When COVID-19 was declared a public health emergency more than three years ago, it signaled the beginning of huge change for the health care industry.
That was especially true for telehealth.
Under relaxed regulations, patients could more easily connect by phone or Zoom to doctors many miles away, or get prescriptions from a specialist to treat conditions like ADHD or opioid use disorder.
The federal declaration — and the pandemic policies tied to it — officially ends on Thursday, but patients may not see any big changes in the care they receive via telehealth, at least not yet.
Federal policymakers are allowing these more expansive telehealth services to remain in place temporarily, thanks in part to a last-minute about-face by the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration.
Disruptions delayed — for now
This week, the agencies announced they are keeping in place, for another six months, the pandemic-era rules that let doctors prescribe controlled substances using telehealth.
Most critically, that will mean there will be no requirement of an in-person visit in order to get a prescription.
The agencies had previously planned to roll back that allowance and reinstate the in-person visit requirements for patients seeking a prescription. That controversial proposal, announced in February by the DEA, drew an enormous response. There were more than 38,000 public comments — many of them from doctors and patients who argued that reverting to the old rules would cut off access to care that patients have come to rely on over the last three and a half years.
"We have been able to reach populations that otherwise wouldn't have been able to access this care," says Dr. Shabana Khan, who chairs the American Psychiatric Association's telepsychiatry committee.
Khan practices in New York City, but has a roster of patients upstate. She worries an expiration or gap in the ability to remotely prescribe buprenorphine, which helps people with opioid use disorder combat drug cravings, would put those patients at grave risk of overdose.
If the rules eventually expire and revert back to require in-person care, she says her practice will have to refer those telehealth-only patients to new psychiatrists who are able to see them in person; but the primary reason many of them came to her is precisely because they live hours away from the next available provider.
"In many cases, it's going to mean there isn't any care," Khan says.
Telehealth here to stay?
Telehealth limits the ability of medical staff to perform physical assessments like measuring blood pressure or feeling for tumors. But for behavioral and mental health care, telehealth is immensely popular among patients and many of their doctors who say it's easier and more accessible for patients. They can connect with providers while at work, for example, or in the car.
Some worry relying solely on telehealth could degrade the quality of care or, in the case of controlled substances, lead to abuse. Much of that concern comes from the history of "pill mills" whose growth through remote prescribing two decades ago helped fuel the opioid epidemic. The DEA has found some examples of abuse during the pandemic, but research also shows that these telehealth measures have saved people from dying of overdoses. So regulators are hoping to study the public health impact as they devise permanent rules.
"We recognize the importance of telemedicine in providing Americans with access to needed medications, and we have decided to extend the current flexibilities for six months while we work to find a way forward to give Americans that access with appropriate safeguards," DEA Administrator Anne Milgram said in a statement to NPR.
For most other telehealth services, federal and state regulators have given a longer runway with pandemic-era flexibilities, extending them through 2024 to give more time to study the effects of those allowances.
For example, Medicare patients can continue to receive mental health care — as well as some physical services — via telehealth, including just over a voice-only call. Hospitals are also able to continue caring for some patients remotely by shifting that care into patients' homes, under waivers allowing acute care to be delivered without nursing staff present around the clock.
Many private insurance companies have also extended their coverage of telehealth visits, although in the long term it remains to be seen whether they will compensate healthcare providers the same amount for remote care as they do for in-person care. (States regulate Medicaid and private insurers, and have their own telehealth regulations.)
Meanwhile, many practitioners say it's impossible to imagine going backward on telehealth, and are already assuming the shift toward a hybrid model of both remote and in-person care is here to stay.
"We're teaching this in medical schools today... there is no returning to non telehealth visits. This will be incorporated into what we do for our patients moving forward," says Dr. Tochi Iroku-Malize, president of the American Academy of Family Physicians.
"You have a newer generation of individuals who prefer to have quick access and telehealth has allowed that," she says.
This story was edited by Will Stone.
