Audio-Only Visits: Critical to Bridging the Digital Divide 

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)