Last week a telehealth workgroup comprising insurers, providers, and policy makers from the state of Vermont submitted a recommendation to their state, arguing for keeping the reimbursement for audio-only (telephonic) telehealth. But is audio-only telehealth good medicine? Should there be payment for what some consider to be subpar clinical care?

The Genesis of Widespread Audio-Only Telehealth

The onset of the Covid-19 health crisis in March 2020 brought with it a number of fast, drastic changes as to how healthcare was being delivered. The fast-spreading disease required rigorous physical distancing and keeping patients out of the clinic environment was the best strategy.

While many healthcare organizations quickly switched to thousands of telehealth visits, oftentimes most of these visits were conducted not with a live audio/video connection, but…over the telephone. Most organizations had (and many still have) inadequate technical solutions in place to facilitate smooth video visits. There was little to no training on “webside manners” that would have given clinicians the ability to confidently “practice medicine at a distance” (a.k.a. “telemedicine”).

Thus many clinicians did what had been a common practice for decades (albeit unpaid): they delivered care over the phone.

And in the first weeks of the pandemic, this was absolutely appropriate: checking in with patients how they were coping with the evolving and scary situation. Checking in on medication refills or known health conditions. A quick chat, a quick prescription was all that was needed to “bridge the care gap” for a few weeks or a couple of months.

But weeks turned into months and now have turned into quarters. And here we are in 2021, still delivering care mostly via the telephone, when a video visit has so much more to offer — clinically and financially.

Telemedicine used as a Clinical Tool
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One aspect that most people overlook — clinicians and non-clinicians alike — is that telemedicine is simply a tool in the physicians’ tool chest. It’s one way to deliver care and it can be and should be consciously used. Over the years, clinicians have become excellent masters of “clinical tools”: deciding which exam, which bodily fluid test, which imaging modality will shine more information on the mysterious condition or help to confirm the suspicion, the intuitive assumption about how to best help the patient.

And therein lies the power of telemedicine as a clinical tool: That it is one way to provide healthcare. And the same applies to the telemedicine modality, whether this is via text, over the phone or via live audio/video: the right tool, the right modality must be selected deliberately to provide the best possible care.

What I’m seeing mostly these days is that it is the clinicians “uneasiness” with the video technology that has them justify using the phone only, oftentimes hiding behind excuses that the patients don’t want video, don’t have the technology, or don’t have the technology.

In my analysis of the root causes — as I indicated above — the solutions are simple, cheap, quick and very effective:

  1. Select a user-friendly, designed-for-healthcare telemedicine technology
  2. Create consciously designed clinical telemedicine workflows
  3. Provide clinicians with confidence building training, letting them in on the handful of tips and tricks that are intuitive to integrate
Is Audio-Only Telehealth Good Medicine?

To answer that question, let me get one thing out of the way very clearly: Telehealth, regardless of the modality, is always better than no care. And if telehealth cannot facilitate a diagnosis or care decision, the patient still has the option of being seen in person.

The comparison between in-person and virtual care is “nice”, but often not pragmatic when for example patients in their 80s with underlying health conditions understandably do not want to leave the house during a global pandemic that is highly deadly for people like them. Or when patients do not have the transportation or the time to make it to a doctor’s appointment. Did you know that for many well-executed telehealth services, no shows for telehealth visits oftentimes drop from the mid-20s to single-digit percentages. That’s a very big return on investment into telehealth right there.

So what about comparing telephonic care with video visits? Here, again telephonic care will beat “no care” anytime. But by not exploring and implementing video visits whenever possible, diagnostic accuracy and health outcomes can suffer.

As I said above, Telehealth must be seen and wielded as a clinical tool. It therefore should be a deliberate, conscious decision between telephonic, video and in-person care. There are numerous clinical consult scenarios where telephonic communication is absolutely adequate and even preferred.

Virtual visits over the phone work exceptionally well in established relationships, such as ongoing psychotherapy or chronic care management. Here, the nuances of the voice provide an interpretable picture of the patients’ emotional state, due to the long-standing relationship between clinician and patient.

It is therefore imperative, and we are working on this with multiple clients right now, to develop clinical guidelines as to when which mode of care delivery is appropriate and what the preferred “escalation path” is, i.e., when to switch to a different modality.

