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MARCH 26, 2020 -- In the wake of the coronavirus pandemic, the rules and regulations governing telepsychiatry services have changed dramatically, the most radical of which is the introduction of a new waiver by the Centers for Medicare & Medicaid Services (CMS).
Under the 1135 emergency waiver, Medicare has expanded telehealth services to include patients across the country — not just in rural areas or under other limited conditions, as was previously the case. In addition, there's now a waiver to the Ryan Haight Act that allows the prescribing of controlled substances via telemedicine.
Peter Yellowlees, MD, from University of California Davis, Sacramento, reported that outpatient service at his center was converted to an almost 100% telepsychiatry service over the last 10 days.
During the hour-long event, they answered questions and offered tips on changes in licensure, patient safety, new prescribing rules, and equipment needed.
"Clinicians need to be aware of these changes so they can ensure they are reaching as many people as possible and taking advantage of the reduced barriers to offering safe and effective video visits," Torous told Medscape Medical News.
"This Is Huge"
The new 1135 waiver "basically says CMS will pay for any patient on Medicare who is seen by video by any provider who is correctly licensed in any state in this country," Yellowlees told webinar attendees.
"You don't need to be licensed in the state where the patient is if the patient is on Medicare. This opens up a huge number of patients we can now see on video," he said. "And you can bill at normal Medicare rates for whatever you normally get for your in-person patients."
Although this temporary rule only applies to Medicare and not to private insurers, or to patients on Medicaid, "these are really big changes. This is huge," Torous said.
Previously, the "originating site" rule stated that, for the most part, clinicians had to be licensed in the state where the patient was located and not where the physician was stationed.
Asked about college students receiving mental healthcare who were in school in the psychiatrist's area but are now back home in a state where the clinician doesn't have a license, Yellowlees said that scenario could be a bit "tricky."
"Most of those patients probably aren't on Medicare. Legally, you [usually] can't see them on video if they have private insurance or Medicaid. So, hopefully you can give them a 3-month supply of medication and then recommend they see a local provider," he said.
Still, all states have their own rules, Yellowlees said. He and Torous noted that the Federation of State Medical Boards has a "very up-to-date" listing of policies at FSMB.org, all of which are organized by state. In addition, the American Psychiatric Association provides a telepsychiatry toolkit on its website.
Ryan Haight Act and Prescribing
Physicians are now permitted to prescribe medication to patients assessed via telemedicine.
For those with substance use disorders, the US Drug Enforcement Administration has announced a new waiver for the Ryan Haight Online Pharmacy Consumer Protection Act.
The waiver states that "practitioners in all areas of the United States may issue prescriptions for all schedule II-V controlled substances" — as long as it's for a legitimate medical purpose; real-time, two-way interactive communication with patients has been used; and the clinician "is acting in accordance with applicable Federal and State laws."
"It's now possible to prescribe all the normal psychiatric drugs but also benzodiazepines, stimulants, and potentially narcotics over telepsychiatry," even at a first visit via video, Yellowlees said.
However, he noted, at this point the waiver is only current for 60 days. "This isn't a permanent condition. It could be extended or even shortened at any given time."
In addition, as reported by Medscape Medical News, SAMHSA has relaxed some of its own regulations regarding telehealth and opioid treatment programs. An FAQ section on the organization's website provides guidance for providing methadone and buprenorphine treatment.
"Some of the previous regulations will probably be put back in place later on, but the new changes are helpful now," Yellowlees said.
Simple Equipment Needed
Regarding equipment, Yellowlees noted that the most important component is just a laptop or tablet or smartphone — for the clinician and for the patient.
"You don't need fancy new technology with a separate camera or microphone," he said. However, it might be worth investing in a little better system down the line, he added.
Simple platforms that can be used to meet virtually with patients include FaceTime, Google Hangouts, and Skype.
Although some of these (such as FaceTime) are not Health Insurance Portability and Accountability Act (HIPAA) compliant, "that's okay for now" under the new rules, Yellowlees said. While the health system/commercial version of Skype is compliant, the normal consumer-downloaded version is not, he noted.
"I would still strongly suggest using HIPAA-compliant video conferencing programs in the long run," he added.
Either way, it's important for various safety practices to be put into place. For example, clinicians should be careful because the consumer version of Skype can show names of patients who were previously spoken with.
A Business Associate Agreement (BAA) is something that HIPAA-compliant video systems will offer and should be signed. It's an agreement that "you'll be, essentially, looking through a tunnel at the persona at the other end and the company cannot get inside the tunnel and watch you while you're having your interview," said Yellowlees.
"There are multiple videoconferencing systems around that you can use," he added. "The three major ones are from Zoom, Vidyo, and VSee, but there are probably 40 or 50 more."
"There are a lot out there, and we're certainly not endorsing any one of them," Torous added.
When evaluating potential programs, Yellowlees suggested looking at Yelp-style reviews or telemedicine review sites, or talk to colleagues.
"Basically, you want systems that offer high definition video quality and the ability to 'lock' and 'unlock' the rooms. And you want it to have an app so mobile devices can use it," he said.
Phone vs Video
Some patients, especially older ones, may be resistant to the idea of video chats, preferring to talk via telephone instead.
"If you can use video, it's better to do that if you can, especially when setting up the systems are relatively simple," Yellowlees said, adding that it might just be an issue of patients needing help to get started.
However, "for some people, this is a barrier that we have to respect," Torous said.
Either way, clinicians should check the American Medical Association's web page for information about coding for both video and phone visits.
Asked whether a clinician needs written consent from patients for conducting telepsychiatry visits, Yellowlees said it's important to check state-by-state rules. For example, California allows a verbal consent.
In many cases, "simply jot down a note that consent was given and how" and write down the address where the patient is located at time of visit, such as for their home, he said.
If a patient wants to conduct a telehealth session while in their car, Yellowlees suggested getting the address of the parking lot. For safety, clinicians are also advised to get the cell phone number of the patient as well as of a loved one.
When it comes to checking vital signs, Yellowlees suggested asking patients to purchase an inexpensive blood pressure (BP) monitor, thermometer, etc, prior to an appointment.
"Ask them to do a BP test on video and show you the readings. For the AIMS [Abnormal Involuntary Movement Scale] test, or to check for tardive dyskinesia, instruct patients to come close to the camera to show movement."
In addition, most psychiatric rating scales are available online, which patients can fill out before a telehealth visit. The Serious Mental Illness (SMI) Adviser mobile app also includes several of these scales, Torous noted.
Overall, "there have been dramatic changes in the rules and regulations governing [telepsychiatry] that for the next 60 days make it easier to offer telehealth to patients," Torous said.
Therefore, all psychiatrists need to "get on board," as soon as possible, Yellowlees added.