Examining the Benefits and Challenges of Audio-Only Telehealth

July 27, 2021 - With the pandemic limiting access to in-person healthcare, audio-only telehealth has surfaced as a popular platform for care delivery. But it’s not good for all (or even many) services, and that’s forcing providers and lawmakers to take a close look at what can and can’t be done by phone.

COVID-19 pushed the modality – basically defined as telehealth without the video - into the spotlight, but the debate over its value has been going on for much longer. And it’s tied to a long-standing barrier to telehealth expansion and one of the oft-mentioned social determinants of health: broadband.

Advocates have long argued that telehealth will struggle in parts of the country where broadband is either unreliable or unavailable, because patients won’t be able to access an audio-visual platform and providers won’t want to spend the money creating one. But in those areas – often rural, with their own challenges to accessing care – they will and do connect by phone.

And in that context, a landline telephone might be the only way for someone to get in touch with a care provider.

That said, a telephone conversation isn’t always the best format for healthcare. Opponents argue that a provider should be able to see the patient to establish a basic doctor-patient relationship, and that many diagnoses and treatments rely on visual observations and cues. On the other hand, providers can and do gain valuable information from a phone call, and there are certain instances where that may be enough to push a care plan forward.

Setting Medicare Coverage for a Phone Call

READ MORE: New Letter Urges Congress to Establish a Post-Pandemic Telehealth Policy

Among those wrestling with guidelines is the Centers for Medicare & Medicaid Services, which has proposed covering audio-only telehealth services for mental healthcare in its 2022 Physician Fee Index. The agency had announced temporary coverage for audio-only telehealth during the pandemic and even issued a list of services for which audio-only could replace audio-visual telehealth.

Taking a cue from providers who took advantage of COVID-19 emergency waivers to use the modality during the pandemic, CMS included permanent audio-only telehealth coverage in the proposed 2022 PFS under the following conditions:

• The services are limited to diagnosis, evaluation or treatment of mental health disorders;
• They involve established patients;
• They’re preceded by an in-person visit within the six months prior to using telehealth;
• They take place in the patient’s home;
• The care provider has the technical capability at the time of service to use an audio-visual telehealth platform with the patient;
• The patient can’t access the resources for an audio-visual telehealth visit or doesn’t want to use that modality; and
• The care provider documents the claim as an audio-only telehealth service.

CMS has historically been slow to embrace telehealth, often saying it needs more proof that these care pathways improve clinical outcomes, reduce costs and improve provider workflows, as well as proof that providers wouldn’t overuse the platform to collect reimbursements. The agency had in fact all but banned audio-only telehealth services until the pandemic, when the modality was included in a batch of waivers aimed at boosting access and coverage.

What CMS and many others found, however, was that audio-only telehealth was among the most popular services during the pandemic, with an estimated one in three telehealth encounters being conducted by phone.  And many of those encounters were for mental health or substance abuse care.

This prompted the decision to propose permanent coverage for specific services.

READ MORE: As State Emergencies End, Providers Look for New Telehealth Limits

“Clinically, mental health services often differ from most other Medicare telehealth services in that mental health care often involves verbal conversation, where visualization between the patient and practitioner may be less critical,” Nathaniel Lacktman, a partner with the Foley & Lardner law firm and chair of the firm’s Telemedicine & Digital Health Industry Team, wrote in a recent blog explaining the proposed CMS coverage. “Considering the social determinants that affect an individual’s ability to receive mental health care, assessing clinical safety, and recognizing that patients may have come to rely upon the use of audio-only technology to receive mental health care, CMS opined that terminating the audio-only flexibility at the end of the PHE could harm access to care.”

Supporters: Audio-Only Telehealth Has Value

Among those supporting audio-only telehealth coverage is the American Medical Association, which weighed in on the matter in an April 2021 letter to CMS.

“Many of the same patients who cannot access audio-video telehealth services also face barriers to accessing timely in-person services,” AMA Executive Vice President and CEO James Madara, MD, pointed out. “The decision about whether an in-person office visit is needed is very different for a patient in a rural area who may have to travel for hours to reach their physician’s office than for patients who are located close to the medical practice and do not face barriers such as functional limitations. Similarly, the decision about whether a patient should continue to try and stabilize an acute problem at home or travel to a distant emergency department is a more complicated decision without access to timely in-person care or audio-video telehealth services. The availability of timely audio-only services has made a huge difference to these patients and their physicians.”

