Table 1

(A) Summary of primary care healthcare systems in INTRePID countries. (B) Pandemic timing, virtual care policies and data available for INTRePID countries

CountryType and level of
Payment model for primary care
Cost for patientsPrimary care as gatekeeper?
AustraliaBoth public and private (10%–20%)Fee for serviceVisits: yes, copayments for some visits.
Medications: 6.60 AUD/medicine–41.30 AUD/month.
Yes, for access to specialists
CanadaPublic universal access funded at provincial levelPrimarily capitation in OntarioVisits: none.
Medications: Ontario provincial formulary only covers residents 65+ years, children without private insurance, those on social assistance and partial coverage for low-income residents.
Yes, for access to specialists
ChinaPublic and privateFee for serviceVisits and medications: social insurance with copayment depending on one’s status.No
NorwayPublic funded at a national levelCapitation for 30% of PCPs income, the rest
fee for service
Visits: yes, copayments up to an annual upper limit. No patient visit costs for visits related to suspected or confirmed COVID-19, or for children <16 years old.
Medications: yes, copayments up to annual upper limit.
Yes, for access to specialists
SingaporePublic and private funded differentlyFee for serviceVisits: yes, public polyclinic visits are charged based on residency status and age of patient 14 SGD for adults (citizen) 6.90 SGD for children and elderly (citizen). In private primary care clinics determined by the clinic. However, patients who are citizens can receive subsidies under the Community Health Assist Scheme for visits in private clinics.
Medications: yes, amount based on residency status and age in public clinics, in private clinics determined by the clinic.
Yes, for access to specialists in public hospitals.
No for access to specialists in private hospitals.
Both public and private
(proportions vary according to the level and the type of medical care institution)
Fee for serviceVisits: yes.
Medications: yes.
SwedenPublic funded at a
national level
Capitation 70% and fee for service 30%.Visits: yes, patient pays approximately 1/5 of the fee with an annual maximum copayment of 1200 SEK.
Medications: yes, copayment with a maximum of 2200 SEK.
national health
CapitationVisits: no.
Medications: 40% of the population are eligible to pay prescription charges, but children, older people and medications to treat some chronic diseases are exempt from payment.
USAPrivate with public for low income and veteransFee for serviceVisits: no if covered by insurance.
Medications: copayments typically required.
CountryDate local pandemic or state of emergency was first declaredVirtual care policyData coverage region
AustraliaState of emergency in Victoria on 16 March 2020. State of disaster in Victoria on 2 August 2020Commencing 13 March 2020, and now a permanent feature telephone or telehealth services were made available to physicians and allied health providers. This service is only to be provided where safe and clinically appropriate and limited to patients where there is an established clinical relationship. Bulk billing rates are the same for virtual as they are for in-person visits and the government is encouraging virtual visits.Select coverage
(1256 PCPs in 103 general practices in Victoria).
CanadaState of emergency in Ontario on 17 March 2020. Gradual lifting of restrictions in the summer of 2020. Second wave declared on 28 September 2020, followed by gradual localised restrictions until province wide lockdown on 26 December 2020.In Ontario, as of March 14, 2020, new billing codes were introduced to cover any physician service provided via telephone or video. Recently extended indefinately. Virtual care was very limited before the pandemic. Payment for virtual visits equal to payment for in-person visits during the pandemic.Select coverage (392 PCPs in 95 clinics in Ontario).
ChinaOn 23 January 2020, the Guang Dong province government declared a public health state of emergency.Prior to the pandemic, the hospital did not offer virtual visits. Virtual consultations over a platform called ‘wedoctor’ for any queries on COVID-19 were offered for free on 1 February–30 April 2020, and the healthcare professionals were not paid additionally for these interactions. These virtual consultations are potentially under-represented here as hospital-based doctors (shown here) have been found to have lower utilisation of internet/telephone-based consultations compared with PCPs in the community.Select coverage (13 PCPs and 3 psychotherapists in the University of Hong Kong-Shenzhen Hospital family medicine clinic).
NorwayThere was an almost complete lockdown from 12 March 2020. The lockdown was gradually lifted from April onwards, but some restrictions were maintained during all of 2020.Prior to the pandemic, eHealth was already developed and used to a small extent. Patient copayment was the same for virtual and in-person consultations. From 16 March 2020 consultations by phone were reimbursed in the same way. As of 25 March 2020, it was recommended to use telehealth (phone/video) services as much as possible in place of in-person.Full coverage
SingaporeSingapore implemented a ‘circuit breaker’ from 7 April 2020 to 1 June 2020, which is a set of safe distancing measures that significantly reduces people’s movements and interactions in public and private spaces. People were also encouraged to wear masks when going out.The public insurance system does not reimburse physicians for virtual care. Had a lot of virtual visits in the hospitals, less so in primary care. Most polyclinic patients had their appointments deferred during COVID-19 and were followed up by phone without cost (hence not captured in the data presented here). PCPs in the public health system were deployed to public health sites. Routine follow-up intervals for chronic disease management were extended.Select coverage
(886 PCPs in six public polyclinics).
On 23 February 2020, Infectious Disease Crisis Alert was upgraded to ‘Severe’. Social distancing system (level 1, level 1.5, level 2, level 2.5 and level 3) was applied depending on the severity of outbreak.Prior to the pandemic, virtual visits were not permitted in South Korea. From 24 February 2020, telephone consultation and prescription by fax were temporarily allowed by the Ministry of Health and Welfare. Virtual visits (20 400 KRW) remunerated at slightly lower rates than in-person (20 700 KRW).Select coverage (5 professors, 3 fellows, and 15 residents in primary care at Asan Medical Centre-Seoul).
Sweden1 February 2020: COVID-19 classified as a disease dangerous to the public and society. 26 February 2020: high alert at the National Board of Health and Welfare. 16 March 2020: people over age 70 years were urged to avoid all contact with others. Gradual limitations of public gatherings. In general, Sweden was a relatively open society with no general lockdown, or mandatory mask wearing.Payments for virtual visits are half of the amount for in-person visits. The virtual (telehealth) services have been open to everyone, and in April 2020, the population was encouraged to use a telehealth solution if suitable for their visits. In Sweden, the 21 regions provide care for their own patients, but there are also a few national providers of telehealth that charge fee-for-service.Full coverage of Uppsala region, 150 PCPs.
UKEnacted the Coronavirus Act 2020 on 25 March 2020 that provided government with emergency powers.Virtual care is being used to reduce risk of infection for staff and patients. It is encouraged to promote virtual consultations and introduce it where it does not exist yet. Using video consultation is recommended in addition to telephone. Videoconferencing is encouraged as well as commercial apps such as Skype and Facetime for urgent use. However, physical visits were allowed only if benefits outweighed risks.Select coverage (there are 1800 practices in the network and 15 million patients across England (26% of the population)). This study was done on a subset of 5.6 million patients (~10% of the population), recruited to be evenly geographically spread across England.
USANational emergency declared on 13 March 2020.Very few US healthcare systems had used virtual care prior to the pandemic but by March 2020 most systems provided virtual care.Select coverage (236 PCPs in one health organisation in each of California, Texas and Colorado).
  • Select coverage: convenience sample within a region.

  • Full coverage: all clinics/practices within a region.

  • INTRePID, INTernational ConsoRtium of Primary Care BIg Data Researchers; PCP, primary care physician.