Audio-only visits for behavioral health ‘dramatically increased’ during pandemic

Jefferey Metcalfe

April 18, 2022

4 min read


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Behavioral health visits conducted over the phone or video greatly increased among safety net clinics during the COVID-19 pandemic, according to findings from a RAND Health report.

Audio-only visits were the most common telehealth modality, but many clinic staff members expressed concern about the future of reimbursement for these visits.


Modality of behavioral health visits conducted from June to August 2021

Uscher-Pines L, et al. RAND Corporation. 2022;doi:10.7249/RRA1840-1.

“Perceptions of whether telehealth provided an acceptable level of care were relatively positive, but perceptions of its sustainability — as well as perceptions of equity and quality of care — were nuanced,” Lori Uscher-Pines, MSc, PhD, a senior policy researcher at RAND Corporation, and colleagues wrote.

The researchers reviewed recent literature on telehealth implementation and compiled data from semi-structured interviews with more than 100 staff members at 23 California safety net clinics. The staff members were asked about their telehealth implementation in fall 2020, spring 2021 and fall 2021. Uscher-Pines and colleagues also administered a survey to more than 500 providers at 20 California health centers in April 2021. The survey assessed the providers’ knowledge, attitudes and experiences with telehealth.

Increase in telehealth adoption

While overall visit volumes remained relatively steady during the study period, there was reduced primary care volume in August, October and November 2020, and reduced behavioral health volume in October and November 2020, according to Uscher-Pines and colleagues. However, the proportion of audio only and video visits “dramatically increased” during pandemic months, the researchers wrote.

Uscher-Pines and colleagues reported that audio-only visits in primary care peaked in April 2020 and “remained the dominant telehealth modality throughout the pandemic study period.” In the final three months, from June 2021 to August 2021, 66% of visits for primary care were conducted in person while 30% were audio only and 4% were video visits. A median of 3% of primary care visits across health centers were conducted over video in 2021.

Meanwhile, audio-only visits exceeded in-person visits for behavioral health. From June to August 2021, 28% of behavioral health visits were conducted in person while 52% were conducted over the phone and 20% were conducted via video. A median of 14% of behavioral health visits across health centers were conducted over video in 2021.

“This study shows that telehealth is a good modality for delivering care,” Kathleen Blake, MD, MPH, a senior adviser at the AMA, told Healio.

Blake Kathleen

Kathleen Blake

The findings also provide strong indirect support for behavioral health integration, as the clinics in the study were “almost like a one-stop shop for primary care plus behavioral health care,” according to Blake.

Patient and provider experiences

The report further showed that patients with limited English proficiency participated in significantly fewer video visits than patients who were fluent in English. Uscher-Pines and colleagues reported that patients who preferred a language other than English participated in 45.5% of total primary care visits in August 2019, 37.7% of video visits in August 2020 and 35.8% of video visits in August 2021 (P < 0.01).

Most health care staff reported positive experiences with telehealth overall. However, clinicians and staff did not agree on the quality of care provided through telehealth, specifically for patients with limited English proficiency; 28% of survey respondents had mixed reviews or disagreed that the quality of care provided via telehealth is high. Also, nearly half of the respondents reported that the quality of telehealth was lower for patients with limited English proficiency.

Considering the growing future of telehealth, Uscher-Pines and colleagues focused on key areas where improvements and changes are necessary to improve this modality. These improvements included implementing billing modifiers, conducting more research, expanding access and addressing digital barriers. Ensuring that patients could access telehealth services was a consistent challenge for health centers, according to the researchers. Moreover, a hybrid care model in which patients receive both telehealth and in-person visits requires appropriate staffing models as well as a shift toward team-based care.

Blake agreed that the future of telehealth will most likely involve a hybrid model. The focus now should be on overcoming barriers to telehealth access and improving payment coverage of all available services, she said.

“Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity,” Uscher-Pines and colleagues wrote.

Restrictions to accessible telehealth

Amid the public health emergency, CMS no longer requires a patient’s first behavioral or mental health visit to be conducted in person. However, 150 days after the emergency declaration is lifted, the in-person requirement for initial visits will be reinstated, according to Kyle Zebley, the vice president of public policy at the American Telemedicine Association (ATA) and the executive director of ATA Action.

Kyle Zebley

Kyle Zebley

The in-person requirement was originally established towards the end of 2020 as a way of driving down utilization of telehealth for behavioral or mental health visits, Zebley told Healio. The ATA and mental health advocates oppose in-person requirements for behavioral and mental health because “it is a clinically inappropriate barrier to appropriate care,” he said.

The Mental Health Access Act, which is currently in committee in the U.S. House of Representatives, would permanently repeal the requirement.

Other restrictions to accessible telehealth include constraints against remote prescribing.

“Current law says that you must go in person prior to having your provider prescribe you clinically appropriate controlled substances,” Zebley said.

This requirement has also been waived during the public health emergency but “it still threatens to come back into force, which will be another barrier to clinically appropriate care for vulnerable communities that are relying on these prescriptions,” he said.

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