DEA announces proposed rules for permanent telemedicine flexibilities

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This seems quite limited, almost no different than Ryan Haight. Seems almost easier to not change anything.

No stimulants without in person
30 days max of benzos and bup. Essentially transitioning care to get them somewhere better.

Someone reading this differently?
 
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Yeah the 30 day thing is very unclear if they mean 30 days at a time or just one 30 day script ever. I’m not totally sure based on this.

But yes doesn’t matter for stimulants specifically excludes Schedule II. Could be a boon for things like online ketamine sites depending on how the final rule is written.

Edit: just read the actual text, it’s only a 30 day supply. BUT can use a “referring providers” in person medical exam.

“
Additionally,the proposed rule generally would subject a practitioner practicing
telemedicine to initially limit prescriptions for a controlled medication issued to a patient to a 30-
day supply. Apractitionerwould be allowed to issue multiple prescriptions for the same patient,
but would only be allowed to prescribe an amount less than or equal to a total quantity ofa 30-
day supply ofthe controlled medication." Thereafter, to continue prescribing to that patient,
within 30 days, the prescribing practitioner would be required to examine the patient in person.
Alternatively, ifthe prescribing practitioner receives a qualifying telemedicine referral for the
patient in the manner described herein, the practitioner may rely on the referring practitioner's
in-person medical evaluation in order to prescribe the controlled substance via telemedicine.4”

This is the actual full text:
 
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Oh so this is a good big change in that you can have the PCP do an in person exam and then you can see the patient telepsych without any issues? Thereby completely bypassing limitations on CS? This seems very positive..am I missing something?
 
The DEA is a bad joke. They seem increasingly desperate to remain relevant and protect their fiefdom with state legalization of cannabis, all the emergency changes during COVID, and now the liberalization of suboxone prescribing. They can't make a simple, straight forward rule to save their lives.
 
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Who the hell is referring patients to online ketamine clinics?? Shut those places down
 
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So just get a PCP to refer and do an in person exam and then nothing changes with prescribing of controlled. Sounds like it will delay care for some and PCPs will have an influx of patients for in person visits.
 
People here thinking that a simple PCP referral will do it haven't read the DEA's rule. The referring physician has to specifically note that the visit is for a referral to a telemedicine appointment. They have to make the diagnosis, and then send you the referral for you to keep on file. It's quite onerous and the DEA specifically notes that they are making it easy for big organizations. This will be difficult for private practices.
 
StayOnTop said:
People here thinking that a simple PCP referral will do it haven't read the DEA's rule. The referring physician has to specifically note that the visit is for a referral to a telemedicine appointment. They have to make the diagnosis, and then send you the referral for you to keep on file. It's quite onerous and the DEA specifically notes that they are making it easy for big organizations. This will be difficult for private practices.
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That doesn’t sound that complicated..you go to a pcp, they dx you with “hyperactivity” and refer to telepsych, they print you off a referral and off you go, how is that different from what we are saying
 
forchinet121 said:
That doesn’t sound that complicated..you go to a pcp, they dx you with “hyperactivity” and refer to telepsych, they print you off a referral and off you go, how is that different from what we are saying
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They make it sound like they have to specifically denote you as the referring doctor. Like, "this is a referral for Dr.XXXX"
 
The frustrating thing is that neuropsych evaluations don't seem to count as referrals in this case.
 
I think we can all agree that we shouldn’t create more work for PCPs
 
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Ha yeah like PCPs are going to want anything to do with this. The 30 day prescription isn't worth much unless your practice is super slow. You see the patient for a telehealth eval and then have to reschedule them within a month for an in-person appointment? Not helpful.
 
This seems to be a measure that will make psychiatric care more local once again.

The model that has started the past couple of years where a solo psychiatrist opens a tele practice in Timbuktu and prescribes controlled substances to anywhere in the country seems to be in trouble. Basically, it seems necessary for most psychiatry practices to have some sort of in-person presence, unless you don't want to prescribe any controlled substances, or are associated with a larger organization that can manage these referrals.

