Once a primary means of communication, audio-only telephone calls seem increasingly obsolete to millions of Americans who text with their friends and Zoom with their colleagues. However, the COVID-19 pandemic highlighted the importance of all types of telecommunications. Our recent research among Federally Qualified Health Centers (FQHCs) serving two million low-income patients in California demonstrated that audio-only health care visits were instrumental in maintaining access to care during the COVID-19 pandemic. Despite this, coverage for audio-only visits is likely temporary. Many payers including the Centers for Medicare & Medicaid Services are likely to stop reimbursing for most audio-only visits in coming months because of cost and quality concerns. This is a mistake. We are at risk of devaluing and prematurely casting off a key telemedicine modality, a move that could mean the difference between a needed doctor visit and no visit at all.
Even though many payers did not recognize audio-only visits as a form of telemedicine prior to the COVID-19 pandemic and seldom reimbursed for them, audio-only visits have exploded in the past few months. Once the national emergency was declared, many payers started reimbursing for audio-only and video visits at the same rate as in-person visits to support social distancing. Policymakers recognized that given the digital divide, mandating video visits would leave certain patients behind. However, payment for audio-only visits was not intended to be permanent policy. We argue that reimbursement of audio-only visits should continue for several years after the public health emergency to avoid exacerbating disparities in access to care.
Findings About Greater Telemedicine Adoption in California
In July 2020, the California Health Care Foundation provided funding to 43 Federally Qualified Health Centers and community health centers in California to grow their telemedicine programs and provide data to our evaluation team. Early evidence showed that unlike many organizations in the health care delivery system, health centers were able to maintain patient access to care and keep overall visit volume stable during the first six months of the pandemic. In interviews with our study team in October and November 2020, health center leaders across the 43 health centers attributed this success during the pandemic to several factors, all of which relate in some way to humble audio-only visits. First, many observed that their (typically high) no-show rates were lower than usual across all visit types (audio-only, video, and in-person) after May 2020, allowing clinicians to fill their schedules with billable visits. Offering different care modalities provided additional — often more convenient — options to patients, allowing them to select the modality they wanted and could accommodate. Health centers were even able to convert no-shows into visits by calling and conducting audio-only visits with patients who missed an in-person appointment. Second, health centers conducted individual outreach to patients they had not heard from, often emailing or calling them directly, to highlight the various safe ways to interact with their health care team. Finally, and most importantly, health centers could leverage simple and frictionless audio-only visits to maintain access to care. From March to August 2020, we found that more primary care visits among health centers in the study occurred via audio-only visits (49%) than in person (48%) or via video (3%). Audio-only visits comprised more than 90% of all telemedicine visits.
Reliance on audio-only visits during the pandemic is not surprising given the digital divide. However, what we found particularly interesting was that video visits did not replace audio-only visits as the pandemic progressed, despite signals from payers that video visits were the more sustainable model and with months of additional implementation time.
What is preventing greater adoption of video visits among health centers? Interviews again provided insight. First, many low-income patients are not ready for video visits because they lack devices, broadband, or digital literacy. Yet, even among patients who are able to participate in video visits, many have a preference not to because of cultural or privacy concerns. For example, some patients are not comfortable showing their home environment. Furthermore, health center leaders pointed out that patients with limited data plans may not want or be able to use their data on a video visit. The costs of in-person care are often offset by health centers and health plans that provide or subsidize transportation. Yet, to date, there has not been sufficient attention to addressing video visit costs for patients. Finally, a video visit, like an in-person visit, typically requires multiple steps such as clicking links, downloading mobile apps, troubleshooting connection issues, and waiting in a virtual waiting room. Even when these steps are relatively easy for patients to navigate, automated instructions and communications about them are seldom available in multiple languages. This technology can be challenging for many, especially non-English speakers, compared to audio-only visits that you can passively receive as you go about your day without the need for any instruction.
Telemedicine can serve as a tool to reduce disparities in health care access, but limiting reimbursement to video visits may actually increase them.
Not all the barriers identified in interviews were at the patient level. Some clinicians opted for audio-only visits in the early months of the pandemic because it was difficult to learn new video platforms and workflows at a time of great uncertainty. Also, video visits often required clinicians to take on additional responsibilities within the visit, diagnosing and treating patients’ technology as well as physical problems. Health center leaders reported numerous challenges with video platforms and equipment (for example, connectivity issues) that disrupted video visits, negatively impacted the user experience, and required additional staff time to address. Furthermore, some health centers used video platforms that were separate from their scheduling systems or electronic medical record, which proved cumbersome. Others implemented multiple video platforms, thereby increasing complexity and training needs. Some health centers reported additional challenges connecting with interpreter services via video.
Audio-Only Visit Reimbursement Should Continue Alongside Other Efforts
While the ease of audio-only visits and their effectiveness in addressing certain patient needs suggests that reimbursement should continue, there are important concerns to consider. There is widespread concern among policymakers that reimbursing for telephone visits will lead to fraud and abuse and additional (unnecessary) utilization. Payers are also worried that they will end up reimbursing for activities (for example, communication about lab results) that used to occur without payment. Furthermore, many assume that care delivered via audio is lower in quality because clinicians cannot visually assess the patient. However, among the health center leaders we spoke to, audio-only visits were not just easier than video visits; health center leaders credited telephone visits with increasing access to care, reducing wait times, and in certain circumstances, offering care they perceived to be of comparable quality.
