HHS, Providers View Audio-Only Telehealth as Key Health Equity Strategy

As telehealth became a must-have in the age of COVID-19, the federal government responded by enacting regulatory flexibilities, providing funding for virtual care efforts, and supporting workforce education and technology implementation at facilities across the country.

Now that demand for virtual care has leveled off, federal agencies are examining ways to boost telehealth adoption and access. Their efforts include tackling entrenched health inequities and further widening access to behavioral health, agency leaders said at the first-ever National Telehealth Conference hosted by the Department of Health and Human Resources on May 16 and 17.

Leaders also acknowledged that audio-only telehealth has emerged as a critical health equity and behavioral health integration tool. Behavioral health providers echoed this at the virtual event, describing how audio-only services helped them ensure access to virtual mental healthcare.

"We're in the middle of a transformational change in the way we deliver healthcare," said Andrea Palm, HHS deputy secretary, at the conference. "And it is up to us to maximize telehealth benefits for all Americans."

FEDERAL ACTIONS TO ADDRESS TELEHEALTH BARRIERS

A critical infrastructure issue that heavily impacts telehealth is the lack of access to high-speed internet.

President Joe Biden and his administration are committed to expanding the availability of reliable internet services, Palm said. Earlier this month, the administration announced the launch of the Affordable Connectivity Program, which will enable millions of American households to reduce their internet service costs by up to $30 per month or $75 per month on Tribal lands. The administration has secured commitments from 20 major internet providers to either increase speeds or cut prices.

Meanwhile, the Centers for Disease Control and Prevention is ramping up its telehealth-focused activities. The agency is currently in the midst of 31 telehealth activities, and has 17 more planned for 2023, Rochelle P. Walensky, CDC director said during the virtual event.

These activities include working with federal partners to identify areas where the CDC needs to gather more data, identifying promising policies and practices to expand telehealth access, and focusing on efforts to drive equity and access to telehealth.

For example, the CDC's National Center for Health Statistics added telehealth questions to many of its national surveys in 2020, including the national health information survey and the national ambulatory medical care survey.

"I'm pleased to see so much enthusiasm for telehealth as a modality to deliver care," Walensky said. "But as we work to expand access to many via telehealth, we also have to be sensitive to those it may leave out. We at CDC and across HHS…are committed to learning more about access and impacts on health equity to ensure that telehealth is a service that provides equitable access and does not create additional disparities or widen the technology gap."

One modality that has the potential to improve telehealth access is audio-only services, particularly within the telebehavioral health sphere.

With telehealth remaining a popular mode of care delivery for people with mental health and substance use disorders, HHS' Substance Abuse and Mental Health Services Administration (SAMHSA) has supported flexibilities surrounding the use of audio-only technology, which can help address the disparities in broadband access, said Miriam Delphin-Rittmon, PhD, assistant secretary for mental health and substance use at SAMHSA.

Further, SAMHSA has provided grants to certified community behavioral health clinics to encourage telemedicine use and alleviate workforce shortages, along with block grants to states to expand telehealth services in rural and frontier areas and widen technology options for patients, including text and the telephone.

"Telehealth has already positively impacted service delivery with improved access for under-resourced populations, and [it] can be used in conjunction with in-person services to develop tailored individualized service planning," Delphin-Rittmon said at the conference.

EXPANDING BEHAVIORAL HEALTH ACCESS VIA TELEHEALTH

A critical arena in the continued integration of telehealth is behavioral healthcare. Alongside the COVID-19 pandemic, a mental health epidemic emerged, with one in five US adults reporting that they experienced mental illness in 2020. The epidemic is especially prevalent among US youth.  

"From my perspective, the integration of behavioral health into the healthcare system is one of the last miles of work that we need to do in healthcare," Palm said. "Telehealth is an important tool in that effort."

Recognizing the benefits of virtual care, particularly for underserved communities, behavioral health providers around the country have already incorporated telehealth into their care delivery models.

In a session on telehealth's role in behavioral health access, Chris Fore, PhD, detailed the impact of the pandemic on the use of telemental health services within Native American communities.

Fore is the director of the Telebehavioral Health Center of Excellence within the Indian Health Service, which provides care to 2.6 million Native Americans over 37 states. As seen within other healthcare organizations, the pandemic significantly drove up telehealth use.

"Specifically, regarding telebehavioral health, the change was even more dramatic… What we found was that from 2019 to 2020, there was a 238-percent increase in telebehavioral health visits," he said.

But amid this rapid pivot to virtual care, telebehavioral health providers had to contend with the digital divide within Native American communities.

The Indian Health Service relied heavily on audio-only telehealth visits to ensure continued access to mental healthcare.

"For us, that is the way that we've been able to engage our patients successfully," Fore said. "We love to do video [but] there are barriers to that, that we're trying to address. Audio-only is really a key for us to provide that kind of care in our patient population."

Kari Law, MD, associate professor and director of telepsychiatry at West Virginia University School of Medicine, echoed Fore.

"Internet bandwidth and availability is absolutely an issue [in West Virginia]," she said during the conference. "We did at the onset utilize audio-only visits, which had historically not been funded, and the show rate actually was excellent for those."

WVU Medicine, the medical school's affiliated hospital, saw a 429-percent increase in telebehavioral health virtual visits during the height of the pandemic. Even today, about 55 percent of total behavioral health visits are conducted via telehealth, Law said.

Recognizing the critical role audio-only modalities play in expanding access to telehealth, the Centers for Medicare & Medicaid Services made reimbursement for audio-only telehealth permanent in the 2022 Physician Fee Schedule proposed rule.

But there are certain stipulations for audio-only telehealth reimbursement.

"There has to be, within the first six months, an in-person visit, and then in-person visits once a year with an opportunity for an exception — if a provider doesn't feel an in-person is necessary, or there are other issues," said Meena Seshamani, MD, PhD, CMS deputy administrator and director for the Center for Medicare, at the conference.

CMS has also adopted a policy to extend reimbursement for services currently on the telehealth coverage list until the end of 2023.