While telehealth has been embraced as the pandemic’s silver lining, concerns about telehealth (or just audio-telehealth) continue to plague its advocates.
Before the pandemic, federal law required telehealth services to be delivered to Medicare beneficiaries via two-way video. However, given the technological challenges many seniors face, the administration waived the request during the COVID-19 public health emergency.
In an analysis of traditional Medicare beneficiaries, the Bipartisan Policy Center (BPC) took a detailed look at the use of audiohealth services.
We found that audio-only telehealth use remains high among Medicare beneficiaries, but especially among the most vulnerable.
Even as provider offices began to reopen in late 2021, nearly one in five telehealth visits were delivered to Medicare beneficiaries over the phone. Almost 10% of users had at least one audio visit in the same year. It is important to note that given the challenges in accurately encoding audio-only services, these figures are an underestimate of how much audio-only care is provided.
BPC’s analysis found that vulnerable Medicare beneficiaries—those who were elderly, disabled, and those with multiple chronic conditions—were more likely to rely on audio-only services during the pandemic. Consumers over 75 and those under 65 who qualify for Medicare because of a disability are more likely to rely on audio-only services (see chart below). We found similar patterns for users with five or more chronic conditions, which, compared to those with fewer diagnoses, were disproportionately more prevalent among audio-only users. Beneficiaries were three times more likely to rely on audio-only services for primary care and behavioral health services compared to 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 twice as much as other Medicare beneficiaries during the pandemic. These individuals are most likely to live in rural and frontier communities in Arizona, Alaska, South Dakota, New Mexico, and Oklahoma, and in 2021, at least 40% of the telehealth services they received were by telephone.
Although many people think that audio-only telehealth is of 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 (the same pattern held and for two-way video visits). However, audio-only visits accounted for a slightly higher proportion of all telehealth visits in rural areas.
In addition, our analysis found that safety net providers provided an increasing share of telehealth visits to Medicare beneficiaries from 2020 to 2021, compared to other outpatient providers whose reliance on telehealth remained stable 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 over time at replacing audio-only visits with video visits, despite likely serving similar patient populations.
Are there risks to audio-only Care?
While BPC’s analysis found that more vulnerable Medicare beneficiaries were using more audio-only care, what was most striking was the sustained overall number of phone visits after the peak of the pandemic. This raises a number of questions: Are more people choosing to visit by phone than the number of people who have real barriers to accessing two-way video? Do provider preferences encourage continued patient reliance on audio-only care?
Policymakers should be wary of proposals to expand audio-only services for several reasons. The quality of audio-only care, whether delivered alone or as part of a hybrid model of care, remains untested. Therefore, more research is needed to learn whether the high use of audio-only visits among vulnerable Medicare beneficiaries may put certain populations at risk for lower quality of care. In fact, voice-only flexibilities could theoretically lead to substandard care for the very people for whom such unhindered phone access is intended. As part of a series of qualitative interviews conducted by the BPC, providers highlighted their concerns about the quality and effectiveness of audio-only visits for new patients.
Increased access to audio-only services also has an unknown impact on Medicare spending. Multiple factors contribute to the overall cost of telehealth services, including the reimbursement rate, the degree to which the service generates new utilization, the ability of telehealth to replace or replace in-person care, and its impact on patient outcomes and downstream costs. More research is needed before we fully understand the impact of sound-only care on health care expenditures and whether this type of care threatens overuse or fraud for the Medicare program.
Widespread, prolonged adoption and reimbursement of audio-only services could also affect how states prioritize their broadband investments. Rural Americans, who face disproportionate connectivity challenges, have the most at stake. The Infrastructure Investment and Jobs Act of 2021 included $65 billion for broadband — the largest such cash infusion in US history. Decisions about how to strategically invest those dollars now largely rest with the states. If audio-only telehealth is permanently opened to all users, states may rethink how to allocate their investments.
If the current policy does not change in the long term, service providers may be less inclined to make the investments required to fully transition their workflows to two-way video. In addition, some providers may be less inclined to maintain as much in-person appointment availability as they were before the pandemic if reimbursement for telehealth remains equal to in-person care.
A few weeks ago, Congress extended telehealth flexibility for Medicare through the end of 2024. This was welcome news, as the flexibility extension will allow time for a thorough evaluation of their impact, including a rigorous evaluation of audio-only care. Given the insufficient amount of evidence supporting audio telehealth alone, we recommend that use be limited to established patient-provider relationships and that use outside of primary care and behavioral health services — for which critical demand exists — be limited to those who live in rural America or have a valid, verified need for telephone visits. Audio-only visits should remain an option for users who have access barriers and cannot complete two-way video visits — but for those without disabilities, the policy should require the use of two-way video visits.
Although telehealth generally enjoys broad bipartisan support, unresolved issues such as how to handle audio-only flexibilities delay a permanent policy resolution. We hope that our analysis and recommendations will help policy makers to carefully consider the ongoing role of audio-only services and to strike the right balance between access, quality and cost in the long term.
Julia Harris, MPH, MIA, is the Associate Director for Health at the Bipartisan Policy Center. This paper is based on a new BPC report, “The Future of Telehealth After COVID-19: New Opportunities and Challenges,” and accompanying analysis of Medicare fee-for-service data.