News Release 

Nearly all telehealth appointments at clinics for lower-income Americans were audio-only

Pandemic findings raise questions about quality and equity

RAND Corporation

Research News

Telehealth use has surged during the pandemic at clinics that serve lower-income Americans, which allowed the clinics to maintain access to care at a time when many other health care organizations saw significant declines in utilization, according to a new RAND Corporation study.

However, most of the telehealth appointments have been audio-only visits, which may pose challenges in the future if payers consider dropping reimbursement for such services.

Studying more than 500 clinic locations across California, researchers found that while overall visit volume remained stable during the pandemic, about half of primary care medical visits from March to August 2020 were done via telehealth. More than 77% percent of behavioral health visits were conducted via telehealth during the same period. Prior to the pandemic, there was minimal telehealth use.

The breakdown of telehealth visits by type greatly favored telephone-only service. Among primary care medical visits, 48.5% occurred via telephone, 3.4% occurred via video and 48.1% were in person. For behavioral health, 63.3% occurred via telephone, 13.9% occurred via video and 22.8% were in person.

The findings are published in the latest edition of the Journal of the American Medical Association.

Prior to the pandemic, many definitions of telehealth excluded audio-only visits and such services were seldom reimbursed by private insurers and government programs. In addition, some payers including the federal Centers for Medicare & Medicaid Services have signaled they may stop reimbursing for audio-only visits when the public health emergency ends.

"While there are important concerns about the quality of audio-only visits, eliminating coverage for telephone visits could disproportionately affect underserved populations and threaten the ability of clinics to meet patient needs," said Lori Uscher-Pines, the study's lead author and a senior policy researcher at RAND, a nonprofit research organization.

When the coronavirus pandemic struck in March 2020, federal officials agreed to reimburse federally qualified health centers to provide both video and audio-only telehealth services to their patients.

Federally qualified health centers are community-based organizations that provide comprehensive primary care and other health services to people of all ages, regardless of their ability to pay or whether they have health insurance. Such clinics are eligible for support from the federal government and are considered a linchpin of the nation's medical safety net.

Since the use of telehealth expanded, few studies have examined differences in the use of telehealth modalities. However, one federal agency estimated that 30% of telehealth visits have been audio-only during the pandemic.

The RAND study examined telehealth services provided by 41 health centers that operate 534 physical locations in California. The group included about 20% of the state's federally qualified health centers.

Researchers collected information from February 2019 to August 2020 about outpatient primary care and behavioral health visits, as well as demographic information about patients.

The total number of primary care visits dropped by 6.5% during the study period, while there was no significant change in total behavioral health visits.

The use of telehealth declined slightly during the study period after spiking at the start of the pandemic. Audio-only telehealth visits peaked in April 2020, comprising 65.4% of primary care medical visits and 71.6% of behavioral health visits.

"Lower-income patients may face unique barriers to accessing video visits, while federally qualified health centers may lack resources to develop the necessary infrastructure to conduct video telehealth," Uscher-Pines said. "These are important considerations for policymakers if telehealth continues to be widely embraced in the future."

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Support for the study was provided by the California Health Care Foundation.

Other authors of the study are Jessica Sousa, Christopher Whaley, Colleen McCullough and Allison J. Ober of RAND, Maggie Jones of the Center for Community Health and Evaluation at Kaiser Permanente Washington Health Research Institute, and Christopher Perrone of the California Health Care Foundation.

RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.

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