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There’s a saying, “never let a crisis go to waste.”  The pandemic was horrific in many ways.  One positive change that came about was the lifting of restrictions around the use of telemedicine.  Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic.  Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others.  So now that the emergency response has ended, what’s to be done? 

In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brooke Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness.  This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world.  Now is the time to act, dear listeners!  You can:

Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth.  Enjoy!


Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are delighted to welcome Joe Rotella, who’s the Chief Medical Officer of the American Academy of Hospice and Palliative Medicine. Joe, welcome to the GeriPal podcast.

Joe: Great to be here. Thanks.

Alex: And we’re delighted to welcome back to GeriPal podcast, Brook Calton, who is a palliative care physician and faculty at the Massachusetts General Hospital, and is also newly the Medical Director of palliative care at Devoted Health. Welcome back to GeriPal, Brook.

Brook: Thank you. Happy to be here

Alex: And we’re delighted to welcome Carly Zapata, who is a palliative care physician faculty at UCSF and directs the Palliative Care Fellowship at UCSF. Carly, welcome to GeriPal.

Carly: Thanks for having us.

Eric: We’re going to be talking about telemedicine for those who have serious illness, and this came out of a recent publication Carly did in the San Francisco Chronicle titled Telemedicine Helps People in Pain, Don’t Take That Away. So we’re going to dive into that topic. Before we do, I think, Joe, you have a song request for Alex.

Joe: I do. I would like to hear Space Oddity and it’s because I can’t imagine being more lonely and isolated than being in a tin can orbiting around the earth by myself and just how comforting it is even to hear that scratchy little voice from ground control. And the other reason is that you remind me of David Bowie.

Alex: Oh, thank you.

Eric: Wait, which version? The Labyrinth version or?

Alex: I don’t think it was in Labyrinth.

Eric: David Bowie was in Labyrinth.

Alex: David Bowie was in Labyrinth. But not Space Oddity.

Eric: Not Space Oddity. Well, I also get a feeling that the tin tin can analogy, its analogy to telemedicine in some ways, right?

Joe: Right. From a distance. And I’m thinking about that tinny little voice. I mean, have you ever been lonely enough that you go to get a burger just to hear that little guy say, “You want fries with that?” I mean that’s the kind of sensation that I’m having right now.

Eric: Well, Joe, I think we got to touch base more often if you’re going to a burger place for … [laughter]

Joe: Okay.

Alex: (Singing).

Eric: Alex would go on for another five minutes if I allowed him to.

Joe: That was amazing.

Brook: That was so good.

Joe: That was amazing. We had thought about asking for Video Killed The Radio Star, but I’m glad we went with this one.

Brook: I am too.

Joe: That was great.

Brook: I feel like you’re getting better year after year, so good.

Alex: Hope so. Thank you.

Eric: Yeah, we actually did Video Killed the Radio Star on another telemedicine podcast. We did the Geriatric 5M approach to telemedicine with Lauren Mo. So that song was already taken so we can’t do it.

Alex: And that was during the pandemic.

Eric: That was during the pandemic.

Alex: And our podcast today is about post pandemic world. Well, what do we do now?

Eric: Yeah. So Carly, I’m going to start off with you. So we’re going to be talking about telemedicine, telehealth for people with serious illness. You wrote the SF Chronicle article on an op-ed. What instigated you to write an op-ed?

Carly: I’ll just start first by acknowledging my co-authors who are Kara Bischoff, who I know has been on this podcast before, and Steve Panto, who is our division chief, and Bob Watcher, who is our department chief. So I did not write that alone by any means. And we wrote that in response to the May 11th deadline that was given to the Ryan Haight Act going back into effect after it was temporarily paused or restricted since the beginning of the pandemic. And the Ryan Haight Act I think was passed in 2008, which was in response to a young person who died of an opioid overdose. And they were prescribed those opioids from an online prescriber, that was not from a palliative care practice by the way, but some online prescriber of opioids. And that put into place this rule that people had to have an in-person visit within a certain amount of time to receive an opioid or a controlled substance prescription via telemedicine.

And I will be honest here and say that I actually didn’t know that that rule existed until they were going to put it back in place in May. And so I’m not sure if this is true for Joe or for Brook, but even before the pandemic in our practice here, we saw somewhere around 40 to 50% of our patients via telemedicine anyway, because we have a catchment area of patients who live very far away, many of whom have a lot of physical disability and other limitations to coming in person. And I had been prescribing opioids for them without having done an in-person visit, not even realizing that this was a law that was in place because I think there might not have been a lot of oversight and there hadn’t been any big issues around that. And then when the DEA announced that this was going back into place in May of this year, many of us have really expanded our telehealth practice even compared to our pre-pandemic levels.

And the thought of a huge number of our patients who had really come to rely on being able to do their visits from home or from a place that was close to home and getting medications that they’ve really come to rely on for symptom management was just really kind of terrifying for us and for them. I imagine that this might be the case for Joe and Brook too, that for lots of our patients, it’s not just preference about doing their visits via telemedicine, they are physically and sometimes financially unable to come for an office visit with any kind of regularity and sometimes even once. And so as with many things, I think that plan by the DEA was put into place in response to something bad that happened. And we should take safety precautions after something like that happens. But perhaps without consideration of all of the people who would be affected, some particular populations, including many of the people that we take care of, where that balance or the risk of addiction versus the benefit that they’re getting from those medications just looks different than it does from the general population that I think that they were trying to protect with the Ryan Haight Act.

Eric: Brook, for you, I’d like to just talk about thinking about what was life like prior to the pandemic? What did we learn during the pandemic? What changed and where are we now? Where we should be going? What was life for you as a provider pre-pandemic? Was there much telemedicine going on?