While it is important to explore the potential downsides of audio-only visits and determine the specific use cases for which they are appropriate, eliminating payment for audio-only visits in the near term will disproportionately impact safety-net settings and patients who are not prepared or equipped for video visits. Telemedicine can serve as a tool to reduce disparities in health care access, but limiting reimbursement to video visits may actually increase them.
One potential path forward after the public health emergency is to continue to reimburse for audio-only visits for a trial period and specifically in cases where there is a documented barrier to video visits. During this time, policymakers could amass more evidence, as there has been limited research (PDF) to date on the quality of audio-only visits to inform policy. We may learn that audio-only visits are just as effective as in-person or video visits in particular situations, such as for medication management for a stable patient with attention-deficit/hyperactivity disorder (ADHD), or for insulin titration for a patient with well-controlled diabetes. Furthermore, policymakers should prioritize efforts to prepare all patients and health centers for video visits by ensuring that everyone — including patients in rural communities — has access to high-speed internet and devices with affordable data plans. Hands-on assistance navigating video visits is also key. Some health centers we spoke to discussed efforts to train patients on telemedicine platforms when they came in for in-person visits or to provide resources to improve digital literacy. Efforts like this should be expanded. Then, after the vast majority of low-income patients are prepared for video visits, reimbursement for audio-only visits could be eliminated entirely or could be restricted to specific use cases where quality is known to be equivalent to in-person care.
Alexander Graham Bell said, “The great advantage that the telephone possesses over every other form of electrical apparatus consists of the fact that it requires no skill to operate.” Perhaps a day will come when audio-only interactions are truly archaic because other technologies will be just as user-friendly. Based on what we have seen during the COVID-19 pandemic, we are not there yet.
This article first appeared in the Health Affairs Blog on March 3 and is reprinted with permission.
Authors & Contributors
Lori Uscher-Pines
Lori Uscher-Pines is a senior policy researcher at the RAND Corporation’s Washington office. She is also the research quality assurance manager for RAND Social and Economic Well-Being. Her research interests include telehealth, maternal and child health, mixed methods research, and emergency preparedness. She is a mixed methods researcher who has authored over 100 peer-reviewed publications.
Uscher-Pines received her MSc in international relations from the London School of Economics and her PhD in health policy and management from the Johns Hopkins Bloomberg School of Public Health. Before coming to RAND, Uscher-Pines completed a postdoctoral fellowship at the National Center for Preparedness and Catastrophic Event Response at Johns Hopkins University.
Maggie Jones
Maggie is the director of the Center for Community Health and Evaluation (CCHE) at the Kaiser Permanente Washington Health Research Institute in Seattle. She leads large-scale evaluation efforts related to community health improvement, clinical quality improvement, health policy, health equity, and public health training programs. Maggie has focused on providing health-related organizations with the information, tools, and resources to achieve their goals and build their evaluation capacity.
She joined CCHE in 2007 after completing her master’s in public health at the University of Washington. She previously did evaluation work with a cross-cultural health organization in Minnesota and at the Northwest Center for Public Health Practice at UW. Maggie became CCHE’s associate director in 2016 and director in 2018. She holds a BS in business from the University of Minnesota and an MPH from the University of Washington.
Jessica L. Sousa
Jessica Sousa is a policy analyst in the RAND Corporation’s Boston office. She has experience in qualitative data collection and analysis, project management, and direct patient care. Her research interests include policies to address racial and ethnic disparities in health, interventions to target social determinants of health such as racism and poverty, and telehealth policy and implementation. She is a licensed certified social worker in Massachusetts and has worked with adults living with HIV/AIDS, serious mental illness, and substance use disorder.
Jessica holds a bachelor’s degree in psychology from the University of Pennsylvania and dual master’s degrees in clinical social work and health policy and management from Boston University.
Zach Predmore
Zach Predmore is an associate policy researcher at the RAND Corporation’s Boston office. His research focuses on assessing the value of health care services, including new technologies, medications, and health system improvements. He has worked across a variety of clinical areas, including gastroenterology, psychiatry, and infectious disease, with an emphasis on health care services for people with HIV/AIDS. He is a mixed-methods researcher and has authored more than 30 peer-reviewed articles and reports. Zach received his PhD in health policy and management from the Johns Hopkins Bloomberg School of Public Health.
Allison J. Ober
Allison J. Ober is a senior health policy and behavioral science researcher at the RAND Corporation’s Santa Monica headquarters. She has extensive expertise in implementation science and intervention research, and deep experience conducting substance use disorder and HIV prevention research with underserved populations. Ober’s current research interests include increasing access to and retention in substance use disorder and HIV treatment and innovative methods for improving quality of care, including telemedicine.
Ober received a bachelor’s degree in psychology from the University of Vermont, a master’s degree in social work from Catholic University of America, and a PhD from the UCLA Department of Social Welfare, School of Public Affairs.
