Since the start of the COVID-19 pandemic, the efficiency and reimbursement of over-the-phone therapy (also called “over-the-phone counseling” or just “telephone therapy”) have become a hotly debated issue. For years, many stakeholders have argued that health care over the phone was better than no health care, and/or that it should be reimbursed on par with in-person therapy to help improve much-needed access to healthcare providers. Since the beginning of the COVID pandemic, telephone use has skyrocketed, and numbers of missed appointments dropped – but now that the end of the current pandemic is within sight, the issue of continued reimbursement for over-the-phone visits is more hotly debated than ever.
Over-the-Phone Therapy During & After the Pandemic
The March 2020 CARES Act included a provision that allowed telephone visits to be reimbursed at the same rate as in-person visits for Medicaid and Medicare beneficiaries. Many third-party carriers followed suit. A debate has since raged over whether or not services delivered by telephone are as effective as in-person or video-based formats. In-person or video-based visits are seen as being more valuable, given the extra visual information available during these more visually-based interventions. The issue of a therapist’s ability to better understand whether a client or patient is alone for the meeting or joined by silent participants is also one that can complicate telephone-based privacy. Another is the increased ease of distractibility by one or both parties. See Controversy about Eliminating Telephone Telehealth Coverage for details.
The controversy continues not only with respect to efficacy, but also reimbursement. Some parties claim that audio-only visits are not as effective and therefore, that reimbursement rates should not be equal to in-person visits or video visits. See Telehealth.org’s COVID-19 Telephone Telehealth Reimbursement for more reimbursement specifics, including popular CPT codes.
As the pandemic begins to recede in some areas, the heart of the issue about reimbursement for over-the-phone therapy is that lawmakers nationwide are at odds about how much taxpayer money should be spent on telephone therapy appointments. Proponents of over-the-phone therapy claim that it is in some cases better than in-person or video therapy, such as with patients concerned unduly with their looks, people who don’t have any experience with computers, and people who live in remote areas. This same argument was offered by many email therapy advocates in the 1980’s, 90’s and well into the first decades of the current century. However, to the chagrin of many email therapists, the data has not yet shown acceptable levels of efficacy for email-only interventions to treat a wide variety of disorders. The previously hot debate over email therapy has since subsided.
During this same time, the use of videoconferencing has not only met but in some cases, exceeded the in-person standard and now stands as the digital standard for healthcare. See Telehealth Is As Good As In-Person Care? Consider the Telehealth Evidence. After a year of COVID-required telehealth delivery, many clinicians report a surprisingly positive experience with telehealth. Numerous clinics and hospitals as well as smaller groups and independent practitioners see their future as involving at least a hybrid blending of telehealth and in-person care, or in some cases, telehealth-only care as they move forward.
The often-undiscussed, yet strongly mitigating factor when discussing the use of any technology is the competence of the clinician using it, which in effect, boils down to whether or not the clinician has conducted their own literature review, found the best studies, reviewed them carefully to extract relevant findings, and last but not least, implemented the suggestions made across the best of those studies. In lieu of such rigor, many opt for evidence-based professional training to learn the basics for responsibly addressing clinical, legal, and ethical dilemmas.
Over the Phone Counseling State Actions to Date
While Medicare is weighing options for over-the-phone-therapy or over-the-phone-counseling reimbursement at the federal level, some states are taking matters into their own hands with regard to Medicaid and third-party carriers. For example, New Hampshire passed legislation in March 2020 that mandated Medicaid and private health insurance pay for over-the-phone visits at the same rate as in-person visits. Similarly, Vermont extended its emergency rules for clinicians to be paid the same rates as in-person visits through 2022, with a state working group recommending the practice become permanent. Colorado, Connecticut, Delaware, and New York have also passed legislation to count phone visits as telehealth and to pay for them at varying rates. On the other hand, Pennsylvania has passed rules against some forms of telemedicine.
Lowering of Standards for Over-the-Phone Therapy?
The crux of the issue about reimbursing telephone-telehealth is, simply stated, whether telephone-only healthcare is as effective as in-person care. While the efficacy of telehealth via video was clearly established and accepted by CMS during 2012-2013, with numerous foundational studies, the same decades of rigor have not yet been applied to researching the efficacy of telephone-only telehealth or teletherapy.
The concern with over-the-phone therapy centers on whether it reflects a lowering of standards to accommodate disparities for people who otherwise will not have access to care post-COVID. Supporters of this position would agree that while tax dollars should be spent to lower disparities, tax dollars should not be spent on services that are not yet clearly shown to be as effective as in-person care. The fact that disparities prevent in-person care often does not enter into the same argument.
Decision-makers then are facing the difficult decisions of what exactly to change related to reimbursement and CPT codes to effectively balance disparities. For instance, for which procedures and diagnoses should reimbursement be approved? More precisely, which evidence-based protocols for telephone telehealth should be used, and when in the trajectory of one’s care is it most feasible to use telephone-only interventions to achieve acceptable efficacy rates? While some stakeholders negate the relevance of these types of inquiries, legislative decision-makers are held to a higher standard when it comes to spending tax-payer dollars.
