In a bid to assist healthcare centers, the California Healthcare Foundation established a quality assurance program, the Connected Care Accelerator program (CCA), in July 2020. RAND researchers worked with 45 CCA health centers in compiling the report, “Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic.”

RAND Report Findings
The RAND report found that the number of clinical visits remained the same during the study period compared to before COVID-19. However, over-the-phone therapy for behavioral health issues was a standout in terms of services received by patients. Audio-only visits were favored for both primary health and behavioral health practitioners when the study started. Many primary health visits had reverted to in-person consultations, but over-the-phone therapy for behavioral health care remained high by the end of the study.

There were significant differences in video consultations across health centers, particularly behavioral healthcare. Health centers transitioning from audio-only telehealth visits to video visits had varying degrees of success. Of those that transitioned to video visits, the most successful shared these characteristics:

Telehealth video platforms were easy to use.
Clinicians obtained leadership support and staff training.
Everyone involved experienced a sense of urgency.
Patients were willing to try the technology.
Health center staff who took part in the study noted that it was challenging to set up video calls, which led to the preference for over-the-phone therapy. Also significant were the changes in the telehealth reimbursement policy.

Audio Telehealth Can Bridge the Digital Gap
According to the RAND report, healthcare centers had varying degrees of success in implementing telehealth. The availability of digital assets is one of the barriers to entry regarding telehealth access. The report suggested that telehealth phone calls offer the next best option where other telehealth resources are lacking.

The American Medical Association (AMA) issued a brief, Equity in Telehealth: Taking Key Steps Forward, which recently provided more data about audio-only telehealth.

The report points out that one in five adults in the US does not have broadband, which means that these people cannot avail themselves of the benefits of video-based telehealth.
The study also reported that 15% of patients don’t have a smartphone to facilitate a video connection with a provider.
AMA suggests that hospitals and healthcare providers should invest in initiatives to broaden the reach of telehealth for the inclusion of marginalized communities. According to the brief, some health centers have increased their support staff to help bridge the digital gap. They have also made available wi-fi and telehealth booths. The AMA report also states:

The AMA urges health plans to be required to cover telemedicine-provided services on the same basis as in-person services and not limit coverage only to services provided by select corporate telemedicine providers.

Telehealth Reimbursement for Over-the-Phone-Therapy
In recent years, telehealth reimbursements and healthcare coverage changes are another reason why over-the-phone therapy and audio-only telehealth visits have gained popularity. Before the pandemic, telehealth reimbursement for over-the-phone therapy was rare. Medicare and many states did not classify audio-only calls as part of telehealth services. Many have now increased telehealth reimbursement to include audio-only telehealth visits. See TBHI’s previous articles related to telehealth reimbursement for more information:

7 States Change Telehealth Coverage for Telehealth Reimbursement
Telehealth Expansion: 6 Additional States Announce Telehealth Coverage
Audio-Only & Other Telehealth Services Approved for Reimbursement
Moving Forward with Over-the-Phone-Therapy and Audio-Only Telehealth Reimbursement
It is difficult to monitor how audio-only telehealth visits are now being used because historically there were no codes and modifiers on the claims applications. Medicare and Medicaid providers have recently added audio-only modifiers and coding to their listings. See Telehealth Reimbursement Alert: 2022 Telehealth CPT Codes Released. Data collection regarding telehealth phone calls will be forthcoming as a result.

There is a general belief that over-the-phone therapy is open to improper use and can lead to increased costs and inequitable use. Data transparency may help mitigate this belief as clinicians’ preference for other modalities is revealed. See Audio-Only Telehealth: A Classic Solution to a Modern Crisis.

RAND Report Recommendations
The RAND report concluded that audio-only telehealth policies should be limited until evidence is better gathered and understood since audio-only telehealth data is lacking. Implementing policies with in-person and video requirements and different telehealth reimbursement rates is recommended. It pointed out that healthcare centers and professionals need support and resources for effective telehealth implementation. Professional training is also available.

A complementary and recently published report described telehealth systems’ use, access, and quality. It showed how telehealth reimbursement and services have spread into all primary forms of healthcare to the satisfaction of providers and their clients. Over-the-phone therapy will remain an essential part of ensuring that clients receive the care they need until we bridge the digital divide. Policymakers need to balance their concerns with interpretations that support audio-only telehealth policies to reduce digital inequities while efforts are made to reduce the digital divide.