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Vinagolu-Baur JR, Goodman D, Morgan A. Reducing health disparities with audio-only telemedicine post-COVID-19. HPHR. 2021;39.
DOI:10.54111/0001/MM4
Before the COVID-19 pandemic, traditional telehealth visits required video capability in order to qualify for reimbursement by Medicaid. The 2020 public health emergency declaration temporarily waived this requirement, allowing patients to participate in audio-only telehealth visits. From a public health perspective, telehealth visits reduce crowding at hospitals and health centers, preventing transmission of the SARS-CoV-2 virus. Audio-only telehealth also increases access to healthcare by reducing barriers to both video- and in-person care across different patient populations (varying by age, rurality, availability of safe transportation, and income), and may be the only telehealth option available to patients due to economic or geographic constraints. This paper highlights how access to audio-only telehealth can reduce disparities, and increase patient satisfaction, safety, time-savings, and reduce cost. Significant stakeholder benefits can be realized by continuing Medicaid reimbursement of audio-only telehealth during and beyond the continuing COVID-19 pandemic.
Prior to the COVID-19 pandemic, telehealth visits required video capability to qualify for Medicaid reimbursement. With the onset of the 2020 public health emergency declaration,¹ this requirement was temporarily eliminated, allowing health care providers to bill for providing both audio-only and video telehealth, with the goal of reducing crowding in health centers and preventing transmission of the SARS-CoV-2 virus. As a result, there was a rapid transition of as many healthcare services as possible to virtual platforms, the most popular being synchronous telemedicine interactions with patients using a smartphone, tablet or computer.2
However, especially for patients in rural and remote rural areas, limited access to digital technology,3 and poor internet connectivity precludes engagement in video telehealth.4 For many of these patients, necessity led to a sharp rise in audio telehealth visits.5 As the pandemic enters its third year now, there are important lessons to be learned from this transformation in health care delivery, including innovations which have proven to be of significant value in reducing health inequities, and should be maintained.
Telemedicine is defined as the secure sharing of medical information between patients and healthcare providers in different locations, through a variety of information technologies which can include video, audio-only, and asynchronous messaging platforms such as patient portals.6 Before the onset of COVID-19, telehealth use overall was increasing in prevalence and popularity, but had yet to reach many patients.7 According to a Harvard Medical School study comparing telemedicine use in different specialties before and during the COVID-19 pandemic,8 fewer than 2% of clinicians in each specialty surveyed had used telemedicine prior to the pandemic, with the exception of psychiatry, at 5.5% utilization. During the first months of the public health emergency in the United States (from mid-March to mid-June of 2020), telemedicine use by clinicians increased to about 68% among endocrinologists, 57% among gastroenterologists, and 50% among pain management physicians. Disciplines which used telemedicine the least were optometry (3.3%) and physical therapy (6.6%).
Despite the increase in access promised by telehealth, a 2021 commentary by RAND acknowledges that expanding telehealth can inadvertently exacerbate health disparities by creating a digital divide for patients lacking smartphone technology and/or affordable broadband, necessary to participate in telehealth visits.9 This disparity in access is especially pronounced for residents or rural regions where broadband access is sometimes unavailable, and cell phone signals are weak, leaving people reliant on traditional telephone service.10
According to a recent report by the Pew Research Center,11 disparities in smartphone ownership exist based on rurality, income level, and age: with only 80% of rural residents, 76% of people making less than $30,000 a year, and only 61% of people over 65 years of age owning a smart phone. While video telehealth has advantages in its ability to allow visual assessment of a patient’s condition, requiring video capability widens disparities among people without smartphones or other digital technology, making it difficult to participate in video-telehealth.12 Audio-only telehealth enables patients without a smartphone, computer or tablet to participate in telehealth, increasing access to telehealth and promoting continuity of care.13 Reducing disparities in access is particularly important for populations who face barriers to participating in health care more generally due to income, transportation, or distance, therefore amplifying positive impact on health outcomes.
To facilitate the safe provision of care for patients who lacked access to video telehealth during the pandemic, the Centers for Medicare and Medicaid Services (CMS) expanded reimbursement to include audio-only telehealth visits, which utilize phone calls between a patient and healthcare provider as a framework for a therapeutic encounter. This modality removes the requirement for digital technology access as healthcare services can be provided over a land line. However, this authorization was time limited to the duration of the pandemic-related Public Health Emergency and will require reauthorization at the state level if it is to be maintained post-pandemic.14
Several states, including New York,15 and New Hampshire,16 have already ended their public health emergencies, citing successful vaccination programs and declining hospitalization rates. On the other hand, others, including California, Arizona and Washington renewed their emergency declarations, including maintaining enhanced Medicaid eligibility and other health related coverage. 17 On a national level, the pandemic public health emergency declaration was renewed in October 2021, but only through January, 2022.18
Data from the past year indicate that the audio-only telehealth option has effectively increased access to healthcare. An article comparing different telehealth modalities in federally qualified medical centers in California found that during the pandemic, “48.1% [of primary care visits occurred] in person, 48.5% via telephone and 3.4% via video,” confirming the importance of audio-only telehealth in low-income populations.19 For patients who are not connected to broadband networks due to geographic or financial reasons, do not own webcam-enabled video-technology equipment, or lack digital literacy to participate in telehealth visits, audio-only options provided a literal lifeline during the pandemic. As a result, about 1/3 of Medicare beneficiaries who participated in telemedicine in the past year did so in an audio-only capacity with a traditional telephone.20 In addition, according to Pew Research, a substantial majority of Americans still use traditional cellphones (without internet capability) as smartphone ownership varies across age, household income levels and education level.21
As noted above, audio-only telehealth also reduces disparities related to age, and age-related factors such as digital literacy and smartphone ownership, as well as rurality and income level. According to data from the Centers for Medicare and Medicaid Services (CMS),22 about 65% of Medicare beneficiaries ages 75 and older, and about 65% of Medicare beneficiaries in rural areas, reported using primarily audio-only modes of telehealth. Furthermore, about 40% of Medicare Advantage Plan enrollees earn under $25k a year, and of those, about 35% lack access to broadband internet,23 Because lower income is correlated with reduced likelihood of smartphone ownership, this highlights the importance of an audio-only option for older lower-income and lower-resource patients, 24 a group also more likely to have chronic medical conditions requiring regular engagement with the health care system.
