Audio-only telehealth visits rate worse, and Black patients get more of them

Virtual care is usually discussed as one thing. In practice it is two: a video visit and a phone call, and the difference between them is not only technical. Two studies published this month measure what that difference costs, and who pays it [s1][s2].

The patient experience study

Researchers analysed one year of ambulatory virtual visits at a US health system, linked to patient experience survey data — 90,670 virtual encounters in total, of which 16% were audio-only [s1]. Using nested logistic models with the patient's likelihood to recommend the provider as the primary outcome, and adjusting for patient- and physician-level covariates, they compared audio-only against video encounters [s1].

Audio-only visits were associated with lower likelihood to recommend (odds ratio 0.75, 95% CI 0.70 to 0.80) and with worse experience across many technical aspects of virtual care [s1].

An odds ratio of 0.75 on a satisfaction measure is a real but not dramatic gap. The more consequential finding is who ends up in the audio-only group.

The disparity, and where it does not come from

Black patients were more likely to have audio-only encounters and reported worse overall patient experience [s1]. Crucially, that experience disparity persisted after adjusting for visit modality [s1] — meaning it is not simply an artefact of being routed to phone visits more often. Something else is operating on top of the modality effect.

The study reports that the residual disparity was partly mediated by differences in perceived respectful provider communication and associated interpersonal aspects of care [s1].

That is a specific and uncomfortable result. It locates part of the gap in how the encounter felt interpersonally, not in bandwidth. A hospital that solved the digital divide tomorrow — put a working video connection in every home — would, on these data, close some of the gap and not all of it.

The authors' framing is that audio-only virtual care remains central to ensuring access, while posing challenges for patient experience, and that investment is needed in both technical facets and provider communication [s1].

Modality changes more than satisfaction

The second study measures a different consequence of the same choice. It is a retrospective cohort of 1,220,902 veterans who newly initiated integrated mental health services within primary care (PCMHI) between 1 October 2018 and 30 September 2023 [s2].

The outcome was "same-day access" — whether a mental health visit occurred on the same day as a primary care visit, the pattern that in-person clinics achieve through a warm handoff from one clinician to another down the corridor [s2].

Patients whose initial mental health visit took place via telehealth had 86% lower odds of same-day access than those seen in person (95% CI 0.1444 to 0.1448) [s2]. Broken out by modality, the odds ratio was 0.0912 for video (95% CI 0.0909 to 0.0915) and 0.1604 for phone (95% CI 0.1602 to 0.1606) [s2].

Those confidence intervals are extraordinarily tight, which is what happens with 1.2 million observations; they reflect precision, not the size of the effect. The effect itself is large.

It did improve over time. The odds ratio rose from 0.10 in fiscal years 2019–2021 (95% CI 0.09 to 0.12) to 0.18 in fiscal years 2022–2023 (95% CI 0.16 to 0.20) [s2] — better, and still far from parity.

What the two studies do and do not show

Both are observational. The experience study covers one health system for one year and cannot establish that modality caused lower ratings; patients who choose or are routed to phone visits differ in ways no covariate set fully captures [s1]. The VA study spans five fiscal years and a single, unusual health system with its own scheduling structures, and same-day access is a process measure, not a clinical outcome — no symptom, diagnosis or treatment endpoint is reported [s2].

Neither study argues against telehealth. The first is explicit that audio-only care remains central to access [s1]; the second frames its finding as a question about how primary care workflows need to adapt rather than a case against tele-mental health [s2].

Why it matters now

Audio-only visits exist because video does not reach everyone — because of broadband, devices, digital literacy or disability. That makes them an equity instrument. What these two studies show is that the instrument carries costs of its own: a measurably worse experience, and in the VA setting, a much lower chance of the immediate handoff that in-person integrated care is built around.

What to watch

Whether health systems begin reporting patient experience separately by modality. Aggregate "virtual care" satisfaction scores average a 16% audio-only minority into an 84% video majority [s1], which is precisely the arithmetic that hides a disparity.

Sources

• Disparities in patient experience with video and audio-only virtual care — Journal of Telemedicine and Telecare, 2025-09-08
• Association Between Telehealth Delivery and Same-day Access to Integrated Mental Health in a National VA Sample — Journal of General Internal Medicine, 2025-09-19