Feb 16, 2024
Telehealth and Prescribing
CCHP
On January 31, 2024, the Department of Health and Human Services (HHS) finalized rules for the prescribing of buprenorphine through the use of telehealth (rules first proposed in December 2022). In these final rules, opioid treatment programs (OTPs) will be able to use telehealth to prescribe buprenorphine without an in-person visit. It is important to note that these final rules are not in regard to using telehealth to prescribe a controlled substance in general. This is a very specific rule that applies to OTPs and the use of telehealth to prescribe buprenorphine with some additional applications specifically to methadone. The broader policy of using telehealth to prescribe controlled substances without an in-person visit (or meeting one of the narrow exceptions found in federal statute) still remains a temporary allowance through the end of 2024.
BACKGROUND
Readers may be aware that the COVID-19 public health emergency (PHE) activated one of the exceptions to using telehealth to prescribe a controlled substance without an in-person visit (or meeting one of the other narrow exceptions) which the Drug Enforcement Administration (DEA) oversaw during the pandemic. During the PHE, the Substance Abuse and Mental Health Services Administration (SAMHSA) also created a specific exemption for OTPs from having to conduct an in-person physical evaluation of patients who were being treated with buprenorphine if an OTP physician, primary care physician or authorized healthcare professional under the supervision of the program physician determined that such an evaluation could take place via audio-visual or audio-only telehealth. SAMHSA’s flexibility was extended for one year after the end of the PHE (to May 2024) or until a final rule is published. At this time, the waiver that the DEA oversees for prescribing of controlled substances has been extended to the end of 2024. This final rule only addresses the SAMHSA flexibility, as their regulatory authority in this area is limited to OTPs. SAMHSA developed the rule in consultation with the DEA and it addresses the use of telehealth for both buprenorphine and methadone use by an OTP.
WHAT DOES THE FINAL RULE DO?
Additional items are included in the final rule however this newsletter will only focus on the telehealth-related issues. Please see the full final rule for details on the other items.
Buprenorphine
The final rule simply makes permanent what had been allowed during the pandemic in the case of buprenorphine. Buprenorphine initiation at an OTP by the OTP practitioner if an OTP physician, primary care physician or other authorized health care professional under the supervision of a program physician determines that an adequate evaluation of the patient can be done via audio-visual or audio-only telehealth.
SAMHSA based their decision on past evidence and the positive outcomes found during the pandemic when these policies were allowed. Note that for buprenorphine, audio-visual and audio-only modalities may be used.
Methadone
SAMHSA has been more hesitant to extend flexibilities on using telehealth in relation to methadone but wrote that it believes some limited use of audio-visual telehealth would be appropriate. Therefore, in the final rule, audio-visual telehealth may be used “for any new patient who will be treated by the OTP with methadone if a program physician, or an authorized healthcare professional under the supervision of a program physician, determines that an adequate evaluation of the patient can be accomplished via an audio-visual telehealth platform.” SAMHSA believes that there would be a higher risk in missing crucial information if an audio-only platform is used and therefore, unlike for buprenorphine, is only allowing audio-visual to be used for methadone. There is an exception to allow the use of audio-only to conduct the evaluation only when audio-visual is not available to the patient and the patient is with a licensed practitioner who is licensed to prescribe and dispense a controlled medication.
It is noted that, “The final rule is not applicable to, and does not authorize, the prescription of methadone pursuant to a telehealth visit. Instead, this change applies to the ordering of methadone by appropriately licensed OTP practitioners and dispensed to the individual patient by the OTP under existing OTP procedures.”
ACCESSIBILITY
The final rule also reminds providers that their telehealth platforms will need to be accessible to patients with disabilities and those with limited English proficiency. Providers are reminded that discrimination based on disability or national origin is prohibited and that providers will need to make reasonable modifications or steps to accommodate these patients.
CONSENT
Consent for treatment has been changed to where it can also be obtained verbally or electronically and must be documented. This change was made in acknowledgment of the increased use of telehealth and the difficulty in obtaining a signed, in-person consent when technology is involved.
It is very important to note that this is a narrow final rule and it is not the DEA’s rule on using telehealth to prescribe controlled substances. However, with so many telehealth policies at this time having a temporary extension date, this is one policy where the permanent status has been finalized. Additionally, the decision with these rules may impact the forthcoming DEA rules. More importantly, the final rule will continue to create greater accessibility for patients who would benefit from treatment that OTPs offer. You can read the final rule to obtain more details. The final rules go into effect on April 2, 2024. |
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| With funding from the National Association of Community Health Centers (NACHC), CCHP has created a separate section on its policy finder that lists the Medicaid fee-for-services policies on telehealth as they relate to the FQHCs. Check out CCHP's FQHC policy finder to view the policies that exist in YOUR state! |
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CCHP knows that telehealth policy can be a complicated subject and from time to time questions about policies related to your specific situation may arise. You’re in luck…We’re here for you! Just submit your question via our easy to use contact us form, or send an email to info@cchpca.org
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