Question regarding Ryan Haight Act/Telehealth/COVID and prescribing stimulants?

[shahseh22]

Hi,
I am planning on working part time as an attending at a Resident/Fellow run Child clinic this is a county clinic so the patient's are not the most affording. I've heard numerous excuses regarding being unable to get Zoom access (some of it is genuine, the family only has one Smartphone). But regardless, my understanding is that even if a person is on a stimulant (started by former resident) if you continue the stimulant (new resident) you need see them via telehealth (Zoom or some time of Video) as it is the first time you are prescribing the stimulant, it can't just be a phone visit. Unfortunately, the clinic is closed due to the COVID cases in the area.

I want to make sure what we are doing is Kosher as the liability is on me but I also understand the limitations of some of these families (many of them are struggling to get by especially now with unemployment) and I don't want the kids to be deprived of stimulants due to this barrier.

https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf

Thanks for any advice.

 

[splik]

Yes, there needs to be audiovisual component to prescribe controlled drugs if pt has not seen in person. Also for billing its much less for a telephone visit vs telemedicine (not clear if this matters in your work setting). The vast majority of households have households have a smartphone (only one is needed for the visit) or some other access for a video visit. Some patients will have to go another family member's house. 71% of households with <30 000 income have at least one smart phone. This will be a rare reason for lack of access to stimulants.

I think liability is likely to be low in the circumstances you are talking about during the pandemic. However the law is clear that phone visits do not count for prescribing controlled drugs. Make of that what you will but in the rare circumstance that this becomes an issue you would not be able to defend yourself.

A separate issue is that it falls below the standard of care to evaluate a patient you have never met before via telephone only.

 

[TexasPhysician]

You can’t do it without audio and visual during the national emergency.

Once the national emergency ends, you will need an in-person visit to continue stimulants.

 

[hamstergang]

Also for billing its much less for a telephone visit vs telemedicine

In my hospital in NJ, I've been told the billing is currently identical for follow up visits in-person, virtual with video, and just by telephone.

 

[Stagg737]

Does this apply for every visit where one is prescribing stimulants or only initial? Meaning, if one initially sees a patient via video or in-person and starts stimulants, can follow-ups where stimulants are prescribed be via telephone or does it always require a visual component?

 

[clausewitz2]

Have we actually had real clarification or confirmation that on-going stimulant prescriptions will require an in-person visit if they were started during the COVID emergency? I have several patients I have never met in person who are going to suddenly need to come in February or whenever the emergency declaration ends if that's the case. Fingers crossed for grandfatherhing, I am really hoping to not have to maintain office space if I can help it, but I guess this would be a situation where a flex or temporary office space rental would make sense.

I suppose given that I don't prescribe them without a thorough dedicated ADHD eval to begin with it wouldn't be terrible to tell folks that they'll have to come to a special one-off in-person appointment if that's even on the table.

 

[birchswing]

Once the national emergency ends

Is that one of the options?

 

[calvnandhobbs68]

Have we actually had real clarification or confirmation that on-going stimulant prescriptions will require an in-person visit if they were started during the COVID emergency? I have several patients I have never met in person who are going to suddenly need to come in February or whenever the emergency declaration ends if that's the case. Fingers crossed for grandfatherhing, I am really hoping to not have to maintain office space if I can help it, but I guess this would be a situation where a flex or temporary office space rental would make sense.

I suppose given that I don't prescribe them without a thorough dedicated ADHD eval to begin with it wouldn't be terrible to tell folks that they'll have to come to a special one-off in-person appointment if that's even on the table.

I worry this is gonna happen with all the telemedicine ADHD mills that have been popping up online since March. The actual people prescribing are based all over the country and are NPs doing this for easy money. There’s suddenly gonna be a bunch of new patient intakes who find that they need an in person visit to continue their meds for “ADHD” that they got diagnosed at 30 years old.

 

[TexasPhysician]

Have we actually had real clarification or confirmation that on-going stimulant prescriptions will require an in-person visit if they were started during the COVID emergency? I have several patients I have never met in person who are going to suddenly need to come in February or whenever the emergency declaration ends if that's the case. Fingers crossed for grandfatherhing, I am really hoping to not have to maintain office space if I can help it, but I guess this would be a situation where a flex or temporary office space rental would make sense.

