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Physicians at Southern California’s nonprofit Venice Family Clinic never envisioned caring for most of their patients via telephone—until the pandemic.
When office visits dwindled last spring during local stay-at-home orders to prevent the spread of coronavirus disease 2019 (COVID-19), clinic staff had to make an abrupt shift. Soon, 75% of appointments were being handled by telephone. But none of them used video call apps such as FaceTime, WhatsApp, or Google Duo. These were old-fashioned audio-only calls.
Despite the rise of video visits as communities locked down, basic telephone calls remained popular among the 50-year-old clinic’s patients, three-quarters of whom live below the federal poverty line. Even after video visits began in late spring, telephone conversations still constituted most virtual visits and about half of all visits months later.
“We were all pleasantly surprised to find out how much care we can provide on the telephone,” the clinic’s chief medical officer, Despina Kayichian, MD, said in an interview.
The Venice clinic isn’t alone. Since payers temporarily lifted restrictions to encourage people to stay home during the pandemic, many practices have relied on telephone calls to provide a range of services that had been handled face-to-face.
For people who can’t access a computer or smartphone, basic telephone calls are a lifeline. Internist Jacqueline Fincher, MD, president of the American College of Physicians, said in an interview that pandemic disruptions created a “precarious time” for her older patients in rural Georgia who have only a landline.
“I wouldn’t doubt that some of their telephones are still rotary,” she added.
Telephone visits have also been a huge benefit for patients who struggle with technology or have work or family responsibilities that interfere with their ability to have a video or in-person visit. The calls have become such a vital tool for vulnerable populations that some physician groups are pushing for temporary pandemic-related reimbursement to become permanent.
A Health Equity Issue
Data aggregator BroadbandNow recently pegged the number of people without high-speed internet at 42 million, or 13% of the population. However, that’s only 1 slice of the population that can’t access video visits. Plenty of people lack the technical know-how to use an app, for example.
Not surprisingly, the inability to access video visits disproportionately affects low-income and medically vulnerable people.
The Pew Research Center reported that almost a third of households with incomes of $30 000 or less lack a smartphone, and more than 40% lack a computer or high-speed broadband access. A quarter of Medicare beneficiaries lack both a smartphone and a computer with high-speed internet—essential technology for a video visit—with higher percentages among low-income, Black, and Hispanic beneficiaries, and those with disabilities, a research letter in JAMA Internal Medicine reported.
Telephones calls can bridge that gap.
Nearly a third of Medicare patients who received telehealth services from mid-March to mid-June did so using audio-only telephone calls because they either couldn’t access video technology or weren’t comfortable using it, according to the Centers for Medicare & Medicaid Services (CMS).
Older adults, Black patients, those needing an interpreter, and Medicaid recipients were more likely to use audio-only visits than others who were treated at the University of Michigan between April and June, according to unpublished data provided by university internist Julia Chen, MD, who has studied the demographics of patients treated remotely during the pandemic.
In tribal communities, where broadband is scarce, about 80% of 33 000 virtual visits provided monthly by the Indian Health Service during the pandemic have been over the telephone, an agency spokesman said via email.
Triaging COVID-19 by Telephone
For patients on the wrong side of the digital divide in the COVID-19 era, telephone calls have enabled physicians to provide a wide range of services efficiently and safely. They’ve taken medical histories, ordered or followed up on lab and imaging tests, and decided whether a patient needs to come in for a physical examination or start a medication. What’s more, discussing a new medication’s symptom relief or adverse effects by telephone can save patients time and money, Fincher said.
Notably, telephone calls have triaged throngs of patients with respiratory symptoms, including suspected COVID-19 cases. Video conferencing “wasn’t supplying that much additional information” about those patients, Chen said. “Even on the telephone you can hear if someone is in some respiratory distress, if they are having trouble completing their sentences, or if they are sounding winded.”
Almost half of all telehealth visits logged by the University of Michigan during April and May were conducted by telephone, Chen and other researchers reported in The Conversation, an online collection of articles written by academics.
For a Venice Family Clinic patient who had COVID-19 symptoms, a telephone call “was adequate to give her the information she needed to treat her symptoms and understand how to isolate herself,” clinic Chief Executive Officer Elizabeth Benson Forer, MSW, MPH, wrote in the Capitol Weekly, a California publication about government and politics. On the same call, a physician refilled an asthma inhaler prescription for the woman’s son and advised a relative living with her who also had COVID-19 symptoms.
Telephone calls also can help physicians keep tabs on patients with chronic conditions such as diabetes, heart disease, chronic kidney disease, high cholesterol, and hypertension. By using devices such as glucose meters, scales, and blood pressure cuffs at home, patients can record their own vital signs and report them to a physician’s office with a telephone call or through a web portal like MyChart.
The Venice clinic provides free blood pressure cuffs that patients with hypertension can pick up and learn how to use during a 10- to 15-minute in-person appointment with a health educator. Between physician visits, patients regularly touch base with clinic staff to report their numbers, helping them feel cared for. Kayichian calls it “the ultimate patient engagement.”
Uses in Specialty Care
Although primary care lends itself to telephone visits due to established relationships between physicians and patients, telephone calls have similarly been deployed in many areas of specialty care.
Perhaps the most widespread use is in mental health, which has largely switched to virtual care during the pandemic. A 2019 evidence assessment in Psychological Services supported using telephone calls for 4 common mental health conditions: depression, posttraumatic stress disorder, anxiety, and adjustment disorder.
In fact, some patients with depression are more comfortable talking by telephone rather than video, Glenda Wrenn, MD, chief medical officer of 180 Health Partners, a behavioral health practice in Franklin, Tennessee, noted in an interview. Wrenn also practices telepsychiatry at primary care clinics operated by Grady Health System in Atlanta.