The referring provider thing doesn't seem that helpful for solo practitioners. Which provider would want to collaborate with someone like this and take on the potential liability? I certainly wouldn't want to unless I knew the person that I was referring to or was a part of the same organization.

I could be wrong, just my read. Would appreciate clarification from more knowledgeable people.
 
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If the final rule ends up looking like this, I am going to have to seriously contemplate whether I want to just start telling new patients that I am unable to prescribe controlled substances. I'm full enough that routinely going into the office just for new evals ain't worth it.
 
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clausewitz2 said:
If the final rule ends up looking like this, I am going to have to seriously contemplate whether I want to just start telling new patients that I am unable to prescribe controlled substances. I'm full enough that routinely going into the office just for new evals ain't worth it.
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Don't threaten me with a good time.
 
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wolfvgang22 said:
Don't threaten me with a good time.
Click to expand...

Trouble is I'm the sort of weirdo who likes helping people taper off benzos and have reasonably good results with it. There are definitely people out there who go looking for someone to do this for them and I find it quite rewarding, but alas.

Definitely accelerates my timeline to moving towards cash-only with therapy focus.
 
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clausewitz2 said:
Trouble is I'm the sort of weirdo who likes helping people taper off benzos and have reasonably good results with it. There are definitely people out there who go looking for someone to do this for them and I find it quite rewarding, but alas.

Definitely accelerates my timeline to moving towards cash-only with therapy focus.
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You can do a 30 day taper with benzos no problem (literature might recommend longer tapers but still doable without the risk of serious symptoms like seizures). The axe was thrown to schedule 2 meds (pain meds and stimulants), from my recollection no benzos are schedule 2.
 
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clausewitz2 said:
If the final rule ends up looking like this, I am going to have to seriously contemplate whether I want to just start telling new patients that I am unable to prescribe controlled substances. I'm full enough that routinely going into the office just for new evals ain't worth it.
Click to expand...
You don’t do any in person? You’re fully remote?
 
Something had to be done to address the virtual pill mills. A thousand nps seeing 100 follow ups a day each, with one doctor supervising
 
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clausewitz2 said:
If the final rule ends up looking like this, I am going to have to seriously contemplate whether I want to just start telling new patients that I am unable to prescribe controlled substances. I'm full enough that routinely going into the office just for new evals ain't worth it.
Click to expand...
I will go this route if I have to, but like you I strongly dislike an important tool being taken out of my toolbox. Sigh.
 
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littlefred said:
You can do a 30 day taper with benzos no problem (literature might recommend longer tapers but still doable without the risk of serious symptoms like seizures). The axe was thrown to schedule 2 meds (pain meds and stimulants), from my recollection no benzos are schedule 2.
Click to expand...
Oh I know it can be done safely from a medical perspective but I tend to do much longer and more gradual tapers if someone has been on them chronically. The people who are actively looking for help coming off them that I end up encountering are serious about stopping but also looking for a gentler process.
 
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forchinet121 said:
You don’t do any in person? You’re fully remote?
Click to expand...

I am in person at my part-time public sector gig working with a population that absolutely does need some controlled substances sometimes and so unfortunately I won't even get the minor benefit of not having to renew my DEA.
 
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clausewitz2 said:
If the final rule ends up looking like this, I am going to have to seriously contemplate whether I want to just start telling new patients that I am unable to prescribe controlled substances. I'm full enough that routinely going into the office just for new evals ain't worth it.
Click to expand...
We are looking at options like just seeing the pt in person for f/u if considering CS rather than trying to predict which evals will need in person evals or just scheduling everyone in person. Or another alternative to basically have pts who need to be seen in person just walk in and get seen between appointments for a minute or two to lay eyes (and maybe good opportunity to have MA get vitals for the stim starts.)
calvnandhobbs68 said:
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Thank you for linking directly.

