State Telehealth Expansions for Audio-Only Services

The Covid-19 pandemic thrust telehealth into the mainstream as it posed a potential solution for people to still seek healthcare while safely remaining inside their homes. As the public health emergency heads into its third year, many states are seizing the opportunity to update their telemedicine policy and make several telemedicine expansions permanent. One such expansion is audio-only telehealth visits, which are those conducted over the phone, and do not include a visual component.

Audio-only telehealth has a particular relevance to older adults, who comprise a vulnerable population that stands to benefit greatly from these policy expansions. By 2030, 72 million people, almost one in every five Americans, will be 65 years or older. Such a dramatic increase in the size of a patient population of course raises questions about how to support quality care for this group. Not only does general telemedicine eliminate barriers to access by erasing distance and transportation costs, (another barrier that disproportionately effects older adults because of mobility issues) but audio-only visits are also easier for older adults to access and use. More than a third of US households headed by a person aged 65 years or older do not have access to a computer, and more than half do not have a smartphone. Given this, it is no wonder that many seniors opt for audio-only telephone appointments, as this is the modality they are most comfortable and familiar with.

Certain states have identified the potential of audio-only telehealth and are capitalizing on its current relevance. For example, Arizona is leading the way with the extremely popular HB 2454, which was signed by Governor Ducey and enacted May 5, 2021. HB 2454 allows audio-only telephone encounters between the patient or client and health care provider if an audio-visual telehealth encounter is not reasonably available due to the patient's functional status, lack of technology or infrastructure limits, as determined by the healthcare provider. Use of audio-only without a pre-established relationship is also allowed in the case of behavioral health or substance use disorder services.

Taking a cue from Arizona, the state of Colorado is also amending its definition of telemedicine with HB 1190 by removing references to interactive audio, video, or data communications, and instead defining telemedicine as “the delivery of medical services through HIPAA-compliant telecommunications systems”. Other states are taking a slightly more limited approach and enacting a “wait and see” policy. For example, Maryland is enacting payment parity via HB 123 until June of 2023, at which point they will reevaluate and make recommendations for the future. Connecticut is doing the same with HB 5596, but with regards to cross state licensing.

For all the potential benefits of audio-only telemedicine for older adults, there are still many obstacles when it comes to access and equity. For example, older adults have vastly differing levels of digital health literacy, and even audio-only visits pose challenges because of disabilities, hearing loss, dementia, and other issues. Furthermore, not all states are taking steps to expand telemedicine, and “commercial payers have already begun to eliminate payments for audio-only visits, and CMS has not committed to continue telehealth reimbursements following the public health emergency”. This reduction in payments means potentially decreasing telehealth appointment availability, with telephone visits likely the first to be cut. This not only leaves behind large numbers of older adults but also Black, American Indian, Medicaid, and non-English speaking patients who are unable to attend in-person appointments and rely on audio-only visits. The future of audio-only telemedicine shows great promise for vulnerable populations, but states must continue its inclusion and expansion, or telemedicine will not be the great healthcare equalizer states hope it will be, but rather will exacerbate healthcare disparities.