Ryan Haight Act

[milesed]

---

Members do not see this ad.

I haven't seen anything regarding another suspension or any exceptions as the federal state of emergency ends in 2 weeks. I see a few kids each week on stimulants by telehealth, but they are local so can see me in person w/o too much inconvenience. I did find info in the original law stating covering practitioners are ok within the same practice. Has anyone seen any updates?

 

[littlefred]

Is October 13 going to be the date when they announce the end of the emergency?

Also, people more knowledgeable than me on this topic could maybe bring facts... but I recall that when Ryan Haight was active you had to have at least a face to face on initial contact and then at minimum every two years.

There's going to be a ridiculous influx of patients on stimulants from online shops to outpatient clinics. Glad I'm not in the outpatient world.

 

[comp1]

Ha, no one will be immune. They'll be in the ED and inpatient right quick when the benzos stop flowing.

 

[wolfvgang22]

This whole mess is why I decided that Ryan Haight was back in effect for my clinic in July. I'm sick of the waffling. I won't be surprised whatever they do now.

 

[calvnandhobbs68]

I bet they renew it one more time so they can keep student loan payments paused until Jan. Then we're all done with the rolling "public health emergencies" (which are a joke at this point anyway and just continuing to erode trust in CMS/HHS...CDC says you don't even need to mask in healthcare facilites yet we're somehow still in an "emergency").

DEA is already starting to crack down on telemedicine only operations in preparation for this. Outside of the Ryan Haight part of things, to have a DEA number you're required to have a physical address DEA can come to inspect, which many telemedicine only places don't have.

 

[Merovinge]

Anyone have any inside political information about this? I have a hard time believing these huge money startups that are entirely focused on NPs cranking out controlled substances to patient's that live in a state they have never set foot in don't have something up their sleeves to circumvent this.

 

[trophyhusband]

Is October 13 going to be the date when they announce the end of the emergency?

Also, people more knowledgeable than me on this topic could maybe bring facts... but I recall that when Ryan Haight was active you had to have at least a face to face on initial contact and then at minimum every two years.

There's going to be a ridiculous influx of patients on stimulants from online shops to outpatient clinics. Glad I'm not in the outpatient world.

The Feds had said previously that they'd give 60 days notice of when RHA is supposed to restart... we'll see of course.

The bolded bit is an APA "conservative" recommendation it's not actually in the Act that I could find or in the DEA instructions. But people should check with their malpractice insurers before not following it as some folks have said their carrier won't cover them if they don't follow the recommendation.

 

[milesed]

I've scheduled all of my patients, who have only seen me by telehealth, to come to my office in person and it was a small number.

Is October 13 going to be the date when they announce the end of the emergency?

Also, people more knowledgeable than me on this topic could maybe bring facts... but I recall that when Ryan Haight was active you had to have at least a face to face on initial contact and then at minimum every two years.

There's going to be a ridiculous influx of patients on stimulants from online shops to outpatient clinics. Glad I'm not in the outpatient world.

I can't find anything in the law stating there must be a follow up, in person visit every 2 years after the initial one.

https://www.congress.gov/110/plaws/publ425/PLAW-110publ425.pdf

Where did you find that info?

 

[clausewitz2]

You are going to want to keep an eye on this bill:

https://www.congress.gov/bill/117th-congress/house-bill/4040

It passed the house back in July and was referred to the Senate Finance Committee. Hasn't come to the floor for a vote yet but it would extend the Ryan Haight waivers till December 2024 with an eye to making them permanent, among other things.

The lobbyists are also all over this:

AAMC, Nearly 400 Groups Urge Senate Leaders to Extend Telehealth Waivers

The AAMC joined nearly 400 groups in a Sept. 13 letter urging Senate leaders to extend key telehealth waivers.

www.aamc.org

Apparently HR 4040 passed the House by a vote of 426-12, was introduced by Liz Cheney, and is co-sponsored by Debbie Dingell among others, so properly bipartisan. Smart money is on something like this passing.

The Biden administration is also apparently throwing their weight behind it:

https://www.whitehouse.gov/wp-content/uploads/2022/07/SAP-H.R.-4040.pdf

 

[TexasPhysician]

You are going to want to keep an eye on this bill:

https://www.congress.gov/bill/117th-congress/house-bill/4040

It passed the house back in July and was referred to the Senate Finance Committee. Hasn't come to the floor for a vote yet but it would extend the Ryan Haight waivers till December 2024 with an eye to making them permanent, among other things.

The lobbyists are also all over this:

AAMC, Nearly 400 Groups Urge Senate Leaders to Extend Telehealth Waivers

The AAMC joined nearly 400 groups in a Sept. 13 letter urging Senate leaders to extend key telehealth waivers.

www.aamc.org

Apparently HR 4040 passed the House by a vote of 426-12, was introduced by Liz Cheney, and is co-sponsored by Debbie Dingell among others, so properly bipartisan. Smart money is on something like this passing.