85% of communication is Non-Verbal
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It’s amazing how much our five senses are actually taking in when we and especially clinicians are communicating. Clinicians, by default, are trained to be excellent listeners and observers. And human communication is very rich: it includes body language, tone of voice, facial expressions, pauses, pitch and speed, choice of words, micro expressions. But it also includes smell and touch and taking in the whole person – clothes, personally hygiene, etc.

And once you get a video image of the patient’s home in the background, you now get a completely new glimpse into the patient’s life. Thus, the power of the image (we’ll work on smell-o-vision next) cannot be underestimated.

By limiting our communication to audio-only, we are robbing clinicians of the rich experience of communication that we’ve developed over tens of thousands of years.

And this downside not only applies to the physician. A lot of healthcare is about behavior change (including taking medications or complying with a therapy) which requires that patients are engaged. Research has shown repeatedly that we follow those we trust, and it is very difficult to establish a trusting relationship in a matter of minutes when all you have is the doctor’s voice.

The Doctor’s Voice

Speaking of the Doctor’s Voice — to answer the question on the viability of telephonic care, I turned to my fellow Ingenium Digital Health Advisor, Dr. Tom Davis. Tom is a family physician who, after nearing burnout while running a multi-specialty clinic, discovered telehealth “way back when”. He now works directly with physicians helping them to make the most out of telehealth, so they can deliver extraordinary care to their patients in turn.

He highlights the following to points to illustrate that telephonic care in the end is only marginally better than no care:

  1. Telephony offers a greatly diminished “sensory bandwidth”, which not only refers to body language and microgestures but also includes smell, touch, non-filtered sound, environmental cues, etc. This makes a differential diagnosis all the more difficult.
  2. Audio-only care limits the assessment of competencies in both directions: Is the patient sober, alert? Is the physician trustworthy and competent?
  3. To engage patients in their care (including self care) requires certain behaviors by the clinician that are known by experts in the influence and persuasion science. The limitations of audio-only make this extremely difficult.
  4. The uninformed perception that a phone call (or even a video visit) is akin to an in-person office visit, just simpler. Doing telemedicine well, as Dr. Davis points out, requires a “completely different skill-set to effectively perform such encounters”.
Should Telephonic Reimbursement Stay Beyond the Pandemic?

One of my favorite quotes is that “every system is perfectly designed to get the results it gets”. And I share with Dr. Davis and many others my pet peeve that if we would stop talking about “fee-for-service” and instead shift to payment models that reward value, clinicians would be at true liberty to select the best care delivery tool and have as many touch points, no matter how frequent or how short, as long as it improves the patient’s health outcome.

So yes, reimbursement for telephonic care should be available – but preferably as part of a value-based payment model that allows telephonic care.

Having worked for over 8 years to set up telehealth services in predominantly rural areas, I also appreciate and recognize the technical challenges of connecting patients to a sufficiently fast and reliable internet connection to allow for an adequate video image that makes the experience pleasant. But here I’d rather like to see the lobbying efforts being put into building out the internet infrastructure.

So, what’s Next?

So, what’s an organization to do? My recommendations are as follows:

  1. Educate clinicians on the mindset that telephonic, video and in-person care delivery modalities are clinical tools.
  2. Establish clinical guidelines for all specialties and telehealth services as to the clinical appropriateness of each modality.
  3. Train physicians on the technology (and swap it out for something more user-friendly if it’s not) and give them the confidence, through mentoring, to effectively use the tools to provide extraordinary care at a distance.
  4. Wean the organization off of telephonic care where clinically or financially inappropriate.

While I’m bullish on a lot of telehealth-conducive changes staying lifted beyond Covid-19, I’m not so sure on fee-for-service reimbursement for telephonic care – and it’s definitely not going to be at the same level as video telemedicine.

As always, let me know your thoughts!

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Christian Milaster and his team optimize Telehealth Services for health systems and physician practices. Christian is the Founder and President of Ingenium Digital Health Advisors where he and his expert consortium partner with healthcare leaders to enable the delivery of extraordinary care.

Contact Christian by phone or text at 657-464-3648, via email, or video chat.