoting to telehealth. This, plus a sizeable B2C field, could make the  2019 market worth €18.4m. 

In 2016 Article 43 of the VAT Act, which forbade remote consultation, was removed from Polish law. But while telemedicine is now permissible it is difficult to get reimbursed. Polish sources say that local authorities do not outsource to private clients, especially under the current nationalist government, so it’s likely that penetration is limited to those operating outside the NHS system.

Warsaw-based eDoktor24, tells HBI it has run just shy of 50,000 consultations in two years. It charges its 15,000 customers between 20 PLN (€4.60) and 160 PLN (€37) for remote consultation and sells both directly to the customer and to statutory-insurance companies.

Symptom-checker Infermedica, based in Wroclaw, hasn’t verticalised its product, it is instead selling the software B2B to private clients like insurers Allianz Partners and Slovakia-based Dôvera. CEO Piotr Orzechowski tells HBI the software has run over 3m patient assessments across Europe and has 2017 revenue approaching €1m. In early 2019 it announced a partnership with Polish lab company Diagnostyka. 

If the market reaches 1% in 2019, HBI estimates that it will jump to 3% in 2020, making the market worth around €68m. 
This level of growth is in line with other European countries that also have established markets, like the UK and Sweden.
 

Largest companies:

eDoktor24

Medicover

PZU

Infermedica
 

COVID-19 UPDATE - June 19, 2020
The coronavirus crisis has led to telemedicine being allowed and reimbursable under the country's healthcare system from May, albeit temporarily. This gives scope for diagnosis and prescription and is reimbursed as a normal consultation but with special codes. We suspect that in the short term this has led to increased use of email and telephones but that if the measure lasts then doctors will start to look at buying digital solutions. 

We have seen the entrance of a few new players since the original update. Doctor booking platform Doclandia has launched video consultation solutions and offered its service to the Ministry of Health for free during the pandemic. Regina Maria delivered 30k online consultations in April but these were delivered through Microsoft Teams. 

Overview, Last updated Nov 2018. 
Romania’s telehealth market is limited by the country’s NHS, and regulations. The legislation is a grey area: it dictates that patients cannot be treated without a physical consultation. This means that the companies offering telemedicine services have to advertise themselves as ‘medical advice’ companies and can neither diagnose nor prescribe.

Medic Chat, the only substantial for-profit player, charges between 15 lei (€3) and 40 lei (€8.60) to send a question to a doctor, which is answered within 24 hours. The company says it has been in operation for about a year and only receives a few queries a week. However, German-telehealth company has launched a project with philanthropic foundation Fondation Botnar to deliver telemedicine to most of the country’s population.

We estimate the market to be less than €0.1m and only growing to €2.6m by 2020. 

Last updated June 19. Includes COVID-19 update. 

Background
The Kremlin legalised telemedicine in 2016. But two years later, talks between the authorities and are still ongoing. In fact, despite the ongoing coronavirus crisis the Duma blocked the use of telemedicine for diagnosis and treatment in May 2020. So far, the service has been used for follow-up consultations and health monitoring. Although we suspect that there is a grey area that has been exploited. 

That hasn't stopped investment and activity in the market. Sberbank acquired the telehealth company whose software it was using, DocDoc, and rebranded as SberHealth in June2020. It claims to treat 7.5m patients through 4,000 clinics, through 30k consultations a month. The bank is making a wider move into e-health services. 

Doc+ (backed by Baring Vostock) withdrew its B2C solution from the market in late 2019, closing its clinics in the process, saying that it wants to focus on B2B solutions. We also see new entrants like BestDoctor who are selling into employers. 

In 2018, Ivan Kartrovitsky, from the Russian National Association of Telemedicine and founder of the forum Doctor at Work said that the plan was to "increase the quality of telemedicine between doctor and doctor. Next year will be devoted for the healthcare between doctor and patient and we will see how the regulation changes." But we see that has not happened. 

Market size
Market estimations and forecasts are vague. Sberbank tells HBI the 2018 market is worth around 3bn rubles (€38m), while Kartrovitsky believes it to be one billion rubles less (€26m). His growth estimates are high: within just three years the market he expects to reach 18bn rubles (€232m) and multiple forecasts predict ten-fold growth within five years. 

We are being a little more cautious. We think the 2018 market is worth 2bn roubles (€26m) and predict that it will grow to 4.9bn rubles (€64m) in 2019, boosted largely by the occupational health and value-added service market. We have downgraded an earlier forecast of 15bn rubles by 2020 and now think it hasn't shifted too far from the 2018 market size because of exits from and entrants into the market place.

COVID-19 has had a negligible effect on the market because the legislation is quite restrictive but we expect the occupational healthcare market to pick up especially here. 

Old update: Nov 2018
Around five or six teleconsultation providers were operating in Russia as of September 2018. One, DocDoc, runs a B2B model through Russia’s largest bank, Sberbank, opening teleconsultations to a potential 100m people. The other platforms, which largely run B2C and are reliant on an out-of-pocket payment, are yet to receive a windfall of cash. Doc+ turned over US$2m last year. “We are open to discussions and investing significant resources in the development of telemedicine in Russia. Now we are engaged in a dialogue with a number of large American companies about partnerships,” Doctis CEO Igor Vornovitsky tells HBI.

