End of COVID-19 Emergency Declaration. Outpatient Psychiatrists brace yourselves!

[littlefred]

Incoming stream of patients on controlled medicines that need to be seen in person.

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[HowAreYaNow]

It's going to be an absolute nightmare; I have at least one of my patients in mind who's going to cause problems when we try to get them to come in person.

 

[randomdoc1]

Love it. I get a sick pleasure out of saying : nope, our prescribers are too part time and we don’t have the staffing capacity to oversee such highly regulated substances.

Should have thought carefully before seeking it from questionable places…

 

[wolfvgang22]

I already started dealing with this last week. Have some to see next week, also. Lots of people who were getting benzos elsewhere.

 

[jbomba]

When is the actual deadline? And am I allowed to do one fill after that deadline before they need to be seen again in person?

 

[TexasPhysician]

When is the actual deadline? And am I allowed to do one fill after that deadline before they need to be seen again in person?

No. They gave ample warning to prep in advance. I have 0 patients needing in-person. Most psychiatrists have been transitioning back to requiring in-person for months as this was an expected change.

 

[forchinet121]

If you don’t want to see them in person have their PCP see them and refer them to you, that’s an option right?

 

[TexasPhysician]

If you don’t want to see them in person have their PCP see them and refer them to you, that’s an option right?

I wouldn’t make decisions on a proposed rule that hasn’t passed and can be amended. If/when final, what are the requirements of that referral and will the PCP sign off? It is a medicolegal question that I expect many PCP’s will refuse. They may not want to state that they are referring a patient for ADHD stimulant treatment and risk future lawsuits.

 

[Jules A]

When is the actual deadline? And am I allowed to do one fill after that deadline before they need to be seen again in person?

I didn’t think they made a final announcement as I thought the comment deadline was 3/31? This is what I read:

6. Are patients who received a telemedicine-only exam during the COVID-19 PHE “grandfathered” or must they have an in-person exam before the COVID-19 PHE ends on May 11, 2023?​

The Controlled Substances Act does not have a feature allowing patients to be “grandfathered” from the in-person exam requirement at the conclusion of a PHE. The current DEA waiver of the in-person exam requirement falls under exception #4 of the Ryan Haight Act, i.e., the PHE. It will expire when the COVID-19 PHE ends May 11, 2023.

To address this, the proposed rule creates a new term, “telemedicinerelationship established during the COVID-19 public health emergency.” Such a relationship exists if: 1) between March 16, 2020 and May 11, 2023 (i.e., the PHE period); 2) the practitioner prescribed a controlled substance based on a telemedicine encounter; and 3) the practitioner never conducted an in-person exam of the patient.

In that situation, the DEA will extend the in-person exam waiver an additional 180 days, making the new deadline early November 2023 (or later if the final rule publishes after May 11). For any prescribing after that date, that practitioner must either conduct an in-person exam, meet a different telemedicine exception under the Ryan Haight Act, or stop prescribing for the patient.

 

[forchinet121]

I wouldn’t make decisions on a proposed rule that hasn’t passed and can be amended. If/when final, what are the requirements of that referral and will the PCP sign off? It is a medicolegal question that I expect many PCP’s will refuse. They may not want to state that they are referring a patient for ADHD stimulant treatment and risk future lawsuits.

Idk..the alternative is the PCP has to prescribe it which is a much higher liability…if they refuse to refer and prescribe they are essentially telling the patient they cannot continue to see their current psychiatrist and they have to find a new in person psychiatrist..I don’t expect that to go over well

 

[Jules A]

Idk..the alternative is the PCP has to prescribe it which is a much higher liability…if they refuse to refer and prescribe they are essentially telling the patient they cannot continue to see their current psychiatrist and they have to find a new in person psychiatrist..I don’t expect that to go over well

Or that they need to drag their butt in for one appointment. Totally agree it is absurd to dump on pcp but I’m not working harder than the patient. Other than the SMI they need to take some responsibility yes even the SUD crowd. The idea of behavioral modification strategies to yield growth is underrated.

 

[DOswag]

wait... is covid still a thing? I kid I kid, in military we're still required to wear masks in patient care... But patients are coming in person to appointments.

 

[TexasPhysician]

Idk..the alternative is the PCP has to prescribe it which is a much higher liability…if they refuse to refer and prescribe they are essentially telling the patient they cannot continue to see their current psychiatrist and they have to find a new in person psychiatrist..I don’t expect that to go over well

It is not the PCP’s fault that the patient won’t have 1 in-person appointment with the psychiatrist. If anything, it is the psychiatrist’s fault for not understanding that this temporary Covid allowed option was always designed to end. The psychiatrist should be doing in-person visits to accommodate or should have referred to someone prepared to do so months ago.

 

[ChudsMgee]

Started preparing for this 6 months ago dismissing any clients out of county on CS. I'm in a pretty central location seeing people once a year in person won't be hard as 70% of my visits are in person anyway

 

[clausewitz2]

I am going the letter/referral route. Will be a pain in the ass up front but that is life. I can imagine losing some patients over it but the minute I indicate I am accepting new patients in Psychology Today the floodgates will open. Just not set up to do in-person visits and don't plan to be in my current practice setting. I am going all in on red telehealth.

This has had the effect of a couple of my more anxious patients who I am weaning off their chronic benzos have already had multiple providers send me referral letters, so going to have to emphasize that it's just the one that I need.