The Medicare Payment Advisory Commission (MedPAC) also supports permanent coverage for audio-only telehealth “if there is potential for clinical benefit.” But it also notes that researchers haven’t studied the value of audio-only telehealth against audio-visual telehealth or in-person care, so the benefits so far are anecdotal rather than proven.

There have been a handful of studies on the matter. The RAND Corporation, for instance, studied telehealth traffic at federally qualified health centers during the pandemic and found a majority of the visits were conducted by phone.

READ MORE: Congress to Debate Medicare Coverage for Audio-Only Telehealth Services

“While there are important concerns about the quality of audio-only visits, eliminating coverage for telephone visits could disproportionately affect underserved populations and threaten the ability of clinics to meet patient needs,” Lori Uscher-Price, a senior policy researcher at RAND, said in a press release accompanying the study.

“Lower-income patients may face unique barriers to accessing video visits, while federally qualified health centers may lack resources to develop the necessary infrastructure to conduct video telehealth,” she added. “These are important considerations for policymakers if telehealth continues to be widely embraced in the future.”

Is a Phone Call the Same as a Visit?

Aside from allowing providers to deliver healthcare via telephone, there’s the question of how much they should be reimbursed for using it. Opponents argue that a simple phone call doesn’t have the same value as an in-person or audio-visual exam, while proponents point out that it may be the only way for a patient and provider to connect.

This taps into the argument about payment parity. Some worry that providers will stay away from using a telehealth service that’s reimbursed at less than an in-person service, even if there are other reasons to use that service.

In California, that’s what prompted the California Medical Association to oppose a plan by Governor Gavin Newsom to establish Medicaid reimbursement for audio-only telehealth services at 65 percent of in-person care.

“Overwhelmingly, Medi-Cal patients opt to utilize audio-only telehealth over audio-visual telehealth,” the organization said in a May 2021 press release. “This could be due to a lack of good broadband connectivity, a need to take those telehealth visits on their mobile phones that have data limits, or for privacy reasons. Whatever the reasons, it makes little sense to eliminate an option for access to care, for those individuals who already lack it the most, further exacerbating existing inequities.”

Among the states that are supporting audio-only telehealth is New York, where S8416, passed in the summer of 2020, ensured permanent coverage for the modality. That state is one of more than 20 to expand telehealth coverage after the pandemic to cover the modality, according to a recent survey by the Commonwealth Fund.

But that survey also noted the challenges faced by lawmakers in regulating coverage.

“Regulators observed that some providers have begun to charge for short, three- to four-minute phone calls (for example, to answer a brief question of convey test results) that previously would not have required an in-person visit and thus would not have been billed,” researchers wrote. “Regulators noted that these short calls can leave patients with unexpected cost sharing.”

Lawmakers in Arkansas and New Hampshire, meanwhile, have pushed back against expanding coverage, saying the phone isn’t a good modality for treatment. They envision instances in which providers bill Medicaid or Medicare for every little phone call or make incorrect diagnoses based on what they hear from a patient.

Some groups have suggested even stricter regulations on coverage for audio-only telehealth. In May 2020, America’s Physician Groups t told CMS that diagnoses obtained from the modality should be eligible for risk assessment if they met certain conditions:

• They are restricted to established patients;
• They are limited to pre-existing conditions previously submitted for risk assessment purposes;
• They are limited to visits initiated by the patient, unless a provider or health plan had requested the visit to share specific lab results;
• Diagnoses must be captured by two care providers from different practices;
• They’re supported by additional documentation in the medical record beyond the diagnosis;
• Any diagnoses should be tied to specific lab test results;
• All audio-only telehealth visits must be self-audited using an independent auditor and reported back to CMS; and
• CMS should impose a cap on how much the diagnoses can affect average risk scores from the previous year.

Regardless of the arguments, most agree that there’s enough value in the phone call – and there are enough people in the country for whom the telephone is the only modality to access care – to merit some sort of coverage. The challenge lies in identifying which specific services can be delivered and how they can be reimbursed.