Data Inconsistencies Provide Blurry Picture of Audio-Only Telehealth Use

In a piece published in Health Affairs, researchers from Harvard Medical School and RAND Corporation wrote that predicting the future of audio-only sources is hard, mainly due to the common difficulties in data analysis and the lack of clarity regarding reimbursement.

Throughout the rapid uptake and high use of telehealth during the COVID-19 pandemic, many payers, including Medicare, began reimbursing for audio-only and video-based telehealth services at the same rate as in-person services. Although this and other regulatory flexibilities will remain active throughout the remainder of the pandemic, there are difficulties in predicting the future of virtual care use.

To determine the rate of use and efficacy of telehealth, groups such as government agencies and payers use surveys, claims, and her data.

The authors of the Health Affairs article used this type of information to identify 25 different telehealth visit estimates. Across these, the proportion of audio-only telehealth visits spanned from 9 percent to 98 percent.

For example, audio-only visits comprised 25 percent of total visit volume in claims-based studies, 50 percent according to survey-based studies, and 55 percent among EHR-based studies.

"While some of these differences are obviously driven by differing patient populations and clinical settings, this heterogeneity raises concerns that the underlying data may also be problematic," the authors wrote.

Further, when examining data from a survey of Medicare beneficiaries in fall 2020, the authors found that only 20 percent of patients who reported only having an audio-only visit had a claim for one, while 96 percent of those who reported only video visits in the survey had a video-visit claim.

According to the authors, this indicates that providers billed audio-only visits as video visits.

"Recognizing these data and the biases, we believe the fraction of telemedicine visits that are audio-only is much higher than what is reported in claims—but how much higher is unknown," they wrote.

As a result of this data inconsistency, it is hard to assess the use and impact of audio-only telehealth. Thus, the authors urge researchers and policymakers to be careful when using this data to determine audio-only telehealth use.

But even though getting a clear picture of audio-only telehealth use is a challenge, the Centers for Medicare and Medicaid Services (CMS) has proposed ending reimbursement for the care modality.

In its proposed 2023 Medicare Physician Fee Schedule (PFS), released earlier this month, CMS said it plans to discontinue reimbursement.

“We believe that the statute, [the Social Security Act], requires that telehealth services be so analogous to in-person care such that the telehealth service is essentially a substitute for a face-to-face encounter,” stated CMS in its proposal.

CMS decided that the lack of face-to-face communication of audio-only telehealth means it does not meet the standard set by the statute, according to a blog post by law firm Foley & Lardner LLP.

But research has also shown that audio-only telehealth proved effective during the COVID-19 pandemic and provided many people, including those from vulnerable populations, with access to care.

For example, a study published in November 2021 showed that older, Black patients were more likely to use audio-only telehealth. This was due to various reasons, one of which was that many people within these demographics face technology-access barriers and a lack of digital health literacy.

Another study published in March revealed that many telehealth providers offered audio-only telehealth, as they believe it provides flexibility for patients who face issues when accessing services.

Further, a RAND Corporation report from March explained that safety-net facilities rely heavily on audio-only telehealth, particularly for behavioral health services.