The Regulatory Barriers Holding Back Telepsychiatry
Last semester, our staff writer Nikita published a piece on computational psychiatry, which analyzes the upstream and downstream ramifications of novel mental health technologies. In this piece, I want to focus on a mental health innovation that is straightforward from the technology side but a complicated mess from the regulatory side: telepsychiatry.
Stepping back, access to mental health care today is abysmal – especially in the wake of the opioid crisis. From the most recent Mental Health America statistics, over 26 million individuals (57.2% of adults with a mental illness) in America are going untreated, almost a quarter (22.3%) of all adults with a mental illness who sought care reported that they were not able to receive the treatment they needed, and 59% of youth with major depression do not receive any mental health treatment. As a result, patients are often first treated in the ER but are released without seeing a psychiatrist, even if they screen positive for substance abuse, PTSD, and/or self-harm in the last 4-8 weeks. As can be expected, many of these patients rebound back to the ER within a few weeks in far worse shape.
Telepsychiatry – the delivery of psychiatric assessment and care through videoconferencing – has been touted as a way to begin mitigating this gap. It enables psychiatrists to significantly increase their patient volumes and enables care for many patients who would not otherwise be able to receive it, whether it be because of stigma surrounding seeking treatment or geographical constraints for those in non-urban areas. Its efficacy is at parity with in-person treatment, with well-documented studies showcasing positive clinical outcomes for a variety of mental health conditions, including panic disorders, depression, and PTSD. Currently, telepsychiatry has so far found the widest implementation among veterans and children: the former because the VA has taken a very forward-looking funding approach in light of how hard the opioid crisis has hit veterans, and the latter because the need in adolescent populations is especially high.
For the rest of the population, the barrier is clearly not technology – the only technology needed is a video camera on a laptop and Zoom Video Conferencing, which most people have access to at home or nearby in a community facility. Rather, the issue lies around barriers to prescription and reimbursement: 10.3% (over 4.7 million) of adults with a mental illness remain uninsured, and there are very stringent regulations around online prescription of controlled psychiatric substances.
First, the prescription front. In 2008, the Ryan Haight Online Pharmacy Consumer Protection Act was passed by Congress after a teenager overdosed on Vicodin he had purchased online. The act prohibits dispensing controlled substances via the Internet without a “valid prescription… A doctor must conduct at least one medical evaluation of the patient in person or via telemedicine…so long as the patient ‘is being treated by, and physically located in, a hospital or clinic’ or ‘while the patient is being treated by, and in the physical presence of, a practitioner.’” In short, small caveats aside, a patient must see a trained psychiatrist in person prior to being prescribed most psychiatric substances, which renders much of telepsychiatry’s positive potential moot. Of course, there’s always the concern that mental health disorders, especially ADHD (which can lead to an Adderall prescription) or anxiety (which can lead to a Xanax prescription), are easier to “fake” over video, but faking the disorders in person is not much different. I believe that the pros of relaxing regulations to promote greater access to much needed psychiatric care far outweigh the cons of potential misuse, which can be mitigated over time with better (and tech enabled) assessment rubrics. Congress largely ignored calls to revise Ryan Haight until last year, when the Justice Department released guidelines around the SUPPORT Act in the wake of the opioid crisis. However, the act was not landmark legislation and is primarily designed to relax some of the most stringent regulations surrounding the prescription of drugs implicated in opioid treatment over telemedicine. Certain states like Connecticut have relaxed regulations around prescription of controlled substances via telemedicine, but far more progress needs to be made on the national front. 
The other large regulatory headwind facing telepsychiatry lies around reimbursement for treatment. Medicare, which provides health insurance for more than 52 million Americans primarily over the age of 65, only covers telepsychiatric care if a patient lives in a pre-designated Health Professional Shortage Area (i.e. rural area). More technically, “reimbursement through Medicare is dependent on the location where the consumer is receiving services, known as the originating site. The originating site must be in a rural location deemed a Health Professional Shortage Area (HPSA)…the originating site must be a medical facility such as a hospital, rural health clinic, federally qualified health center, skilled nursing facility or a community mental health center.” Importantly, care at home is not covered. In 2019, Medicare Advantage (which a subset of Medicare recipients receive) “began covering virtual check-ins across the country, meaning that patients can connect with their doctors by phone or video chat…whether they live in rural or urban areas.” While this is a step forward, regulations surrounding reimbursement still vary drastically state to state (especially for private insurers, but also for Medicare and Medicaid) and are poorly understood by psychiatrists and patients alike. 
In the face of gaping issues around access to mental health care, it is clear that telepsychiatry can play a beneficial role in delivering care to huge swaths of neglected populations, who need treatment today more than ever. We need a much more concerted effort to drive regulatory change around prescription and reimbursement to allow basic technologies like video conferencing, which have immense potential for social good, to take more of a foothold for psychiatric applications. The bar for technology is very low, but it is time for regulation to catch up.
 On March 16th, 2020, the DEA published a COVID-19 Information Page, stating that the in-person requirement will be waived for the duration of the public health emergency. However, there is no guarantee that this lasts after the crisis passes.
 As of March 17, 2020, for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for telehealth services provided to beneficiaries in their home. Once again, there is no guarantee that this lasts after the crisis, and does not apply to commercial insurers.