 

[Ironspy]

Does anyone have a sample referral form they are willing to share?

 

[TexasPhysician]

Does anyone have a sample referral form they are willing to share?

DEA proposals on the matter have been changing to more then less then more restrictive. I’d wait to generate such a referral letter until such time as the DEA provides guidance on the specifics of the referral letter.

 

[Stagg737]

And this is when I become grateful that I'm in an outpatient consultation clinic. I do prescribe some controlled substances from patients I inherited when clinic was run as a continuity clinic, but the only patients I've started on stims were directly referred by PCP for ADHD eval, and surprisingly those 2 or 3 people legitimately have it (fairly obvious during appointments). Makes it fairly easy to send a letter to patients and PCP stating PCP will be taking over prescribing again.

Idk..the alternative is the PCP has to prescribe it which is a much higher liability…if they refuse to refer and prescribe they are essentially telling the patient they cannot continue to see their current psychiatrist and they have to find a new in person psychiatrist..I don’t expect that to go over well

Is it though? The primary prescribers of stimulants pre-COVID was pediatricians/FM docs anyways, I don't see how the liability is increased significantly unless PCP is also prescribing other controlled substances that we don't simultaneously, ie opiates.

 

[forchinet121]

And this is when I become grateful that I'm in an outpatient consultation clinic. I do prescribe some controlled substances from patients I inherited when clinic was run as a continuity clinic, but the only patients I've started on stims were directly referred by PCP for ADHD eval, and surprisingly those 2 or 3 people legitimately have it (fairly obvious during appointments). Makes it fairly easy to send a letter to patients and PCP stating PCP will be taking over prescribing again.


Is it though? The primary prescribers of stimulants pre-COVID was pediatricians/FM docs anyways, I don't see how the liability is increased significantly unless PCP is also prescribing other controlled substances that we don't simultaneously, ie opiates.

You’re saying that a PCP referring a patient to a psychiatrist who then prescribed a treatment is the same liability as the PCP prescribing the treatment themselves?

 

[Stagg737]

I'm saying that there shouldn't be much of a difference if each physician does a thorough evaluation (or even moderate one given general standards) regardless of if it's a psychiatrist or PCP. Pre-COVID pediatricians were the highest proportion of stimulant prescriptions, but they didn't have any higher liability than us prescribing.

 

[FlowRate]

If you don’t want to see them in person have their PCP see them and refer them to you, that’s an option right?

The rules as proposed seem to imply the referral must come before the patient is established with a psychiatrist. While not stated explicitly, the proposed rules strongly imply that retroactive referrals do not count.

 

[forchinet121]

The rules as proposed seem to imply the referral must come before the patient is established with a psychiatrist. While not stated explicitly, the proposed rules strongly imply that retroactive referrals do not count.

That’s insane..

 

[clausewitz2]

The rules as proposed seem to imply the referral must come before the patient is established with a psychiatrist. While not stated explicitly, the proposed rules strongly imply that retroactive referrals do not count.

I don't think this is quite right. The referral undoubtedly does have to come before the stimulant is prescribed, though. It looks likes it would be possible for someone to see a psychiatrist for initial consultation and be told to get a referral letter if ADHD treatment was on the table. Or a longer term patient who hems and hawd and finally says yes they do want to try it after all.

 

[forchinet121]

I don't think this is quite right. The referral undoubtedly does have to come before the stimulant is prescribed, though. It looks likes it would be possible for someone to see a psychiatrist for initial consultation and be told to get a referral letter if ADHD treatment was on the table. Or a longer term patient who hems and hawd and finally says yes they do want to try it after all.

The other way around makes no sense, why would they prevent someone who already has a telepsychiatrist from going to their PCP and getting medically cleared?

 

[FlowRate]

I don't think this is quite right. The referral undoubtedly does have to come before the stimulant is prescribed, though. It looks likes it would be possible for someone to see a psychiatrist for initial consultation and be told to get a referral letter if ADHD treatment was on the table. Or a longer term patient who hems and hawd and finally says yes they do want to try it after all.

You're right/I agree, it does focus more specifically on timing of the prescription. I had conflated established patient and established/preexisting controlled substance prescription. I think we're in agreement that a retroactive referral does not count if you're already prescribing a CS?

A lot of the proposed ruling stuff is arcane and cumbersome. Hopefully they refine/streamline with the feedback from the past month.

 

[clausewitz2]

You're right/I agree, it does focus more specifically on timing of the prescription. I had conflated established patient and established/preexisting controlled substance prescription. I think we're in agreement that a retroactive referral does not count if you're already prescribing a CS?

A lot of the proposed ruling stuff is arcane and cumbersome. Hopefully they refine/streamline with the feedback from the past month.

I think you are right re: retroactive referral, although not clear how this will be applied to prescriptions started during COVID PHE. It is all rather ludicrous.

 

[forchinet121]

I am all for targeting these psycho money crazed online companies but they shouldn’t also impose these burdens on us small time doctors, they should include like a different set of rules for organizations with more than 10 providers or some idea that a smarter person can come up with along those lines to target abuse from cerebral et al

 

[Mad Jack]

I've never been more thrilled to be exiting outpatient practice

 

[Shikima]

There never should have been the public declaration with the authoritarianism. Plus with the rise in many online clinics curating the patient population, outpt clinics that don't have enough therapists on staff will be hurt the worst.