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Analysis

Psychiatrists Decry Barriers to Wider Adoption of Telemedicine

By MedPage Today  
   February 20, 2020

Well-intended laws on remote prescribing stand in the way.

This article was first published on Wednesday, February 19, 2020 in MedPage Today.

By Shannon Firth, Washington Correspondent, MedPage Today

WASHINGTON -- Psychiatrists urged lawmakers to support the expansion of telepsychiatry and to remove barriers to care for patients in remote and underserved areas, during a Capitol Hill briefing on Tuesday sponsored by the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry.

The panel's core recommendations included eliminating what are known as "originating geographic site requirements" and relaxing restrictions on in-home telehealth visits. Panelists also highlighted difficulties related to remote prescribing and obtaining licensure in other states.

"A sick person is a sick person and we should be able to take care of them where they live," said panel member Robert Caudill, MD, professor of psychiatry at the University of Louisville in Kentucky.

While there remains reluctance in some circles around telepsychiatry, there are cases where it may be the best option for that patient. One patient, who he referred to as Sandy was "suicidal every single day of her life."

Caudill saw Sandy 20 years ago, before he used telemedicine. She had survived horrible trauma and stayed as his patient over several years as he moved to offices in different cities. In his slides he showed photographs of some of the incredibly long bridges Sandy would have to drive across over various rivers in order to receive treatment. Sandy's suicidal thoughts included jumping and driving off those same bridges.

While she is no longer alive, Caudill said, she was an example of someone for whom telemedicine could have been useful.

Shabana Khan, MD, assistant professor of child and adolescent psychiatry at NYU Langone in New York City, spoke about the difficulty of caring for patients, particularly those who move out of state for college.

Licensure issues are "huge," she said.

The patient's psychiatrist has to ensure he or she is licensed in the state where the patient now lives in order to continue serving that patient. In Florida, psychiatrists can register as an out-of-state practitioner and some states have limited special registrations for telemedicine, "but that's falling out of favor," Khan said.

Additionally 29 states, the District of Columbia, and Guam have an interstate compact where if a practitioner has a "full, unencumbered license" he or she can serve patients in the other states in the compact.

But even then practitioners must get licensed in those other states, pay an administrative fee, and meet each state's continuing education requirements and practice standards.

"It can get very complicated" and costly, she said.

APA President Bruce Schwartz, MD, the briefing's moderator, estimated the cost of licensure in one state is about $1,000 for a 2-year period.

The idea of a national licensure process has surfaced over the years, but hasn't gotten traction because as Kahn explained each state still wants to be able to regulate its own licensure process.

More than one panelist spoke about another challenge: the unintended consequences of a decades-old law called the Ryan Haight Act which bars providers from prescribing certain medications without an in-person visit.

The goal of the 2008 law was to shutter internet pharmacies, but telemedicine somehow became "collateral damage," Caudill said.

Schwartz noted that the SUPPORT Act of 2018 gave the Drug Enforcement Administration a deadline of October 2019 to issue regulations to clarify "the limited circumstances" under which prescribers could get authorization to prescribe remotely and to develop procedures, but the DEA failed to do so.

Caudill said the uncertainty around prescribing has kept some clinicians from participating in telemedicine, and called on the audience to do "whatever you can do to help with that."

“A sick person is a sick person and we should be able to take care of them where they live.”


KEY TAKEAWAYS

The panel's core recommendations included eliminating what are known as "originating geographic site requirements" and relaxing restrictions on in-home telehealth visits.

Panelists also highlighted difficulties related to remote prescribing and obtaining licensure in other states.


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