The Right Care at the Right Time
Audio-Only Visits Are a Critical Option in the Care Delivery Continuum
The declaration of a federal public health emergency (PHE) in response to the COVID-19 pandemic enabled payers and regulators to loosen restrictions over telehealth for the good faith provision of care, unleashing a massive surge in reimbursable virtual care visits, roughly half of which were behavioral health visits. (i) While it remains to be seen if temporary waivers will be made permanent after the PHE is lifted, the fate of audio-only visits–real-time telephone visits unaccompanied by a video component—is a topic of wide-ranging opinion and debate.
Whereas early in the pandemic, audio-only visits provided a critical lifeline for patients and clinics facing barriers to video telehealth and in-person care, today there is an emerging contingent voicing concern about a potential unintended consequence that may be unfolding as the pandemic unwinds. In California, many FQHCs serve low-income people living in geographically remote locations that lack reliable broadband services. Compound this with lack of transportation or childcare, housing instability, and language or cultural barriers, and the necessity for audio-only virtual visits comes into sharp focus.
Director of Integrated Health Services, Ellie Lopez, of Borrego Health in Southern California explains, “Oftentimes patients must choose between spending five dollars on gas to get to the clinic or using that money to eat dinner. Patients also find difficulty arranging childcare, or a ride, and must take the day off work, or take a two-hour bus ride each way to get to the appointment.”
Yet some argue that FQHCs reimbursed at the same rate for in-person, video, and audio-only visits are de-incentivized to evolve strategies to rebound in-person care or expand video visits at levels comparable to commercially insured patients. They point to emerging data linking fewer in-person visits for FQHC patients to lower rates of preventive cancer screening. This development may undermine the original goal for audio-only to advance greater health equity, instead of leading to a two-tiered system by which patients with greater means receive higher quality care in person or via video visits while Medicaid patients and the uninsured get inferior care via emergency provision developed during the pandemic as an alternative to receiving no care at all. (ii)
The one glaring exception to this critique of audio-only visits is the successful transition of behavioral health and substance use disorder (SUD) treatment to audio-only visits. Even in the waning days of the pandemic, rates of audio-only behavioral health and SUD visits continue to climb across the board. Evidence was so compelling, CMS opted to make permanent reimbursement for several audio-only behavioral health and SUD visits in addition to extending reimbursement for more than 80 telehealth services through the end of 2023. Consult the CMS 2022 Physician Fee Schedule and the CMS List of Telehealth Services for 2022 for details.
It may be too soon to discern such patterns in the data. For now, the consensus appears to support audio-only visits as a plausible remedy to advance health equity. A recent study by the RAND Corporation found rates of audio-only visits across 45 California FQHCs consistently surpassed the rates of video visits throughout the pandemic, (iii) echoing findings by the California Initiative for Health Equity & Action (Cal-IHEA) and the Centers for Medicare and Medicaid that audio-only virtual visits were utilized more frequently by low-income and older adults as well as people of color. (iv, v)
Further, an American Medical Association survey of more than 2,200 physicians conducted at the end of 2021, found that two-thirds of physicians regularly utilized audio-only visits as a means to extend
capacity. (vi) This appears to be particularly true for small, under-resourced practices that might be reluctant to invest in support staff or technological capital until there is greater certainty surrounding telehealth reimbursement policies.
In the meantime, the fact remains that the majority of virtual care modalities are predicated on access to broadband, smartphones with generous data plans, and a moderate level of technological and health
literacy. According to the medical director of an FQHC in the heart of Silicon Valley, “We have a good number of patients who don’t know how to read or write. They can’t even use Google Maps. Most of
them don’t have the technology to participate in virtual care. They just have a flip phone with a poor data plan.”
Perhaps at present, the best solution lies somewhere in between. In August 2021, CTRC published A Healthy Balance: Hybrid Virtual Care Models for Optimal Patient Experience:
Considerations for California Healthcare Executives. This guide offers a blueprint to tailor a hybrid virtual care model to complement in-person care based on clinical efficacy and patient preference. It recommends offering the broadest spectrum of virtual care options possible to enable providers and patients to choose the right care delivery option at the right time. Each patient has individual needs, and those needs are not static over the course of a given care journey. Audio-only visits may be just the right complement to in-person care at a particular point in a care journey.
Some clinical conditions are more amenable to virtual options than others. For example, audio-only may be completely appropriate for psychological counseling or titrating insulin dosages with established
patients, whereas Pap smears and immunizations must be administered in the office. Likewise, some patients are more well-suited to benefit from virtual care options than others. Those with visual impairments, hearing loss, limited manual dexterity, or cognitive impairments, as well as the very young and very old, may struggle with some virtual care options.
Consider screening patients annually to gauge whether they might be good candidates for virtual care options. These data taken in aggregate can help health centers inform long-term care delivery strategies. The bottom line is that each health center must weigh the many factors influencing health care delivery from the individual patient point of care to the long-term strategic goals of the organization to strike the appropriate hybrid balance.
According to Ellie Lopez of Borrego Health, “Being reimbursed for services delivered over the phone helped keep the clinic numbers up and generate revenue during the pandemic. Providers feel empowered by having the flexibility to treat their patients using whatever modality they feel is in the best interest of their patients. The patients also feel empowered to choose how and when they want to
access their healthcare treatments. Telehealth options—including audio-only—allow for us to meet our patients where they are.”
Until which time broadband, smartphones, and frictionless technologies become universally available, audio-only virtual visits will continue to have a place on the care delivery continuum and a role to play in advancing health equity. The degree to which health centers rely on audio-only visits to serve their patients must be guided by clinical efficacy and patient preference.
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(i) Wong Samson, L., Tarazi, W., Turrini, G., and Sheingold, S. (2021, December). Medicare beneficiaries’ use of telehealth services in 2020—trends by beneficiary characteristics and location. Issue Brief no. HP-2021-27. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937
(ii) Uscher-Pines, L. & Schulson, L. (2021). Rethinking the impact of audio-only visits on health equity. Health Affairs, https://www.healthaffairs.org/do/10.1377/forefront.20211215.549778/full/
(iii) Uscher-Pines, L., Arora, N., Jones, M., Lee, A., Sousa, C., McCullough, C.M., Lee, S., Martineau, M., Predmore, Z, Whaley, C.M., & Ober, A.J. (2022). Experience of health centers in implementing telehealth visits for underserved patients during the COVID-19 pandemic: Results from the Connected Care Accelerator Initiative. Santa Monica, CA: RAND Corporation. https://www.rand.org/pubs/research_reports/RRA1840-1.html
(iv) Cuadros, P. (2021). Evaluating Medi-Cal telehealth policy for audio-only visits post-pandemic. Berkeley, CA: California Initiative for Health Equity & Action (Cal-IHEA). https://healthequity.berkeley.edu/sites/default/files/audioonlytelehealthpolicy_0721.pdf
(v) Verma, S. (2020). Early impact of CMS expansion of Medicare telehealth during COVID-19. Health Affairs, https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full/
(vi) American Medical Association. (2021). American Medical Association 2021 Telehealth Survey Report. https://www.ama-assn.org/system/files/telehealth-survey-report.pdf