Although Wrenn prefers video appointments, she said the telephone can help overcome a patient’s reluctance about therapy. “I may start with a telephone call so they can hear my voice and feel comfortable,” she said.
Some practices assess conditions by viewing photos or video clips that patients send through a web-based portal. Wrenn said she diagnosed a tremor based on a patient’s video clip. Photos can help identify rashes, Chen noted, although they might not be useful for evaluating a potentially cancerous skin lesion.
In ophthalmology, a good-quality image can help triage situations such as a foreign object lodged in the cornea or bleeding under the conjunctiva, said Maria A. Woodward, MD, MSc, associate professor of ophthalmology and visual sciences at the University of Michigan, a coauthor with Chen of the telehealth article in The Conversation.
During the pandemic, the University of Michigan’s ophthalmology department mailed patients paper eye charts so they could perform their own acuity examinations. The department also created a rapid testing clinic to minimize patient contact for specialized examinations that can’t be performed at home, such as imaging the back of the eye to monitor diabetic eye disease. Those patients could be followed up with a video or telephone call.
Studies have shown that telephone calls can help patients with heart disease adhere to medication regimens and avoid rehospitalizations. Cardiologist Ami Bhatt, MD, of Massachusetts General Hospital in Boston, said telephone calls are a “high-value tool” for reaching out to patients shortly after coronary stent placement or a hospital stay due to heart failure.
Benefits and Limitations
Even when a patient has the technical capability to use video, glitches occur, they’re pressed for time, or they can’t figure out how to use a video app. Not only is a simple telephone call a reliable fallback, it also might afford more privacy than a video conversation or make it easier to include translators or family members.
Still, there are obvious gaps. Vaccinations, screening tests, certain skin conditions, and musculoskeletal problems don’t lend themselves to care via telephone. There’s no getting around hands-on care for trauma or surgical procedures that can’t be delayed.
Patients who require ongoing care for chronic conditions or other health issues might do best with a hybrid arrangement. In-person visits are better for evaluating symptoms such as edema, which could indicate kidney disease or congestive heart failure.
Similarly, alternating in-person visits with telephone calls might be useful for prenatal care, which typically requires a mother-to-be to check in a dozen or more times during the course of a pregnancy.
At Parkland Health and Hospital System, a large safety net hospital in Dallas, more than 4000 prenatal visits were handled by telephone early in the pandemic. Despite the lack of a physical examination, 99% of 238 expectant mothers who were surveyed reported that telephone visits with advanced practice nurses met their needs. Still, the majority said they’d prefer a mix of in-person and virtual visits.
The survey’s lead author, Denisse Holcomb, MD, assistant professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center in Dallas, said in an interview that patients seem to value the convenience and extra counseling time afforded by telephone visits as well as the safety of avoiding close contact.
Cardiologist Bhatt prefers video to teach her patients how to take their own pulse or palpate their abdomen. She’d like to see local internet hubs created to allow patients without Wi-Fi to at least have video visits close to home.
Importantly, the telephone doesn’t allow a physician to observe a patient’s body language or facial expression. Those nonverbal cues can be vital in helping physicians to assess a patient’s emotions, gauge whether he or she understands the medical information being communicated, and build rapport—all key elements in practicing medicine.
Wyatt Decker, MD, MBA, chief executive officer of OptumHealth, a managed care subsidiary of UnitedHealth Group, said in an interview that despite its advantages in so many medical encounters, the telephone isn’t a suitable way to deliver devastating news. Physicians, he said, need to maintain “the human touch” for those encounters.
Advocating a Blended Care Model
An opportunity to refashion medicine with a blend of approaches—face-to-face meetings, state-of-the-art telehealth platforms, consumer-friendly video apps, and telephone calls—could be on the horizon.
However, it’s unclear whether payers will support such changes. Citing long-standing concerns about increased utilization, fraud, and lack of quality data, staff analysts at the Medicare Payment Advisory Commission have suggested ending payments for audio-only visits and lowering rates for video visits after the pandemic.
To bolster the case for remote care after the pandemic, physician organizations have a duty to mine the mounds of data they’re generating on quality, cost-effectiveness, and improved access—even if it’s observational—said Bhatt, who chairs a collaboration between the American College of Cardiology and telemedicine platform Heartbeat Health.
For example, it would help to know whether remotely monitoring patients with chronic conditions affects hospitalizations or emergency department visits.
Payers should also consider whether they risk a backlash if they yank away a service that many patients—not just those without Wi-Fi access—have come to appreciate. CMS Administrator Seema Verma wrote in a Health Affairs blog post that it’s “hard to imagine merely reverting to the way things were.” Her agency, which influences other payers’ practices, has requested public input on a potential billing code for telephone visits.
In the meantime, at least 2 states—New York and New Hampshire—have passed legislation to expand Medicaid coverage for telephone visits after the pandemic.
Too often, vulnerable patients have been inconvenienced or prevented from getting care altogether in a brick-and-mortar system that incentivizes face-to-face encounters, some reform-minded physicians believe.
“We’re asking to finally change a model of care that’s very episodic and practice centered,” said Bhatt, who added that providing better options tells patients that their time and resources are respected. “We’ve never said that before. Shame on us for that.”
Accompanying this article is the JAMA Medical News Summary, an audio review of news content appearing in this month’s issues of JAMA. To listen to this episode and more, visit the JAMA Medical News Podcast.
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Jaklevic MC. Telephone Visits Surge During the Pandemic, but Will They Last? JAMA. 2020;324(16):1593–1595. doi:10.1001/jama.2020.17201
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