Across the U.S. health care system, a debate is underway about whether medical care and services can be adequately delivered through telehealth. The COVID-19 pandemic forced many providers to dive in headfirst when telehealth became the only way patients could access health services. As part of the Public Health Emergency, the Centers for Medicare & Medicaid Services allowed broad flexibility to use telehealth, spurring unprecedented use of telehealth. While many virtual visits used video, audio-only phone visits were also commonly used. Many providers and patients found low-tech phone visits to be high value — resulting in high patient satisfaction and decreased “no show” rates. While not all medical services can be delivered using video (a blood draw) or phone (teledermatology), some services, like telematernity and behavioral health visits, have great potential to meet health needs and improve health equity.

The Toothpaste is Out of the Tube

Because we cannot “put the toothpaste back in the tube” (or “the genie back in the bottle,” metaphors abound), many providers, payers, and consumers are considering how to continue using audio-only visits. People enrolled in Medicaid are among the most likely to benefit from the continuation of audio-only visits. Most Medicaid enrollees can engage in audio-only visits — according to the Pew Research Center, 97 percent of Americans own a cell phone, and 85 percent own a smartphone. However, Medicaid enrollees may be less likely to complete video visits, which can be especially difficult for people who are elderly, live in rural areas, or are non-native English speakers. Medicaid enrollees are also often affected by the “digital divide” — a lack of access to reliable internet services due to income, race and ethnic disparities, and/or rural geography. A recent national survey on trends in telehealth released by the U.S. Department of Health and Human Services confirmed many of these findings. Results indicated that during the COVID-19 pandemic, the highest rates of telehealth visits overall were among Medicaid enrollees, Black, and low-income individuals, while the use of video telehealth services were far lower for elderly, Black, Latino, and Asian individuals than white individuals and people earning over $100,000.  At the same time, telehealth could help people overcome transportation barriers, or prevent loss of income from having to travel to a provider’s office during business hours.

The potential challenges and benefits apply to Medicaid providers as well. Under-resourced safety net primary care providers serving Medicaid enrollees may find it easier and less cost-prohibitive to offer audio-only visits rather than video visits. Video visits may require potential up-front infrastructure costs, as well as recurring maintenance and staff training to use the software effectively, none of which are necessary for audio-only visits.

How States Can Support Audio-Only Telehealth

Medicaid agencies have an opportunity to support phone-based telemedicine in primary care beyond the pandemic, and many are already doing so. Potential strategies include:

• Extending Payment Parity for Telehealth Visits. The simplest way for states to continue to support access to audio-only visits is to pay providers directly for these visits. As many as 27 states have already extended payment parity between telehealth and in-person care for Medicaid providers beyond the Public Health Emergency. Many of these states offer parity for both video and audio-only telehealth services.
• Using Value-Based Payment Models. If a state chooses to not continue payment parity, it can still incentivize the use of audio-only services through new or existing value-based payment (VBP) models. VBP models based on total cost of care inherently encourage the use of low-cost/high-value services, like audio-only telehealth. For this reason, VBP can help bring telehealth where it is needed most, while discouraging low-value use.
• Empowering Managed Care Organizations to Promote Audio-Only Options and Supports. Medicaid managed care can play a significant role in promoting the use of audio-only options. While all states had some telehealth options in their managed care contracts before the pandemic, it still may be underused. Many managed care organizations (MCOs) already have 24/7 nurse hotlines and call centers and expanded direct use of telehealth during the pandemic. These MCOs could be well-equipped to offer expanded audio-only services to people enrolled in Medicaid. In addition, states can encourage audio-only services by offering enhanced rates for this capability to MCOs or primary care practices for this mode of care or by utilizing quality metrics related to telehealth options, or access generally.

A Hybrid Future?

The COVID-19 pandemic has shown that telehealth can be a valuable tool for successful delivery of primary care. While audio-only telehealth cannot completely replace in-person or video-enhanced care, adopting a hybrid approach — where telehealth supplements in-person care — shows promise for Medicaid programs that are interested in expanding access to care, improving enrollees’ experience of care, and advancing health equity.