Some notes from reviewing the full thing:

  • The 30-day period seems to be 30 days from seeing the pt, not multiple 30-day prescriptions. They're just clarifying that you can write multiple shorter duration prescriptions which can't add up to more than 30 days. (edit: for those who haven't read the whole thing, you can Rx CIII-V by telemed but have to see the pt in person within 30 days to continue prescribing CS. No telemed CII at all without in person visit OR qualifying referral.)
  • Six month grace period for patients established during the emergency order.
  • CS Prescriptions written via telemed require writing on the Rx that it's a telemed Rx AND require documenting the address you're in during the encounter as well as the patient's state and city. i.e. if you're working from home you're required to put your home address in the note, unless I'm missing something.
  • There's a lot of onerous sounding data collection but most of it should be handled by EMR automatically.
  • PCP referral does count for large groups when referring to a specialty rather than a specific psychiatrist. There's a bunch of additional steps they added which I think are a very long winded way of saying that getting a PCP referral after the fact doesn't count. This creates an additional grey area with regard to transitioning patients during the six month grace period. (You've already established a relationship and Rx a CS, so unclear if PCP referral counts.)
  • 7 day Rx only if PDMP is down at time of prescription.
  • DEA has decided their rule will have minimal cost impacts to industry. Technically probably true if comparing to going back to pre-pandemic Ryan Haight. Not true when comparing to leaving pandemic status quo in place...
 
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Proposed g 1300.3_(a)(2)would require all practitioners who wish to engage in the
practice of telemedicine to be located in a State, territory, or possession of the United States; the
District ofColumbia; or the Commonwealth of Puerto Rico at the time the relevant telemedicine
encounter occurs.
 
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FlowRate said:
We are looking at options like just seeing the pt in person for f/u if considering CS rather than trying to predict which evals will need in person evals or just scheduling everyone in person. Or another alternative to basically have pts who need to be seen in person just walk in and get seen between appointments for a minute or two to lay eyes (and maybe good opportunity to have MA get vitals for the stim starts.)

Thank you for linking directly.

Some notes from reviewing the full thing:

  • The 30-day period seems to be 30 days from seeing the pt, not multiple 30-day prescriptions. They're just clarifying that you can write multiple shorter duration prescriptions which can't add up to more than 30 days.
  • Six month grace period for patients established during the emergency order.
  • CS Prescriptions written via telemed require writing on the Rx that it's a telemed Rx AND require documenting the address you're in during the encounter as well as the patient's state and city. i.e. if you're working from home you're required to put your home address in the note, unless I'm missing something.
  • There's a lot of onerous sounding data collection but most of it should be handled by EMR automatically.
  • PCP referral does count for large groups when referring to a specialty rather than a specific psychiatrist. There's a bunch of additional steps they added which I think are a very long winded way of saying that getting a PCP referral after the fact doesn't count. This creates an additional grey area with regard to transitioning patients during the six month grace period. (You've already established a relationship and Rx a CS, so unclear if PCP referral counts.)
  • 7 day Rx only if PDMP is down at time of prescription.
  • DEA has decided their rule will have minimal cost impacts to industry. Technically probably true if comparing to going back to pre-pandemic Ryan Haight. Not true when comparing to leaving pandemic status quo in place...
Click to expand...
DEA is going to have a field trip with that one. I would definitely schedule the patient for an in-person appointment, not simply tell them to come in for us to lay eyes on them. The optics of that is just terrible
 
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allantois said:
DEA is going to have a field trip with that one. I would definitely schedule the patient for an in-person appointment, not simply tell them to come in for us to lay eyes on them. The optics of that is just terrible
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I mean the debate is really figuring out how much time is necessary to qualify for an "in person medical evaluation." I already spent an hour talking to the patient over video within 30 days of the in person appointment (in this future state.) I'm having my MA get vitals. What more do you want? I remember being in ortho clinic as a med student and seeing 70+ patients in a day with the attending. The attending only saw those patients for 5 minutes tops, usually 2-3. Quick physical exam, pop some steroid in a knee, move on to the next one.
 
