APA, Others Lobby to Make COVID-19 Telehealth Waivers Permanent

Alicia Ault

May 29, 2020

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The American Psychiatric Association (APA) is calling on Congress to permanently lift restrictions that have allowed unfettered delivery of telehealth services during the COVID-19 pandemic, which experts say has been a boon to patients and physicians alike.

"We ask Congress to extend the telehealth waiver authority under COVID-19 beyond the emergency and to study its impact while doing so," said APA President Jeffrey Geller, MD, in a May 27 video briefing with congressional staff and reporters.  

The APA is also seeking to make permanent certain waivers granted by the Centers for Medicare & Medicaid Services (CMS) on April 30, including elimination of geographic restrictions on behavioral health and allowing patients be seen at home, said Geller.

The APA is also asking for the elimination of the rule that requires clinicians to have an initial face-to-face meeting with patients before they can prescribe controlled substances, Geller said. The Drug Enforcement Administration (DEA) waived that requirement, known as the Ryan Haight Act, on March 17 for the duration of the national emergency.

Telemedicine has supporters on both sides of the aisle in Congress, including Rep. Paul Tonko (D-New York) who said at the APA briefing he would fight to make the waivers permanent.

"The expanded use of telehealth has enormous potential during normal times as well, especially in behavioral health," said Tonko. "I am pushing fiercely for these current flexibilities to be extended for a reasonable time after the public health emergency so that we can have time to evaluate which should be made permanent," he said.

Geller, other clinicians, and advocates in the briefing praised CMS for facilitating telepsychiatry for Medicare. That follows in the footsteps of most private insurers, who have also relaxed requirements into the summer, according to the Medical Group Management Association (MGMA).

Game Changer

The Medicare waivers "have dramatically changed the entire scene for someone like myself as a clinician to allow me to see my patients in a much easier way," said Peter Yellowlees, MBBS, MD, chief wellness officer, University of California Davis Health. Within 2 weeks in March, the health system converted almost all of its regular outpatient visits to telemedicine, he said.

Yellowlees added government still needs to address, what he called, outdated HIPAA regulations that ban certain technologies.

"It makes no sense that I can talk to someone on an iPhone, but the moment I talk to them on FaceTime, it's illegal," said Yellowlees, a former president of the American Telemedicine Association.

Geller said that "psychiatric care provided by telehealth is as effective as in-person psychiatric services," adding that "some patients prefer telepsychiatry because of its convenience and as a means of reducing stigma associated with seeking help for mental health."

Shabana Khan, MD, a child psychiatrist and director of telepsychiatry at NYU Langone Health in New York City, said audio and video conferencing are helping address a shortage and maldistribution of child and adolescent psychiatrists.

Americans' mental health is suffering during the pandemic. The US Census Bureau recently released data showing that that half of those surveyed reported depressed mood and that one third are reporting anxiety, depression, or both, as reported by the Washington Post.

"At this very time that anxiety, depression, substance use and other mental health problems are rising, our nation's already strained mental health system is really being pushed to the brink," said Jodi Kwarciany, manager for mental health policy for the National Alliance on Mental Illness (NAMI), on the briefing.

Telemedicine can help "by connecting people to providers at the time and the place and using the technology that works best for them," she said, adding that NAMI would press policymakers to address barriers to access.

The clinicians on the briefing said they've observed that some patients are more comfortable with video or audio interactions than with in-person visits.

Increased Access to Care

Telepsychiatry seems to be convincing some to reconsider therapy, since they can do it at home, said Yellowlees. The technology is a way of "enlarging the tent for us as a profession and providing more care," he said.

For instance, he said, he has been able to consult by phone and video with several patients who receive care through the Indian Health Service who had not be able to get into the physical clinic.

Yellowlees said video sessions may also encourage patients to be more, not less, talkative. "Video is actually counterintuitively a very intimate experience," he said, in part because of the perceived distance and people's tendency to be less inhibited on technology platforms.

"It's less embarrassing," he said. "If you've got really dramatic, difficult, traumatic things to talk about, it's slightly easier to talk to someone who's slightly further apart from you on video," said Yellowlees.

"Individuals who have a significant amount of anxiety may actually feel more comfortable with the distance that this technology affords," agreed Khan. She said telemedicine had made sessions more comfortable for some of her patients with autism spectrum disorder.

Geller said audio and video have been important to his practice during the pandemic. One of his patients never leaves the house, and does not use computers.

"He spends his time sequestered at home listening to records on his record player," said Geller.  But he's been amenable to phone sessions. "What I've found with him, and I've found with several other patients, is that they actually talk more easily when they're not face-to-face," he said.

Far Fewer No-Shows

Another plus for his New England-based practice during the last few months: patients have not been anxious about missing sessions because of the weather. The clinicians all noted that telepsychiatry seemed to reduce missed visits.

Yellowlees said that no-show rates had decreased by half at UC Davis. "That means no significant loss of income," during the pandemic, he said.

"The no-show rate is incredibly low, particularly because when you call the patients and they don't remember they had an appointment, you have the appointment anyway, most of the time," said Geller.

For Khan, being able to conduct audio and video sessions during the pandemic has meant keeping up continuity of care. 

As a result of the pandemic, many college students in New York City had to go home — often to another state. The waivers granted by New York's Medicaid program and other insurers have allowed Khan to continue care for these patients.

The NYU clinic also operates day programs in rural areas 5 hours from the city. Khan recently evaluated a 12-year-old girl with significant anxiety and low mood, both of which had worsened.  

"She would not have been able to access care otherwise," said Khan. And for rural patients who do not have access to broadband or smartphones, audio visits "have been immensely helpful," she said.

Khan, Geller, and Yellowlees have disclosed no relevant financial relationships.

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