While telehealth has been embraced as a silver lining of the pandemic, concerns around telephonic care (or audio-only telehealth) continue to dog its proponents.
Prior to the pandemic, federal law required telehealth services be delivered to Medicare beneficiaries via two-way video. However, given the technology challenges many seniors face, the administration waived the requirement during the COVID-19 Public Health Emergency.
In an analysis of traditional Medicare beneficiaries, the Bipartisan Policy Center (BPC) took an in-depth look at the use of audio-only telehealth services.
We found that audio-only telehealth use remains high among Medicare beneficiaries, but especially the most vulnerable.
Even when providers’ offices started reopening at the end of 2021, almost one out of every five telehealth visits were delivered to Medicare beneficiaries by phone. Almost 10% of beneficiaries had at least one audio-only visit the same year. Importantly, given the challenges in accurately coding audio-only services, these figures are an underestimate of how much audio-only care is being delivered.
BPC’s analysis showed that vulnerable Medicare beneficiaries — those who were older, disabled, and those with multiple chronic conditions — were more likely to rely on audio-only services during the pandemic. Beneficiaries over 75 and those under 65 who are eligible for Medicare due to a disability were more likely to rely on audio-only services (see bar graph below). We found similar patterns for beneficiaries with five or more chronic conditions, who, when compared to those with fewer diagnoses, were disproportionately overrepresented among audio-only users. Beneficiaries were three times as likely to rely on audio-only services for primary care and behavioral health services versus for other specialty care.
Segmenting by race and ethnicity, we found that Medicare beneficiaries who identified as American Indian or Alaska Native used audio-only services at twice the rate of other Medicare beneficiaries throughout the pandemic. These individuals are most likely to live in rural and frontier communities of Arizona, Alaska, South Dakota, New Mexico, and Oklahoma and, in 2021, at least 40% of the telehealth services they received were via phone.
Although many think audio-only telehealth is a greater benefit to people living in rural areas with barriers to high-speed internet, we found that the closer Medicare beneficiaries lived to an urban area, the more likely they were to use audio-only services (this same pattern was also true for two-way video visits). However, audio-only visits were a slightly larger share of all telehealth visits in rural areas.
Additionally, our analysis showed safety-net providers delivered an increasing share of telehealth visits to Medicare beneficiaries from 2020 to 2021 compared to other outpatient providers whose reliance on telehealth remained steady over the same period. This was consistent with other research that found safety-net providers disproportionately relied on audio-only care and some health centers were more successful in replacing audio-only visits with video-visits over time, despite likely serving similar patient populations.
Are There Risks to Audio-Only Care?
While BPC’s analysis found that more vulnerable Medicare beneficiaries use more audio-only care, what is most striking has been the sustained overall volume of telephonic visits beyond the peak of the pandemic. This raises a series of questions: Are more people choosing telephone visits than the number of people who have actual barriers to accessing two-way video? Are provider preferences driving a sustained reliance on audio-only care by patients?
Policymakers should proceed with caution on proposals to extend audio-only services for several reasons. The quality of audio-only care, either delivered alone or as part of a hybrid care model, remains untested. Therefore, more research is needed to know if high use of audio-only visits among vulnerable Medicare beneficiaries could put certain populations at risk for lower quality care. In fact, audio-only flexibilities could theoretically result in substandard care for precisely the people such frictionless, phone access was intended to serve. As part of a series of qualitative interviews BPC conducted, providers highlighted their concern with the quality and efficacy of audio-only visits for new patients.
Increased access to audio-only services also has unknown impacts on Medicare spending. Multiple factors contribute to the overall cost of telehealth services, including the reimbursement rate, the degree to which the service creates new utilization, the ability of telehealth to replace or substitute for in-person care, and its impact on patient outcomes and downstream costs. Additional research is needed before we can fully understand the impact of audio-only care on healthcare spending, and if this type of care threatens overuse or fraud for the Medicare program.
Broad, prolonged acceptance and reimbursement of audio-only services could also impact how states prioritize their broadband investments. Rural Americans, who face disproportionate connectivity challenges, have the most at stake. The 2021 Infrastructure Investment and Jobs Act included $65 billion for broadband — the largest such cash infusion in U.S. history. Decisions on how to strategically invest these dollars now largely rest with states. If audio-only telehealth is opened to all beneficiaries permanently, states may rethink how to distribute their investments.
If current policy does not change longer-term, providers may be less inclined to make the investments needed to fully transition their workflows to two-way video. Additionally, some providers may be less inclined to maintain as much in-person appointment availability as they did pre-pandemic if reimbursement for telehealth remains at parity with in-person care.
Navigating the Path Forward
A few weeks ago, Congress extended telehealth flexibilities for the Medicare program through the end of 2024. This was welcome news, as extending the flexibilities will allow time for a thorough evaluation of their impact, including a rigorous assessment of audio-only care. Given the inadequate volume of evidence supporting audio-only telehealth, we recommend use be limited to established patient-provider relationships and use beyond primary care and behavioral health services — which are in critical demand — be limited to those who either live in rural America or have a valid, attested need for telephone visits. Audio-only visits should remain an option for beneficiaries who have access barriers and cannot complete two-way video visits — but for those without barriers, policy should require the use of two-way video.
Although telehealth generally enjoys broad bipartisan support, outstanding issues such as how to handle audio-only flexibilities delay permanent policy resolution. We hope our analysis and recommendations help policymakers carefully consider the ongoing role of audio-only services and strike the right equitable balance between access, quality, and cost for the long-term.
Julia Harris, MPH, MIA, is an associate director for health at the Bipartisan Policy Center. This work is based on a new BPC report, “The Future of Telehealth After COVID-19: New Opportunities and Challenges” and an accompanying Medicare fee-for-service data analysis.