In addition to being convenient, telehealth has shown to be safe and effective for many routine visit types when best practices are followed.25 In comparison to in-person healthcare encounters, audio-only telephone services can in some circumstances be “as good as or better than in-person care,” and improve “intermediate outcomes and satisfaction– especially for patients whose alternative is no care at all”26 (emphasis added).
In many cases, audio-only telehealth can be coupled with self-monitoring by patients who conduct their own vital signs (temperature, height, weight and blood pressure, for example) and/or visit a more conveniently located facility for bloodwork and other tests. In this scenario, test results can appropriately be discussed with a provider and medical management arranged in a follow-up, audio-only telehealth visit. Further research on optimizing the clinical quality of audio-only telehealth in terms of health outcomes for patients, and the reliability of self-testing and reporting measures is needed.27 Acceptance of audio-only telehealth varies between medical specialties, but in some areas like prenatal appointments, audio-only telehealth visits are often scheduled between in-person visits, to reduce in-person visit frequency, providing a flexible means of ongoing risk assessment and staying in touch with a provider.28
For rural residents especially, access to telehealth also results in significant time savings by reducing the need to travel. In many regions this also reduces risks experienced by patients due to hazardous weather, or to weather-related delays and missed appointments. Health providers and health delivery systems have reported up to a 10% reduction in missed appointments during the pandemic due to higher utilization of telehealth services,19 particularly in the field of behavioral health, attributing greater appointment adherence with the convenience that telehealth provides.
Additionally, telehealth is associated with cost savings. Timely remote access to a healthcare provider can result in diverting patients from higher-cost settings such as emergency departments and urgent care centers for non-emergency situations. According to one telemedicine study published in the American Journal of Emergency Medicine,29 patients/payers gained cost savings between $19 and $121 when opting for an on-demand, synchronous virtual visit (at a fixed price of $49).30
Audio-only telehealth also provides benefits to other stakeholders such as healthcare providers, hospitals, health centers and healthcare delivery systems, advantages which have been significantly magnified during the pandemic. Benefits of audio-only telehealth for medical providers include more frequent patient engagement, reduced patient no-show rates and sustained provider and patient satisfaction levels,31 while advantages for hospitals and health centers include reduced crowding and fewer unnecessary ER visits.32 On a systems level, telehealth can provide larger-scale cost incentives, especially if Medicaid reimbursement for an audio-only telehealth visit is less than reimbursement of video-telehealth or of coordinating and subsidizing transportation services—an area of research that has yet to be investigated.
Like video telehealth, audio-only telehealth provides access to healthcare for those facing barriers to in-person services,33 such as transportation access (vehicle ownership or public transportation availability), familial responsibilities (childcare) and job responsibilities (limited paid time off work), to name a few. These challenges are not pandemic related, nor will they be resolved along with the Public Health Emergency. Additionally, audio-only telehealth also alleviates many of the technology-related barriers created by video-telehealth, reducing, rather than increasing, disparities for lower resource patients.
While Medicaid reimbursement of audio-only telehealth during the COVID-19 pandemic has provided a modality for underserved patients to access healthcare services, inequities will continue to exist after the pandemic has abated. Therefore, it is crucial to advocate for long-term, sustainable changes to reduce disparities in access, especially for rural, underserved patient populations, as part of ongoing work to address other causes of poor outcomes. Maintaining reimbursement of audio-only telehealth after the resolution of the COVID-19 pandemic is an important interim step. In fact, the advantages of audio-only telehealth have recently also been endorsed by the American Medical Association,34 in a strongly worded brief which urged the Centers for Medicare and Medicaid Services to continue reimbursement for audio-only telehealth beyond the COVID-19 public health emergency.
As described above, audio-only telehealth option can play a critical role in reducing disparities in healthcare access and outcomes, providing valuable time and cost savings for patients, health providers and healthcare systems, especially for disadvantaged patients. Given these benefits, it is critical that this patient-centered option be protected through long-term, sustainable policy changes on the local, state and national scale beyond the COVID-19 pandemic.
The author(s) have no relevant financial disclosures or conflicts of interest.
Julia Vinagolu-Baur is a premedical postbaccalaureate student at Harvard University
Daisy Goodman is an Assistant Professor of Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth, The Dartmouth Institute (TDI) for Health Policy and Clinical Practice, and women’s health nurse practitioner in the Department of Obstetrics and Gynecology at Dartmouth-Hitchcock Medical Center.
Allie Morgan is a medical student at the Geisel School of Medicine at Dartmouth
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