Pill Mill Crackdown Endangers Telepsych Program

It is far too easy in this country to set up and run a pill mill. Recently I attended a session on healthcare fraud and abuse detection where a former regulator noted that in the state of Florida, all that was required to set up an online pharmacy was to prove one was 19 years or older.

Now here come federal lawmakers, trying to solve a problem that may in large part belong to the states. And one such effort, unless amended, uses such broad brush strokes that it threatens to choke off a very good technology-based healthcare program.

Mission Hospital in Asheville, North Carolina is the tertiary hospital serving the 18 counties of western North Carolina. Rural primary and secondary hospitals there are isolated and lack many specialists. Psychiatrists and neurologists are in particularly short supply.

In February 2011, new technology started offering a way for psychiatric patients in those outlying hospitals to get good specialist care without making the treacherous drive over two-lane mountain roads to Asheville.

The program uses a robot from InTouch Technologies, able to freely wander from consult to consult in the local emergency rooms. A psychiatrist sitting in Mission Hospital in Asheville is able to see and hear patients in the remote EDs, and those patients can see and hear the psychiatrist.

"It's all HIPAA-compliant and encrypted," says Carrie Castellon, director of telehealth for Mission Health.

The telepsych program was so successful that Mission Hospital added a second specialty in June 2011 to assess possible stroke victims in these EDs. Using the same robot technology to assess patients, neurologists at Mission can now assess whether clot-busting drugs should be administered to patients in those EDs. "With strokes, time is brains," Castellon says. "Otherwise, if patients were traveling to Asheville or to the closest primary stroke center, we're talking lots of minutes and lots of brains that could be lost."

Although psychiatrists can make decisions less urgently, it doesn't make sense from a time or efficiency standpoint to put them on the state's twisty western roads, and have them drive from remote hospital to remote hospital to make rounds. Patients may just end up sitting in the ED for hours waiting to be transferred to an inpatient psychiatric facility for evaluation.

In many cases, the remote consult from Asheville, using the robots, is sufficient for the psychiatrist to prescribe a new medication or change in medication, Castellon says.

But here's where those federal lawmakers enter the picture.

At least two bills pending in Congress would crack down on pill mills, those notorious health providers and pharmacies skirting the law to contribute to the epidemic of prescription drug overdoses in this country. The CDC's most recent data shows more dying in the U.S. from prescription drug overdoses than from overdoses of illegal drugs.

But the bills are written in such a way as to make illegal the telepsych consults in North Carolina if controlled substances are prescribed without the psychiatrist meeting face-to-face with the patient.

"While we support the effort to stop the inappropriate prescribing of prescriptions, this legislation could have negative and unintended consequences on important telehealth services that we deliver to our patients in western North Carolina," wrote Rowena Buffett Timms, senior vice president of government and community relations, in a letter to U.S. Senator Kay Hagen (D- NC).

As of press time, Sen. Hagen's office had not responded to my inquiry on this proposed legislation, but I hope that her effort to elicit feedback on the bill will result in an amendment that recognizes that face-to-face consultations in 2012 can also be achieved with a robot such as Mission Hospital's.

In her letter, Timms supports the effort to crack down on prescription drug abuse, unscrupulous clinics, and pill mills.

I wouldn't be surprised if technology such as robots can be used to facilitate abuse, so it may not be as simple as writing in an exception for the kind of technology discussed here. Legislation has to be thoughtfully written.

But some form of flexibility must be found to save valuable programs such as Mission Hospital's outreach to its isolated, rural population.

At the very least, the legislation must acknowledge the existence of teleconsults in the reimbursable fee schedules in use by Medicare and Medicaid.

When I suggested to Mission Hospital's Castellon that some decision makers would respond more to the money-saving elements of teleconsults than to its life-saving benefits, she echoed a sentiment I hear often: Patients need this technology regardless of how much money it saves.

One child psychiatrist Castellon I spoke with notes that delayed treatment affects her patients "personally, socially, at home, and at school, not only affecting how they see the world, but how their family and school functions."

Another branch of government, the U.S. Department of Agriculture, recently awarded Mission Hospital $419,000 to expand its telehealth program in largely rural western North Carolina.

"It's a win to the local clinic or hospital, because they won't be boarded up, because they're seeing patients, and it's a win for us because we're able to provide that care more efficiently throughout the region."

With four member hospitals already participating, and three hospitals to be added in the next year, Mission Hospital's robot-powered remote consults deserve continued support, not to get tangled up in the pill mill controversy.

Now, how about putting in some tougher licensing for online pharmacies in Florida?