DEA Extends Telemedicine Flexibilities While Enforcing Even Stricter In-Person Location Requirements
Talking the talk without walking the walk leaves providers confused and frustrated.
The DEA announced last week that the COVID era telemedicine flexibilities, initially set to expire at the end of this year, would be extended through the end of 2025. Many providers breathed a sigh of relief. They kicked the regulatory can down the road for another year.
At first glance, this seems like a good thing. However, without a permanent pathway for telemedicine-controlled substance prescribing, state medical boards and local DEA offices continue enforcing rigid, outdated, and non-medically necessary in-person location requirements.
Case in point: Despite last week’s extension of the DEA telemedicine flexibilities, the Rhode Island and Alabama state medical boards still require an in-person provider visit prior to initiating a controlled substance.
To meet Alabama’s in-person visit requirement, Bicycle Health-a multi-state healthcare organization that provides life-saving medication treatment for Opioid Use Disorder-flew teams of doctors to the southeast state two years in a row. When this became logistically and financially unsustainable, Bicycle Health was forced to pull out of Alabama altogether, leaving thousands of patients without life-saving care. Not surprisingly, Bicycle Health and similar addiction treatment providers like Aware Recovery Care are also unable to provide virtual only medication services in Rhode Island due to the in-person requirement-this during a time in our nation’s history when untreated addiction kills over 116,000 Americans each year. For comparison, t
his is the same amount of people who died in World War One and double the amount that died in the Vietnam War. Geez Louise.
Equally confusing, rather than loosening in-person provider requirements to align with the federal DEA telemedicine extension, state and local DEA offices are now making in person provider documentation requirements much stricter. Huh? As recently as a few months ago, most provider applications for an initial DEA simply asked you to list the physical address of your practice location. In addition to that, DEA now requires that you also present a rental agreement that indicates you (the provider) are indeed the tenant of the proposed registered location and proof in the agreement that the rented space is a private office setting.
So on paper the DEA officially extended COVID telemedicine flexibilities last week. But in practical everyday terms, they have made it almost impossible to provide multi-state telemedicine-based addiction care. This during a time when twice as many Americans are dying from untreated addiction each year than died in the entire Vietnam War.
In my view, the increasingly strict DEA in-person location requirements are a well-meaning but misdirected reaction to the well-publicized scandals at Cerebal and Done-two large ADHD telemedicine companies that tweaked patient appointment algorithms to favor profit over patient safety and clinical quality.
While unfortunate, the COVID telemedicine changes did not cause the Cerebal and Done transgressions. Human greed caused this.
Prioritizing profit over provider autonomy and evidence-based medicine led to this. Cerebral and Done both created leadership cultures that pressured providers to prescribe more stimulants. This pressure can (and does) occur at any organization-in-person or remote- that places profit over patient care. We are seeing the same challenges unfold in the for-profit GLP-1 prescribing space, where everybody with a pulse gets a semaglutide.
There is also some concern that telemedicine evaluations will increase the rate of stimulant addiction and stimulant use disorder. However, a multi-center study completed and published last month in the Journal of the American Academy of Child and Adolescent Psychiatry showed no difference in the rate of development of stimulant use disorder between telemedicine and in-person medication initiated appointments.
While telemedicine is an easy and convenient villain to blame for the rise in healthcare profit over patient safety, its simply inaccurate. The truth is far more nuanced. Making telemedicine impractical for the millions of well-meaning and well-trained autonomous physicians who treat addiction does not solve the problem-it worsens it.
Enacting and enforcing legislation that separates, insulates, and protects evidence-based healthcare provider decisions from business interests gets to the heart of the issue. Existing Corporate Practice of Medicine (CPO) laws that currently regulate this important distinction are not present in all states and are rarely enforced.
Additionally, supporting mid-level providers with experienced, trained autonomous physician leaders who follow evidence-based guidelines and prioritize patient safety over profit is also key. This will help pull the human greed weed up by the root, instead of cutting away at its more visible but misleading leaves. To support this end, The American Professional Society of ADHD and Related Disorders is set to release national, uniform, evidence-based guidelines for the diagnosis and treatment of ADHD in early 2025.
While a few bad actors have used telemedicine as an avenue to expand corporate greed, the vast majority of American medical providers like me utilize telemedicine to provide life-saving addiction and psychiatric treatment to those who would otherwise never receive care. In-person travel requirements disproportionally affect minority and underserved communities who need this care the most.
Let’s hope that the DEA uses the upcoming year to draft a thoughtful, permanent telemedicine prescribing solution- a long-term answer that enshrines the expanded, life-saving access to care that telemedicine offers, while demanding that healthcare decisions are driven by evidence-based data instead of dollar signs.
Both. Are. Possible.
-Lauren