Considerations on the Implementation of the Telemedicine System Encountered with Stakeholders’ Resistance in COVID-19 Pandemic

Regions or countries with high population density are at higher risk of contracting COVID-19. With 529.4 people per square kilometer, Korea is a land-scarce country with the highest population density among Organization for Economic Co-operation and Development (OECD) countries.¹¹ The elderly population (≥65 years) accounted for 14% of the total in 2017, and Korea is estimated to become an ultra-aged society by 2026.¹² In densely populated communities¹¹ with a large proportion of the elderly,¹² outbreak of an infectious disease can result in a serious crisis by rapidly spreading among the elderly and chronically ill who are vulnerable to infection.

In the current critical situation wherein an infectious disease is ravaging society, telemedicine may be useful as a supplementary or alternative mode of health care delivery that can reduce the risk of person-to-person transmission through direct contact and, above all, block possible transmissions to unspecified number of people by medical staff. Furthermore, nonface-to-face consultation can maintain the patients’ quality of life, save medical expenses, reduce patient anxiety, and help keep medical staff safe.^13,14 The COVID-19 pandemic has triggered fundamental changes in the health care services system of every country. As of May 2020, the use of telemedicine has increased in >125 countries across the globe.¹⁵ Such a prompt and adequate response requires a meticulous and well-integrated coordination among the stakeholders of different telemedicine-related functions.^16,17

Conditions Favoring Face-to-Face Consultation

The Korean conditions favoring face-to-face consultation have been the main cause of the low acceptance of telemedicine. First, regarding access to medical care, a welfare-oriented health insurance was introduced in 1977, and the current national health insurance service for the entire population with 100% coverage of core medical care has been in place since 1989.¹⁸ The small land area provides an easy environment for face-to-face consultation.¹⁹ In particular, the urban versus rural physician distribution (total number of physicians per 1,000 population) is 2.5:1.9 (1.32 as ratio), which is more equitable than the OECD average (4.3:2.8 [1.54]).²⁰ The geographic distribution of physicians is 12.1 physicians per 10 square kilometers, ranking third among OECD countries after Israel and Belgium (estimated by deriving the number of physicians from the OECD Health Statistics, and the land area from a list compiled by the World Bank)^11,20 in terms of the distance to the nearest health care provider. Second, with regard to the expenditure on health care per capita in USD purchasing power parity (PPP), Korea’s average expenditure is 48 USD PPP (US = 100), 67% of the OECD average (72 USD PPP).²⁰ Third, in terms of demographics, the number of physicians on duty almost doubled (98% increase) over the past 17 years, marking the highest increase rate among the 34 OECD member countries.²⁰ Fourth, the quality of medical care is rather high; specialists account for 73% of all doctors, higher than the OECD average (65%). In 2020, 3,025 physicians newly entered the doctor’s register and 3,516 physicians entered the specialist register. Consultation with a specialist is readily available.²⁰ Finally, the quality of face-to-face consultation is high, as shown by various indicators, such as waiting time for consultation and surgery in a tertiary referral or specialist hospital, and outcomes of cancer and cardiovascular diseases.²⁰ Considering that telemedicine primarily aims to enhance the quality of and access to medical care,²¹ it is understandable that people receiving high-quality medical care in a land-scarce country have no compelling demand for telemedicine.

Stakeholders of Telemedicine

This environment conducive to face-to-face consultation has led to residents’ indifference to nonface-to-face health care services and low acceptance by civic organizations and stakeholders. Among the various public and private sector stakeholders of telemedicine,²² including the government, primary care clinicians, entrepreneurs, patients, and general hospital staff, primary care clinicians are the largest stakeholder group in the supply of health care.^16,23

As the whole nation was struck at the nationwide spread of an epidemic transmitted by an unprecedented fatal and nosocomial pathogen, its unclear progress, warning mass media reports, and subsequent social anxiety,²² policymakers saw sufficient cause to temporarily relax the legal restrictions on patient–doctor telemedicine to eliminate local transmission. The Korean government, as the policymaker, hastened to implement telemedicine on February 24, 2020, without prior consultation with or involvement of the stakeholders, including doctors as telemedicine providers and patient groups as users.²⁴ However, even in this pandemic situation, the decision has met with concerns about the sustainability of telemedicine applications.²⁵

Barriers to Telemedicine Implementation

When a new system is introduced into an existing system, it is often met with resistance.²⁶ In many countries, telemedicine has not yet been established due to its low acceptance among the users^16,17,27,28 owing to social, technical, political, legal, and contextual factors. Of these, social factors are perceived to be the most complex.²⁹ Implementation of telemedicine has been delayed for various reasons, including repeated and persistent resistance by stakeholders, legal limitations, indifference of patients, lack of a consolidated rationale, and disharmonious implementation by policymakers.^30,31 The reasons for the stakeholders’ refusal include high investment costs for technology, uncertainty about the return on investment, eligibility for reimbursement, and factors originating from the loopholes in the health insurance system.^16,32,33

In Korea, the proportion of public health care providers is as low as 3.76%, and private health care providers perform >90% of all primary care.¹⁸ Likewise, public coverage for outpatient care is 58%, lower than the OECD average (77%).²⁰ Accordingly, the Korean Medical Association, an interest group representing all primary care providers, is aware of the threat posed by a coexistence of telehealth and face-to-face health care services in relation to the problems inherent to the health insurance system.¹⁶ The Korean health care system is not up to its role as a gatekeeper in the process of referral from a primary care provider to a tertiary referral hospital.¹⁶ In many countries where telemedicine was introduced at the community level, primary care providers experienced a threat to their economic standing by tertiary referral hospitals’ superiority in readiness, technological capacity, available human resources, and financial conditions, making them mount organized resistance to change.¹⁷

Some civic groups, as long-standing stakeholders, have proposed privatization of deteriorating public health care services. This is relevant to the last three administrations’ unwavering position in pursuing telemedicine policies as an engine for the country’s industrial development.³⁴ Policymakers’ uncompromising pursuit of such policies disregarding the opinions of important stakeholders within the value chain of health care delivery and consumption is not different from the previous administrations’ attitudes.

Even while facing the challenges of large-scale outbreaks of various fatal infectious diseases over the past decades, the Korean government failed to adopt telemedicine due to the resistance of stakeholders including doctors.^25,35 Among the pre-COVID-19 fatal infectious diseases, SARS spread to 30 countries and infected 8,437 people, killing 10% of them.³⁶ In 2012, Middle East Respiratory Syndrome (MERS) outbreaks caused 2,519 confirmed cases and 868 deaths (case–fatality rate: 34.3%).³⁷ Even in 2009, when 570,000 people died in the novel H1N1 pandemic,³⁸ telemedicine could not be properly utilized in Korea, although people were gripped by the fear of pandemic. Looking back on this decades-old history of resistance by stakeholders, the current unilateral telemedicine policy, riding the bandwagon of the atmosphere generated by the COVID-19 crisis, raises concerns about its sustainability.

Timeline and Content of the Incidents of Stakeholders’ Resistance

The history of resistance of the stakeholders, including doctors’ groups, began in 2002, the year when the Telemedicine Act was amended (Fig. 2). In 2009, the Lee Myung-bak administration promoted patient–doctor telemedicine as one of the high value-added growth engine industries. However, policymakers’ attempts were thwarted in the face of the resistance. The government attempted neither to seek agreement on policy decisions with stakeholders nor to make concrete investment plans, focusing only on the expected and predicted effects of implementing the policies.¹⁶