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AACAP just sent an email about this and apparently they’re reading this somewhere in there too (granted I did not read the entire 60 page document I linked so I don’t know all the specifics):

“To issue more than a 30-day supply for these medications, you must conduct an in-person medical evaluation of the patient. This can include the patient’s in-person visit with another practitioner while on an interactive video link with you as prescribing practitioner.”
 
FlowRate said:
I mean the debate is really figuring out how much time is necessary to qualify for an "in person medical evaluation." I already spent an hour talking to the patient over video within 30 days of the in person appointment (in this future state.) I'm having my MA get vitals. What more do you want? I remember being in ortho clinic as a med student and seeing 70+ patients in a day with the attending. The attending only saw those patients for 5 minutes tops, usually 2-3. Quick physical exam, pop some steroid in a knee, move on to the next one.
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Just schedule them for your normal follow up; unless 2-3 mins is your normal follow up
 
calvnandhobbs68 said:
AACAP just sent an email about this and apparently they’re reading this somewhere in there too (granted I did not read the entire 60 page document I linked so I don’t know all the specifics):

“To issue more than a 30-day supply for these medications, you must conduct an in-person medical evaluation of the patient. This can include the patient’s in-person visit with another practitioner while on an interactive video link with you as prescribing practitioner.”
Click to expand...
This is just absurd
 
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calvnandhobbs68 said:
AACAP just sent an email about this and apparently they’re reading this somewhere in there too (granted I did not read the entire 60 page document I linked so I don’t know all the specifics):

“To issue more than a 30-day supply for these medications, you must conduct an in-person medical evaluation of the patient. This can include the patient’s in-person visit with another practitioner while on an interactive video link with you as prescribing practitioner.”
Click to expand...
It's definitely in there and was basically in Ryan Haight previously, as well. It's kinda silly to imagine arranging appointments where you're on video with the PCP at the same time.
allantois said:
Just schedule them for your normal follow up; unless 2-3 mins is your normal follow up
Click to expand...
If only things were that simple. The DEA wants us to see pts within 30 days. I normally schedule f/u's 6-12 weeks out unless they are notably high risk and right now I have very few apps in less than 8 weeks. Plus the 100 or so extra appointments that need to be fit into my schedule in the next 6 months for all of the grace period pts.
 
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FlowRate said:
Yeah, I didn't mention it since I don't see it applying to the vast majority of us. It's kinda silly to imagine arranging appointments where you're on video with the PCP at the same time.

If only things were that simple. The DEA wants us to see pts within 30 days. I normally schedule f/u's 6-12 weeks out unless they are notably high risk and right now I have very few apps in less than 8 weeks. Plus the 100 or so extra appointments that need to be fit into my schedule in the next 6 months for all of the grace period pts.
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You are starting patients on controlled substances and giving them 2-3 months of those substances to start with? I would say that I've only heard about PCPs doing that and even then not with stimulants
 
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allantois said:
You are starting patients on controlled substances and giving them 2-3 months of those substances to start with? I would say that I've only heard about PCPs doing that and even then not with stimulants
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Yes, as are all of my 30ish colleagues. In the 6-8 weeks from intake to first full scheduled f/u appt, we check in on med effects by portal message and/or RN phone call a few times and have VS and UDS checked through primary care (for stim starts). Although it's more accurate to say they're given a 30 day prescription and have to meet those monitoring requirements in order to receive a second fill or dose adjustment, if relevant, prior to next appointment. I almost never start anyone on standing benzos for more than a two week supply and if I am then it's for very rare situations where I probably am seeing them sooner.

edit: although I just realized this is even less relevant since you either have a legit telemed referral or you can't start a C2 at all anyway, so less pressure for a quick f2f appt (esp since I usually start with nonstims.)
 
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FlowRate said:
  • CS Prescriptions written via telemed require writing on the Rx that it's a telemed Rx AND require documenting the address you're in during the encounter as well as the patient's state and city. i.e. if you're working from home you're required to put your home address in the note, unless I'm missing something.
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Thanks for the summary. This doesn't change much since the practice address and patient address are already on the eRx, unless you are or the patient is traveling. If you're working from home, even during the pandemic, you're supposed to be putting your address where you are physically at so the DEA can investigate at any time so that's also not a change. It seems really onerous confirm the patient's address every single time and get their address if they are somewhere else (taking the appt from a friend/family's home, etc) and document it.