The Biden administration is also apparently throwing their weight behind it:

https://www.whitehouse.gov/wp-content/uploads/2022/07/SAP-H.R.-4040.pdf

Ugh. We need Ryan Haight Act back

 

[splik]

technically there is no waiver of the RHA (despite everyone using the term) as the act specifically allows telehealth only visits during a public health emergency. The law also allows telehealth for the VA, Indian Health System, or under a special registration. The latter category was never created by the DEA despite the law allowing for that and attempts made to nudge them in that direction. The face of telemedicine is quite different than in 2008 when the law came into being. We are never going back to how things were and private equity is betting on that.

 

[forchinet121]

Ugh. We need Ryan Haight Act back

Why?

 

[TexasPhysician]

Why?

Significant uptick in stimulant and benzo Rx and misuse. We as a medical profession just can’t have nice things when we abuse them.

 

[clausewitz2]

technically there is no waiver of the RHA (despite everyone using the term) as the act specifically allows telehealth only visits during a public health emergency. The law also allows telehealth for the VA, Indian Health System, or under a special registration. The latter category was never created by the DEA despite the law allowing for that and attempts made to nudge them in that direction. The face of telemedicine is quite different than in 2008 when the law came into being. We are never going back to how things were and private equity is betting on that.

Yes, technically no waiver, but a compelling legal theory that many high-powered corporate counsels found persuasive enough to convince PE to bet money on. When the moneyed interests line up against federal regulators, woe to the regulators.

 

[Mad Jack]

Anyone have any inside political information about this? I have a hard time believing these huge money startups that are entirely focused on NPs cranking out controlled substances to patient's that live in a state they have never set foot in don't have something up their sleeves to circumvent this.

I think you overestimate how much thinking and underestimate how much cocaine is involved in the startup process

 

[Mad Jack]

Yes, technically no waiver, but a compelling legal theory that many high-powered corporate counsels found persuasive enough to convince PE to bet money on. When the moneyed interests line up against federal regulators, woe to the regulators.

Or woe to those prescribing that get caught in the middle. Usually a few examples are attempted to be made in the process

 

[PsyDr]

CMS/HHS...CDC says you don't even need to mask in healthcare facilites yet we're somehow still in an "emergency").

In "low transmission rate" counties. Which represents a significant minority of the USA.

 

[littlefred]

I've scheduled all of my patients, who have only seen me by telehealth, to come to my office in person and it was a small number.




I can't find anything in the law stating there must be a follow up, in person visit every 2 years after the initial one.

https://www.congress.gov/110/plaws/publ425/PLAW-110publ425.pdf

Where did you find that info?

Legal mumbo jumbo is not my specialty, but here I found something relevant with regards to my point.

https://www.govinfo.gov/content/pkg/USCODE-2020-title21/pdf/USCODE-2020-title21-chap13-subchapI-partC-sec829.pdf

(B)(i) The term ‘‘in-person medical evaluation’’ means a medical evaluation that is conducted with the patient in the physical presence of the practitioner, without regard to whether portions of the evaluation are conducted by other health professionals. (ii) Nothing in clause (i) shall be construed to imply that 1 in-person medical evaluation demonstrates that a prescription has been issued for a legitimate medical purpose within the usual course of professional practice. (C) The term ‘‘covering practitioner’’ means, with respect to a patient, a practitioner who conducts a medical evaluation (other than an in-person medical evaluation) at the request of a practitioner who— (i) has conducted at least 1 in-person medical evaluation of the patient or an evaluation of the patient through the practice of telemedicine, within the previous 24 months; and (ii) is temporarily unavailable to conduct the evaluation of the patient.

With regards to prescribing scheduled meds over the internet, I assume the wording is borrowed from regulations of in-person encounters as well (you can find those if you look for them I guess). What's your address? Sending an invoice your way lol

 

[clausewitz2]

Legal mumbo jumbo is not my specialty, but here I found something relevant with regards to my point.

https://www.govinfo.gov/content/pkg/USCODE-2020-title21/pdf/USCODE-2020-title21-chap13-subchapI-partC-sec829.pdf

With regards to prescribing scheduled meds over the internet, I assume the wording is borrowed from regulations of in-person encounters as well (you can find those if you look for them I guess). What's your address? Sending an invoice your way lol

The section you quoted is about what happens when someone asks you to cover their patients. That is, if you have not conducted an in-person evaluation OR a telemedicine evaluation of the patient in question in the past 24 months, the person you ask to cover for you is not a covering practitioner for the purposes of this law. Not sure why you are asking someone to cover patients you haven't seen in two years, but sure, don't do that.

Go up just a little bit for the part covering you interacting with your own patients:

"(A) The term ‘‘valid prescription’’ means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by—
(i) a practitioner who has conducted at least 1 in-person medical evaluation of the patient; or
(ii) a covering practitioner."

Doesn't say anything about past 24 months.

