New pandemic-era flexibility that allowed audio-only health visits to be routinely reimbursed as telehealth may be leading to substandard care for those it was meant to serve.
Prior to the outbreak of the COVID-19 pandemic in 2020, audio-only visits were rarely included in definitions of telehealth and seldom reimbursed. As clinicians were granted numerous flexibilities to deliver various care modalities at the onset of the pandemic, telephone calls were elevated to the status of reimbursable audio-only visits. Although audio-only visits were used across the health care system, federally qualified health centers (FQHCs) that provide primary care and behavioral health services to millions of Medicaid and uninsured patients were particularly likely to deliver audio-only visits in the spring of 2020. They were also more likely to rely on them as the pandemic progressed (PDF) because of patient and clinic barriers to video telehealth and a supportive policy environment. Almost two years into the pandemic, FQHCs in multiple states are reimbursed at the same Prospective Payment System (PPS) (PDF) rate for in-person, video, and audio-only visits.
The new flexibility to deliver audio-only visits was a welcome change. It was widely recognized that, due to the digital divide, audio-only visits would play an essential role in maintaining access to care for many populations. An audio-only visit was far better than the alternative at the time: no visit at all. Currently, experts who call for the permanent reimbursement of audio-only visits cite concerns for the underserved. They argue that given the widespread lack of broadband, limited digital literacy, and reduced access to devices, requiring video visits may leave certain patients behind and exacerbate inequities in health care.
While this argument had merit in the first year of the pandemic, the risk benefit calculation of audio-only visits has changed, and it is increasingly important to protect patients from potentially lower-quality audio-only visits. We discuss how ongoing delivery of audio-only visits can reduce the quality of care among low-income populations and contribute to health disparities. At the same time, the reliance on audio-only visits may be preventing innovation that could improve video and in-person health care visits for all populations.
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In the spring of 2020, audio-only visits were a lifeline at a time of uncertainty and helped address a critical need when the delivery system was desperate for quick solutions. Numerous data sources showed high use of audio-only visits in this period (11–48 percent of visits), particularly among low-income and older adults. Even though estimates of audio-only use from claims data were high, they were likely underestimates of the total number of visits being delivered. This is the case because of challenges and inconsistencies with coding telehealth visits and the tendency for scheduled video visits to become audio-only visits when technical difficulties arise. For example, using claims data, Medicare estimated that one in three telehealth visits in the spring of 2020 were audio-only visits. However, data from the Medicare Current Beneficiary Survey showed that the majority of beneficiaries (56 percent) who had telehealth visits reported that they were exclusively audio-only.
The Variation in Use Across Settings
As the COVID-19 pandemic continued, audio-only visits retreated in some settings but remained dominant in others. Studies of the commercially insured demonstrated that as in-person visits rebounded in 2021, telehealth visits in general, and audio-only visits in particular, declined and play an increasingly minor role. In contrast, in the summer of 2021, 32 percent of FQHCs (PDF) across the United States reported that the majority of their total visits continued to be audio-only. A study of 43 large FQHC networks in California demonstrated ongoing, high-volume delivery (PDF) of audio-only visits in primary care despite receiving technical assistance and funding to grow their telehealth programs.
Quality Concerns with Audio-Only Visits
Audio-only visits can increase access to care, but this key advantage may come at the expense of quality. Evidence of the quality of audio-only visits in primary care is scant but concerning. First, clinicians report that audio-only visits are not as effective. Challenges range from the relatively minor (for example, not being able to assess facial expressions) to major issues (for example, not being able to verify the patient's identity). Studies have shown that clinicians can miss visual cues and struggle with establishing rapport with patients, and visits are shorter. Additionally, patients report lower satisfaction and comprehension rates. Even as new data emerge about the quality of audio-only visits, it is clear that some patients, including many commercially insured patients, are largely getting more evidence-based, tested services (in-person and video visits) while low-income patients are getting an untested service. Furthermore, cervical cancer screening rates, child weight assessment and counseling, and depression screening and follow-up at FQHCs declined with telehealth (predominantly audio-only) use.
Drivers of Audio-Only Visits
The variation in audio-only use across different populations is likely not fully explained by differences in which conditions are clinically appropriate for audio-only visits or by patient readiness for video visits. Rather, reimbursement, provider preferences, and organizational priorities are playing a significant role in determining how many in-person visit slots there are, and by extension, which patients get audio-only, video, or in-person visits. In October 2021, 33 percent of FQHC visits in California and 24 percent in Arizona, two states that reimburse FQHCs the full PPS for audio-only visits, were conducted virtually. Contrast that with South Dakota (a state that stopped reimbursing for audio-only visits in its Medicaid program as of July 2021 (PDF)), which only saw 5 percent of visits conducted virtually in the same time period.
Although the digital divide is a significant problem in the United States that requires focused attention, it cannot fully explain the variation. A recent paper in Medical Care showed that provider behavior and organizational factors, as opposed to patient digital barriers, are playing the largest role in audio-only visits. Sixty-six percent of Medicare beneficiaries who were exclusively offered audio-only visits during the pandemic had access to telehealth-compatible devices and to the internet.
Creating Conditions for High-Quality Telehealth Care
At present, 22 state Medicaid programs allow for reimbursement for audio-only visits, with nine states adding reimbursement to permanent policy since the spring of 2021. The trend is to increase access to audio-only visits in the interest of health equity. However, telehealth experts have pointed out that failing to rein in audio-only visits risks escalating costs and creating a two-tiered system (PDF) in which affluent patients get video and in-person visits and low-income patients get telephone calls. It may be that this two-tiered system is already coming to fruition and is now harder to justify in the name of emergency response than it was in the spring of 2020. In March 2021, we argued that reimbursement of audio-only visits should continue for several years beyond the public health emergency to avoid exacerbating disparities in access. However, given emerging data about the prominence of audio-only visits in low-income communities, we now have concerns about this approach. Generous parity reimbursement for audio-only visits may be creating perverse incentives to deliver substandard care to the most underserved. It also may be stifling innovation that could be occurring in the delivery of video and in-person visits.
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The patients who have challenges accessing video visits are the same patients who face barriers accessing in-person care. Instead of offering scheduled audio-only visits, health systems could be incentivized to address the social determinants of health that create barriers to higher-quality visits. For example, they could partner with community groups to provide transportation to appointments, provide access to low-cost electronic devices, invest in accessible telehealth platforms, create telehealth access points in the community, and train telehealth navigators. Audio-only visits are a powerful tool for emergency response, and over time researchers and clinicians will identify situations in which audio-only visits alone, or as a component of hybrid care models, can support comparable care. But in the coming months, it may be time to consider limiting audio-only visits in the pursuit of health equity.
Lori Uscher-Pines is a senior policy researcher and Lucy Schulson is an associate physician policy researcher at the nonprofit, nonpartisan RAND Corporation.
This commentary was first published on December 17, 2012 on Health Affairs Blog. Copyright ©2021 Health Affairs by Project HOPE—The People-to-People Health Foundation, Inc.
Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.