I suppose given that I don't prescribe them without a thorough dedicated ADHD eval to begin with it wouldn't be terrible to tell folks that they'll have to come to a special one-off in-person appointment if that's even on the table.

Ive spoken to 1 DEA person that has confirmed that patients will need at least 1 in person immediately after the national emergency ends.

Im actually surprised at how many sketchy online clinics that have popped up offering basically anything for a low monthly fee of $79.99 or whatever the special is. Usually staffed by NP’s. Very disappointing how quickly medicine sells out without government regulation.

 

[Merovinge]

Ive spoken to 1 DEA person that has confirmed that patients will need at least 1 in person immediately after the national emergency ends.

Im actually surprised at how many sketchy online clinics that have popped up offering basically anything for a low monthly fee of $79.99 or whatever the special is. Usually staffed by NP’s. Very disappointing how quickly medicine sells out without government regulation.

Did you really think VC/private equity based control of medicine was going to try and do anything other then become legalized drug dealers that ship right to your nearest pharmacy if given the chance? This is everything business people love, there's a natural moat to controlled substances, easy scalability, get to say some BS about serving the community/patient, mid level providers that don't have anywhere near the same sense of how this is harmful to others. If I had no soul, I would invest in one of those companies just from a business standpoint.

It reminds me of walking down Venice Beach back when Cali only had medical marijuana and seeing those "doctors" (which pains me to put into quotes since somehow someone passed them through school/training).

 

[calvnandhobbs68]

Did you really think VC/private equity based control of medicine was going to try and do anything other then become legalized drug dealers that ship right to your nearest pharmacy if given the chance? This is everything business people love, there's a natural moat to controlled substances, easy scalability, get to say some BS about serving the community/patient, mid level providers that don't have anywhere near the same sense of how this is harmful to others. If I had no soul, I would invest in one of those companies just from a business standpoint.

It reminds me of walking down Venice Beach back when Cali only had medical marijuana and seeing those "doctors" (which pains me to put into quotes since somehow someone passed them through school/training).

Also really concerned about the diversion aspect of all this. People now know they can go fill out an online questionaire, see an NP for 20 minutes and get prescribed Adderall, then turn around and sell that at the local college for multiple times what they pay for the visit.

 

[Sushirolls]

Some times I wonder why we are even fighting this inertia of other 'professions' and society as a whole. Just rip the lid off, end the formal boards/licensure and let pharmacies dispense as they wish. Unleash the wild west of healthcare.

It gets old having patients upset that I dared to inform them cannabis is bad, or perhaps they have sleep apnea and need a work up. Or no they don't need a stimulant. Or benzos are not a solution.

On one hand we are instructed over the past few decades, stop practicing paternalistic medicine... wouldn't the ultimate end of paternalistic medicine be a true consultant role where patients already have access to everything/anything they want medically and we simply offer a professional opinion, that no, that's probably not the treatment plan you want to pick for yourself? I can't help but think that our current role in preventing people from their own self destruction is by default paternalistic medicine?

Not sure where I'm going with this post, but just watching the entropy of the healthcare system around me at times is demoralizing.

 

[birchswing]

Some times I wonder why we are even fighting this inertia of other 'professions' and society as a whole. Just rip the lid off, end the formal boards/licensure and let pharmacies dispense as they wish. Unleash the wild west of healthcare.

It gets old having patients upset that I dared to inform them cannabis is bad, or perhaps they have sleep apnea and need a work up. Or no they don't need a stimulant. Or benzos are not a solution.

On one hand we are instructed over the past few decades, stop practicing paternalistic medicine... wouldn't the ultimate end of paternalistic medicine be a true consultant role where patients already have access to everything/anything they want medically and we simply offer a professional opinion, that no, that's probably not the treatment plan you want to pick for yourself? I can't help but think that our current role in preventing people from their own self destruction is by default paternalistic medicine?

Not sure where I'm going with this post, but just watching the entropy of the healthcare system around me at times is demoralizing.

Not only that but what advances might there be if people could compete on healing and outcomes without needing government designation to do so? Right now you kind of can, but you're limited in a number of ways in what claims you can make.

I'm kind of a big government person myself (when the government is competent), but when I look at the fact that most major pharmaceutical recalls recently were initiated by private labs that do consumer testing that then alerted the FDA (a fairly useless organization IMO), I start to wonder if private industry could self police itself. It could be a nightmare, but you could have parallel tracks where you have government oversight that people could choose to follow or not.