EDIT: I get why primary care folks might end up writing for people they haven't seen in years, but a) this would be incredibly unusual in psychiatry and b) probably isn't something you should do for their controlled substances regardless.

 

[forchinet121]

The section you quoted is about what happens when someone asks you to cover their patients. That is, if you have not conducted an in-person evaluation OR a telemedicine evaluation of the patient in question in the past 24 months, the person you ask to cover for you is not a covering practitioner for the purposes of this law. Not sure why you are asking someone to cover patients you haven't seen in two years, but sure, don't do that.

Go up just a little bit for the part covering you interacting with your own patients:

"(A) The term ‘‘valid prescription’’ means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by—
(i) a practitioner who has conducted at least 1 in-person medical evaluation of the patient; or
(ii) a covering practitioner."

Doesn't say anything about past 24 months.

EDIT: I get why primary care folks might end up writing for people they haven't seen in years, but a) this would be incredibly unusual in psychiatry and b) probably isn't something you should do for their controlled substances regardless.

I’m confused, if I have a patient I prescribe adderall to, I see them in person monthly, can I have my partner who has obviously never seen the patient before refill their script if I’m on vacation? Or does he need to see them before refilling controlled meds?

 

[ObsequiousAplomb]

I’m confused, if I have a patient I prescribe adderall to, I see them in person monthly, can I have my partner who has obviously never seen the patient before refill their script if I’m on vacation? Or does he need to see them before refilling controlled meds?

The above quoted sections say that your partner can cover / refill the controlled substance as long as you (the main treating physician) have seen the patient in person and at least once in the past 24 months.

 

[allantois]

I don't see it going away personally; Quite frankly a lot of people WILL end up in ERs if it goes away. not just the ones on benzos but also the ones on suboxone.

 

[calvnandhobbs68]

I don't see it going away personally; Quite frankly a lot of people WILL end up in ERs if it goes away. not just the ones on benzos but also the ones on suboxone.

Suboxone should honestly get it's own carveout and I see minimal problem with suboxone treatment virtually. The whole X waiver thing to begin with was more of a political issue than medically based in any way. Very little risk on suboxone being a true drug of abuse just from long term ancedotal data and the inherent properties of the med itself as partial mu agonist. Diversion is typically selling to opioid users which they then use to avoid withdrawal or try to self treat opioid addiction which one could argue isn't exactly the worst thing in the world (although of course we would prefer people to be in actual treatment...but there's a good argument that we shouldn't let the perfect be the enemy of the good here).

 

[allantois]

still no declaration..

 

[whopper]

Adding to this problem some politicians are threatening to remove COVID induced relaxations to care not based on what's good for doctors and patients but to score cheap political points with the anti-COVID crowd. E.g. one state completely gets rid of relaxations that allow for telemedicine cause the politician wants to add to the "COVID doesn't exist" mentality.

 

[allantois]

Adding to this problem some politicians are threatening to remove COVID induced relaxations to care not based on what's good for doctors and patients but to score cheap political points with the anti-COVID crowd. E.g. one state completely gets rid of relaxations that allow for telemedicine cause the politician wants to add to the "COVID doesn't exist" mentality.

I suspect these are the same states that are driving GYNs away with their anti-abortion regulations..

 

[whopper]

I happen to live in one of those states. The Governor got rid of a lot of COVID relaxations that oddly my more R-wing patients are like "this is bull$hit! They want to bring back more government." Just goes to show you there's a type of person who's living the rule changes vs those who don't really understand what's going on but are listening to the BS narrative.

We have a (not) so great senator that doesn't seem to understand how the electoral college process works (more like he does understand but is willing to violate his oath), and another politician who literally is trying to make to punish women who leave the state for an abortion. (No that is not a joke. Real Handmaiden's Tale stuff. Don't believe me? Look up "Mary Elizabeth Coleman" in a search). We have a guy with a life-prison sentence who's been found innocent but the governor and attorney general won't pardon him and is unapologetic about it and because he was already found guilty in court, sentenced, and was later found not guilty after the fact it's completely legal. Wow surprisingly he's an African-American. (Don't believe me? Read up, The Government Says These Missouri Men Are Innocent. It Won't Release Them From Prison.)

I complained about laws being changed without telling providers in a similar thread. When the governor removed the state laws that allowed for relaxed practice guidelines due to COVID there was no public announcement. Several of us found out after the fact and while we were not knowingly violating the changed rules.

I've already seen residents and medical students who were going to stay in Missouri saying they're planning on leaving and not coming back after graduation.

 

[littlefred]

For those wondering there was an extension of the emergency declaration through January 11, 2023.

 

[Merovinge]

I've already seen residents and medical students who were going to stay in Missouri saying they're planning on leaving and not coming back after graduation.

Wife was considering a job in St Louis, so glad I talked her out of it. You guys have some nice breweries and the central west end area is great, but that feels like a dodged bullet.

Edit - Anyone going to St Louis, try Wonton King for Dim Sum. Worth the drive, unless you regularly have access to SF/NYC or Hong Kong.