The part where you didn't mention is that if you're prescribing a telemed Rx from a PCP referral, you also have to document that PCP's name and NPI number as well as document any correspondence regarding the referral and both parties have to keep records of that referral.
 
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It's just more rationing-by-inconvenience.
 
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clozareal said:
Thanks for the summary. This doesn't change much since the practice address and patient address are already on the eRx, unless you are or the patient is traveling. If you're working from home, even during the pandemic, you're supposed to be putting your address where you are physically at so the DEA can investigate at any time so that's also not a change. It seems really onerous confirm the patient's address every single time and get their address if they are somewhere else (taking the appt from a friend/family's home, etc) and document it.

The part where you didn't mention is that if you're prescribing a telemed Rx from a PCP referral, you also have to document that PCP's name and NPI number as well as document any correspondence regarding the referral and both parties have to keep records of that referral.
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I'm hoping a lot of the "onerous documentation" stuff should be handled by the EMR, especially if you're in the same EMR system as the PCP. Definitely more bothersome for PP docs to track. Reading it a second time, it looks like they also want you to have an easily accessible log of all telemedicine prescriptions (to make the DEA's job easy), so I'm not sure that just saying "they're all in the charts of the relevant patients in the EMR" satisfies that requirement. Given the national level demand for this, I'd hope EMR companies would get on adding a "telemedicine" check box to prescriptions quickly and then also add a quick reporting ability to list all such Rx.

That's really interesting to know that you were supposed to be documenting home address even previously. It seems a little silly since the location you document on a given day may not reflect the location you'll be in when the DEA wants to come knocking (e.g. for hybrid schedules.) The proposed DEA ruling actually didn't require verifying the patient's full address, just state and city.
 
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FlowRate said:
I'm hoping a lot of the "onerous documentation" stuff should be handled by the EMR, especially if you're in the same EMR system as the PCP. Definitely more bothersome for PP docs to track. Reading it a second time, it looks like they also want you to have an easily accessible log of all telemedicine prescriptions (to make the DEA's job easy), so I'm not sure that just saying "they're all in the charts of the relevant patients in the EMR" satisfies that requirement. Given the national level demand for this, I'd hope EMR companies would get on adding a "telemedicine" check box to prescriptions quickly and then also add a quick reporting ability to list all such Rx.

That's really interesting to know that you were supposed to be documenting home address even previously. It seems a little silly since the location you document on a given day may not reflect the location you'll be in when the DEA wants to come knocking (e.g. for hybrid schedules.) The proposed DEA ruling actually didn't require verifying the patient's full address, just state and city.
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Goodbye, ever-getting-a-refill-while-on-vacation...
 
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This is only screwing over the well meaning solo doc, you guys think the private equity company with unlimited resources is not gonna hire an army of workers to deal with this nonsense? Just dumb
 
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forchinet121 said:
This is only screwing over the well meaning solo doc, you guys think the private equity company with unlimited resources is not gonna hire an army of workers to deal with this nonsense? Just dumb
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Unless Done et al. are planning on opening PCP clinics or physical offices, I think they are done for.
 
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littlefred said:
They are trying to recruit PP psychiatrists to join their ranks.
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Wth do they bring to the table? There is a hoard of stimulant refugees from these platforms
 
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I could envision this leading to in-home evaluations to keep the new subscription-based ADHD prescribing services going. There are already networks of medical examiners in place for life insurance physicals who do this—granted they aren't usually licensed medical professionals to my knowledge, but if you raise the pay I could see it happening. What is the minimum accreditation to do the in person exam for the referral? Whatever that is, that's who could likely fill the role.
 
COVID exception expires May 11.. still waiting on final DEA guidance
 
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wolfvgang22 said:
I think patients self refer after a google search.
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Of course! They know their bodies. What do we know?! We just read those books and research. Not “real life experience.”
 
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