 

[Armadillos]

Hi,
I am planning on working part time as an attending at a Resident/Fellow run Child clinic this is a county clinic so the patient's are not the most affording. I've heard numerous excuses regarding being unable to get Zoom access (some of it is genuine, the family only has one Smartphone). But regardless, my understanding is that even if a person is on a stimulant (started by former resident) if you continue the stimulant (new resident) you need see them via telehealth (Zoom or some time of Video) as it is the first time you are prescribing the stimulant, it can't just be a phone visit. Unfortunately, the clinic is closed due to the COVID cases in the area.

I want to make sure what we are doing is Kosher as the liability is on me but I also understand the limitations of some of these families (many of them are struggling to get by especially now with unemployment) and I don't want the kids to be deprived of stimulants due to this barrier.

https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf

Thanks for any advice.

Talk to your clinic admins about the patients who have been seen in person by someone else in that clinic previously. My understand is some federal/state/county government run clinics are arranged in some way so that all their providers are legally interchangeable, so seeing one in person previously is legally same as seeing you as far as refilling a stimulant

 

[TexasPhysician]

Talk to your clinic admins about the patients who have been seen in person by someone else in that clinic previously. My understand is some federal/state/county government run clinics are arranged in some way so that all their providers are legally interchangeable, so seeing one in person previously is legally same as seeing you as far as refilling a stimulant

Exceptions are few and far between. County governments - none. State and federal are still relatively rare.

 

[Armadillos]

Exceptions are few and far between. County governments - none. State and federal are still relatively rare.

Sounds like your more knowledgeable on this than me so nobody should read anymore into my above post than to say if you work for a government may be worth asking your legal folks.

In my case may have been a unique situation, it was a prior job where I was working for a state government (as a government employee) and we were told so long as a patient had seen one of our doctors then as far as calling in refills they had a relationship with all of us as if we had seen them personally. Again my knowledge of details of this is hazy so maybe I’m not even remembering that correctly.

 

[ednorton]

Hi,
I am planning on working part time as an attending at a Resident/Fellow run Child clinic this is a county clinic so the patient's are not the most affording. I've heard numerous excuses regarding being unable to get Zoom access (some of it is genuine, the family only has one Smartphone). But regardless, my understanding is that even if a person is on a stimulant (started by former resident) if you continue the stimulant (new resident) you need see them via telehealth (Zoom or some time of Video) as it is the first time you are prescribing the stimulant, it can't just be a phone visit. Unfortunately, the clinic is closed due to the COVID cases in the area.

I want to make sure what we are doing is Kosher as the liability is on me but I also understand the limitations of some of these families (many of them are struggling to get by especially now with unemployment) and I don't want the kids to be deprived of stimulants due to this barrier.

https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf

Thanks for any advice.

I am having everybody that I prescribed any controlled medications to via Tele come in during the next few months . I believe the emergency has been extended for another 3 months . Do I believe the Ryan Haight act is actually going to be enforced ... no . It's too messy and there is a good number of providers and from what it seems like any and all administrators who have not even heard of it .

 

[shahseh22]

I think I'll pass on this gig as it was also too low paying.

 

[Jules A]

I think I'll pass on this gig as it was also too low paying.

I pass on any gig that is low paying.

 

[Jules A]

I am having everybody that I prescribed any controlled medications to via Tele come in during the next few months . I believe the emergency has been extended for another 3 months . Do I believe the Ryan Haight act is actually going to be enforced ... no . It's too messy and there is a good number of providers and from what it seems like any and all administrators who have not even heard of it .

I heard the wavier that excused the in person visit was up October 31, 2020 but can't seem to find a link that clearly addresses it. Anyone?

 

[clausewitz2]

I heard the wavier that excused the in person visit was up October 31, 2020 but can't seem to find a link that clearly addresses it. Anyone?

Waiver was linked to HHS COVID emergency declaration, which was renewed at beginning of October for another 3 months. We do not seem on track to that emergency declaration being lifted anytime soon, really.

 

[Mass Effect]

Sounds like your more knowledgeable on this than me so nobody should read anymore into my above post than to say if you work for a government may be worth asking your legal folks.