So what is the legal situation? Doctors can currently analyse conditions remotely but are prohibited from diagnosing, prescribing or altering treatment unless there has been a physical consultation. Licences are granted to premises not doctors, so doctors can only teleconsult a patient from within their own surgery, and even then must only treat patients within their legal catchment. Start-ups, therefore, cannot recruit the scarce specialists whose advice is needed 5,000km away.

Largest players

• Doctis

• Doc+

• Doctor at Work

• DocDoc, in partnership with Sberbank

Overview. Last updated June 18, 2020. (includes COVID-19 update)

Recent reforms to primary care have created a capitated funding model for Ukraine's GPs. Experts say that this has been a huge funding boost for the public sector, meaning that a lot of centres have been investing in improved services, with telemedicine as one of them. We are seeing a mix of business models. DobroDok works in the B2C space charging 49 rubles for a consultation and TeleMed24 and Helsi are selling B2B, coming from a position of IT supplier and booking platform.  

Our sources say that some of the Russian companies wanted to give it a shot, but were halted by geopolitical tensions. The government has to deliver technical infrastructure before telemedicine can grow. We expect the market to stay small as large operators focus on the French, German and Russian markets and predict the market will grow to €1.8m in 2019 and €5.4m in 2020. 

COVID-19 UPDATE: (June 18, 2020)
The coronavirus has left the telehealth market in the UAE firing on all cylinders with landgrab going on from insurers, hospitals, pharmacies, health authorities and booking platforms, mostly as a means to recapture significant drops in inpatient volumes. HBI has counted no fewer than 10 launches and each major hospital has revealed a new initiative with the exception of NMC. Regulatory authority TRA approved six new services in April. All these new customers for the telehealth solutions will provide a boost to the market. 

Background - last updated Nov 2018
Telehealth companies must work with the nation’s insurers, who are responsible for 85% of healthcare spending if they want to significantly penetrate the market in the UAE. 

Market size
There are currently four licensed providers who all operate totally or mostly within this B2B market: the Abu Dhabi Telemedicine Centre (owned by Medgate), Health at Hand, Mobile Doctors 24-7 and Smart Seha. But our sources estimate that less than 1% of primary health consultations are delivered digitally. Still, there is a significant private outpatient, PMI and occupational healthcare market that we believe are implementing telehealth. Therefore we value the 2018 market at $10.5m, growing to $18m in 2019 and $31m in 2020. 

Largest players:

Abu Dhabi Telemedicine Centre

TruDoc 24x7 (previously known as Mobile Doctors 24-7)

Health at Hand 

Babylon

Aetna International

Swiss telehealth-giant Medgate started a joint venture with the Abu Dhabi government in 2014 to set up the Abu Dhabi Telemedicine Centre. The UK-based telehealth company Babylon announced in September that it would licence the AI technology to the public health authority to roll-out to all citizens. Aetna International also provide remote consultations to its corporate insurance clients (mostly expats).

The problem is adoption: access to primary care is easy so the ordinary man does not see the benefits. Sameer Mankani, COO of Dubai-based Health at Hand, says less than 15% of the population say they’re willing to be treated remotely. Therefore, it is the insurers who must enforce the technology to control Dubai’s 10-12% medical inflation and high wastage. Mankani claims he is seeing triple-digit growth of Health at Hand every quarter as the company’s insurance clients start to realise the benefits of the technology.

COVID-19 UPDATE - (JUNE, 19)

The headline in the UK is that during April 48% of primary care was delivered digitally but when we drill down into the NHS Digital data we find that the bulk of this was via telephone, suggesting that doctors have been slow to adopt various video consultation solutions on the market. 

In fact, the use of video consultations is at its lowest point since at least Nov 2018, with just 44k consultations in April (compared to an average of 120k for the previous year). Video performed 0.7% of primary care consultations in Jan 2020 and 0.3% in April. The data doesn’t account for use of digital triage systems and we know that some B2B solutions facilitate the use of telephone calls. 

Regardless, multiple sources tell HBI that the UK has seen one of the greatest pushes in Europe towards digitalisation and that there has been more transformation in the past few weeks than the last few years. Push Doctor, which sells B2B to Trusts and GP practices, tells HBI it saw 80-90% increase orders with existing practices wanting to scale up and new clients looking for triage and remote care tools. 

It's hard to translate any increase or decrease in activity into sales for a variety of reasons. Providers like Livi gave away video conferencing tools for free and many of the solutions aren't paid on usage models.

Overview (last updated June 19)

The UK has been a bit of a petri dish for telemedicine models over the past couple of years. There is no separate tariff so a B2C model is only possible at a private level or if a telehealth provider sets up its own GP practice to receive capitated funding, as Babylon has done. Livi (the UK branding of Swedish KRY) joined the market selling B2B to support out-of-hours contracts and UK-centric players like Push Doctor and iPLATO sell solutions straight into practices. 

The NHS long-term plan includes a commitment that every person will have the right to a teleconsultation within five years. Pre-COVID, video consultations were performing around 1% of primary care and telephone around 14%. We think that the market is worth around £40m.