Dampening Effect of the GAO Report to Congress
These issues related to the evidence base are not to be minimized, as they were reported as being one of three reasons cited by the U.S. Government Accountability Office (GAO) for asking Congress to slow down the approval of telehealth across the board in their May 19 report to Congress. The GOA is recognized as being an independent group that engages in audits and investigations for Congress. Known as the “congressional watchdog” the GOA was commissioned by the original Cares Act “to conduct monitoring and oversight of the federal government’s response to the COVID-19 pandemic.” Additional GAO studies were funded by Biden’s update of the Cares Act in the spring of 2021.
In response, GAO has issued a series of government-wide reports from June 2020 through March 2021. GAO is continuing to monitor and report on these services. The conclusions drawn by these GAO reports to Congress are at least one reason that lawmakers have been reluctant to vote for changes to Medicare reimbursement rates related to telephone telehealth. The specific wording of the GAO’s report regarding the continuation of the COVID-19’s expansions included this one reason for slowing the approvals for continued telehealth across the board, which is pivotal to the discussion herein:
- Beneficiary health and safety. Although telehealth has enabled the safe provision of services, the quality of telehealth services has not been fully analyzed.
The other two reasons for slowing broad-scale approvals were:
- Increased spending. Telehealth waivers can increase spending in both programs, if telehealth services are furnished in addition to in-person services.
- Program integrity. The suspension of some program safeguards has increased the risks of fraud, waste, and abuse that GAO previously noted in its High-Risk report series
For details and how this report applies to telebehavioral health in particular, see Telehealth.org’s June 10, 2021 article entitled, Risks & Benefits of Telehealth: Controversy about Post-Pandemic Telehealth.
In short, the lack of accepted research for some forms of telehealth such as telephone telehealth by groups such as the GAO makes it difficult for elected officials to wholeheartedly support as-yet controversial telephone-only treatment approaches for widescale reimbursement with tax-payer monies through Medicare and Medicaid.
As the pandemic shows signs of abating in some areas, public outcries for long-term telephone therapy reimbursement will inevitably and ultimately rest on the evidence base. Luckily for proponents of over-the-phone interventions, a number of specific telephone-based interventions have been published in 2020 and 2021 show validated efficacy for telephone-based protocols for working with identified populations.
Exactly What Types of Protocols are Clinicians Now Offering Over the Phone?
One doesn’t have to look too far to see that many clinicians have shifted their practices to telephone-based care for more than a year, and prefer it for many reasons. The issue at hand, however, once again, is whether clinicians are competent for the work they are offering the consumer public. Anyone taking professional training can attest to the fact that most clinicians are quite surprised to realize how much they don’t know about telehealth, including telephone-based telehealth.
Some are taking the time to research and implement evidence-based strategies. Many are getting professional training to short-cut the time and energy needed, but most are “making it up” as they go, assuming that they know how to deliver professional services based on prior experience with telephones. Unfortunately, as is often the case with cultural competency/sensitivity/humility, those who need it the most seem to want it the least. And therein lies another part of the problem.
When research is focussed not on what clinicians should be doing but rather, what they are doing in many aspects of US healthcare, clinicians are found to be falling far short of expectations set by the Institute of Medicine and the licensing boards – and they have been for decades. Such poor self-policing by the clinical community also causes alarm in policy-makers, who must look at the facts to see reality rather than see only the positive side of funding services. See Is Phone Therapy Really THAT Simple? and Why Bother with Telehealth Training?
More research is needed to continue validating the already-published data, and that need is currently being addressed by CMS-funded research through the 2121 update to the Cares Act. However, many states are already engaged in debating bills of their own, such as California.
A State Example: California’s Journey Towards a Solution
California’s lawmakers are currently not on the same page regarding reimbursement rates for over-the-phone counseling or over-the-phone telehealth care in general. The Democratic governor’s budget has tasked the state legislature with lowering the rate that Medi-Cal, the state’s version of Medicaid, to pay for phone visits. Still, the Democratic legislature wants to keep paying the same rate as in-person, and video visits for low-income and disabled people to more easily access services. Currently, AB 32 mandates over-the-phone telehealth be paid at the same rate as video and in-person visits in most settings; the legislation has passed the state Assembly and is under debate in the state Senate.
The California Health Benefits Review Program reviewed the matter and found that patients of color and those who are older or live in rural communities are the people who mostly make use of over-the-phone visits. As a result, the Program argues that reimbursing over-the-phone visits at the same rate as video visits provides more healthcare access to typically vulnerable groups. By contrast, the California Department of Health Care Services only wants to reimburse some phone visits at 65 percent of in-person or video rates, claiming that phone visits don’t provide the same quality as video visits.
Federal Legislation Still Unclear
Congress allowed Medicaid and Medicare to pay for over-the-phone therapy in March 2020 and held hearings in April 2021 about how much to reimburse for over-the-phone therapy. In addition, the nonpartisan Medicare Payment Advisory Commission has recommended extending the payments for up to two years after the pandemic. Precisely where this debate will land is as yet unclear.
Advocacy is clearly in order. Readers are encouraged to take 10 minutes to write to both their state and federal legislators and in a single-page letter to voice their concerns in this pivotal debate. Including a short case example or two to illustrate one’s position is strongly suggested.
Telehealth Video & Telephone Best Practices
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