In my case may have been a unique situation, it was a prior job where I was working for a state government (as a government employee) and we were told so long as a patient had seen one of our doctors then as far as calling in refills they had a relationship with all of us as if we had seen them personally. Again my knowledge of details of this is hazy so maybe I’m not even remembering that correctly.

I actually think this is true though I have no proof of it. But it explains why doctors can be on-call for one another and prescribe. For instance if your colleague is away on vacation for 2 weeks and you're on call, I believe you are able to legally prescribe their Adderall or Ambien or Klonopin without seeing the patient in person (or in the case of COVID, on video). This pre-dates COVID.

In response to the original question, as others have said it has to be audiovisual. This has been the case since March/April. Prior to that, it was in person. I doubt anything is changing for another year at least.

 

[TexasPhysician]

I actually think this is true though I have no proof of it. But it explains why doctors can be on-call for one another and prescribe. For instance if your colleague is away on vacation for 2 weeks and you're on call, I believe you are able to legally prescribe their Adderall or Ambien or Klonopin without seeing the patient in person (or in the case of COVID, on video). This pre-dates COVID.

In response to the original question, as others have said it has to be audiovisual. This has been the case since March/April. Prior to that, it was in person. I doubt anything is changing for another year at least.

Maybe I misunderstood the prior posters position. A “covering physician” can send in a refill of a controlled med for a limited time to reach a follow-up with the primary physician without requiring an in-person. However if the primary physician leaves the group or transfers care to another physician in the same group or takes an extended leave, the next physician in the group must immediately have an in-person visit. An in-person within the group doesn’t permanently exempt the rest of the group. It only allows brief continued care for the primary to resume care in the near future. The poster I responded to made it seem like there was no primary and that the physicians believed them all to be interchangeable. That is not true.

 

[SourceOfDenial]

I worry this is gonna happen with all the telemedicine ADHD mills that have been popping up online since March. The actual people prescribing are based all over the country and are NPs doing this for easy money. There’s suddenly gonna be a bunch of new patient intakes who find that they need an in person visit to continue their meds for “ADHD” that they got diagnosed at 30 years old.

I get what you’re saying—but lots of folks get diagnosed with AHDH well into adulthood. Why does this idea (that adults dx with adhd are somehow less deserving of the dx and tx) keep getting perpetuated?

 

[Mass Effect]

Maybe I misunderstood the prior posters position. A “covering physician” can send in a refill of a controlled med for a limited time to reach a follow-up with the primary physician without requiring an in-person. However if the primary physician leaves the group or transfers care to another physician in the same group or takes an extended leave, the next physician in the group must immediately have an in-person visit. An in-person within the group doesn’t permanently exempt the rest of the group. It only allows brief continued care for the primary to resume care in the near future. The poster I responded to made it seem like there was no primary and that the physicians believed them all to be interchangeable. That is not true.

You understood the other poster correctly. I may be wrong on this since I don't have proof either way. I just know that I've been told the same as the other poster - that if the patient is established with the practice and has been seen in person by one of our docs, they have met the legal requirement for an in-person visit. That could be wrong. Just what I was told.

 

[doctosaurus]

While we're on this topic, could someone clarify regarding intakes and managing patients purely by telephone.

At my new job I've been told we manage some patients purely by telephone, but I thought this was not kosher. Any specific references or info so I can learn more about this topic?

 

[calvnandhobbs68]

I get what you’re saying—but lots of folks get diagnosed with AHDH well into adulthood. Why does this idea (that adults dx with adhd are somehow less deserving of the dx and tx) keep getting perpetuated?

Because you have poor diagnosticians (NPs primarily) being pressured by the organization to have happy "customers" coupled with people who are seeking a certain type of diagnosis and treatment (especially because these ads are specifically marketing themselves as "ADHD clinics" or whatever) whose primary treatment is with a controlled substance. There's a very high incentive to overdiagnose and treat with stimulants, since that's basically what these people are expecting when they put down their money for these appointments. Yes, my burden of proof is higher for adults who are suddenly wondering if they have "ADHD" since the potential for diversion and abuse of stimulants is much higher in an adult than a 10yo. There's other things to consider as well. How successful do you think you'll be figuring out if someone has a comorbid substance use disorder as well if you can't even ever do a UDS since this is all 100% telepsych?

Similar to the medical cannabis clinics as mentioned above. Say you have back pain or PTSD? Get your medical marijuana card with a 20 minute appointment for a quick 100 bucks!