Brook: There was so. For us, so I was living in San Francisco, I was practicing with Carly and my team there. I think at least we like to think of ourselves as ahead of the curve. So as Carly mentioned in our practice at UC San Francisco, we were already doing about 50% of our visits by telemedicine before the pandemic. We were the highest utilizers of telemedicine in the whole UCSF health system at that time which we’re very proud of. And I think that it was percolating in a lot of the palliative care community. I was getting asked to give talks on how do you do this? We had submitted a grant to try to establish best practices and I think palliative care programs across the country, especially in the outpatient space, we’re really starting to see how it might add value. And then of course the pandemic hit and then everyone had to do telemedicine, whether it was inpatient, outpatient, you were at a skilled nursing facility and so forth.

Eric: And do you remember, Joe, you can chime in too, were there reimbursement issues with telemedicine pre-pandemic?

Brook: Yeah, so there was. And Joe, feel free to comment too, you may know this better than me. But I know at UCSF there were reimbursement reimbursement issues, especially for some of the private payers. But UCSF had really felt like this is coming down the pipeline, we need to be prepared. And so even if we’re losing money on these visits, we’re going to do them because they sort of saw it as a need coming. This was a commitment before the pandemic.

Joe: Yeah. On the payment aspect, there’s sort of a list of procedure codes that Medicare will allow you to bill for payment. And in response to the pandemic, I believe quite a few codes were added to that list for that could be then used through telehealth. So when we’re thinking about the future of this, we have to think about payment as well as quality, safety, access, all those other concerns.

Eric: And then when we’re using the word tele-… You’re saying you’re doing 40% telemedicine, 50% telemedicine. Is that Zoom, like video conferencing or is that including calling people by phone?

Brook: So I think of telehealth as the umbrella. If we’re going to get really academic, that’s the umbrella, and that can include a lot of things like including phone calls between a provider and a patient or messages in someone’s electronic medical record. And then video telemedicine is basically one of those pieces in the telehealth umbrella. And so we’re really I think focusing for the purpose of this conversation, or at least this is where I’d encourage us to focus on sort of video-based telemedicine care using Zoom or integrated platforms that people use within their electronic medical records.

Eric: Yeah.

Joe: I might add a slightly different perspective, and this predates the pandemic and that’s the hospice medical director or hospice physician who finds themselves responsible for maybe hundreds of hospice patients whose referring attendings either didn’t continue to follow them or aren’t available and based on the conditions of participation, we are responsible for their medical care if the other doctors aren’t available and we can’t go out and make a home visit every time we write a new morphine prescription for a hospice patient. So if you count talking to a nurse on the telephone and then writing an electronic prescription as a form of telemedicine, that was the norm for hospice prescribing of controlled substances even before the pandemic. And one of the things that we need to address going forward with the DEA is the Academy is actually asked that they be explicit about making an exception for hospice patients, which is not something that was done with the Ryan Haight Act, for example.

Alex: Is it all right if I switch gears just a little bit to talk about. Our listeners, what is the saying stories Trump data. Carly, in your piece in the Chronicle, you’ve started out with several stories. I wonder if you could relate some of those stories to our listeners, just kind of to bring home the need for continued support for telemedicine.

Carly: Absolutely, and I will say we had a really hard time narrowing it down to these three because amongst those of us who wrote that article, we can think of hundreds of people. That’s part of what prompted that article is that the list of people who would not be able to get palliative care with us otherwise if it weren’t for telemedicine is so long. And so we kind of focused on these three just as representative examples. In our particular practice, we take care of a very large population of patients with ALS who of course have a lot of physical disability. And because there are not many ALS centers in California, lots of those patients are pretty spread out. We sometimes take care of patients who are on home ventilators, so coming in for an office visit is not practically feasible. And so for lots of patients, sometimes as we’re prescribing very small amounts of opioids, of benzodiazepines to manage pain, to manage dyspnea, for example, for people who truly could not get those things, were it not for our video telemedicine visits.

One of the other patients that we mentioned was cancer patients. We take care of lots of cancer patients here, like I think most outpatient palliative care practices do. And sometimes physical symptoms are so severe that they’re interfering with someone’s ability to actually get sometimes curative or significantly life prolonging chemotherapy, for example. And so one of the patients that we mentioned in that article is a gentleman who lived four hours away who was unable to come to chemotherapy appointments because his pain was so debilitating once we gave him not a huge amount of opioids, he was actually able to come get chemotherapy and then live for much longer. So in so many ways that we’ve demonstrated in some research, palliative care is really a fundamental part of people’s care for their serious illness. And oncology and other subspecialties tend to be more readily available locally, not always certainly, but we have plenty of patients who can get their chemotherapy locally, for example.

But there is not an outpatient palliative care practice locally. And so recognizing that geographic limitation puts a lot of people in the position of relying on doing video visits. And I can think just a couple of weeks ago I saw a patient who I’ve only known via telemedicine who lives three hours away, has interstitial lung disease, and so she’s on 10 liters of oxygen and she doesn’t have a portable tank that will actually meet her oxygen needs for even the way here, much less the way back. And so people just have so many physical limitations, not to mention from an equity standpoint to have gas to drive this far, to pay the bridge tolls to pay for parking when you get here, for your caregiver to have taken the day off to accompany someone with physical limitations. I generally think of palliative care as existing to improve people’s quality of life and asking people to do that is not part of what we’re trying to accomplish.

Alex: Brook, any cases that come to mind for you that are completely anonymous for our listeners?

Brook: Yeah. I was just going to riff on what Carly was saying because a lot of what she was highlighting I think was patient focused features or features of patients that made it difficult to come in which is huge. And so we’re able to provide access to those patients that may be home-bound or home limited or have a lot of struggles to get in. I think the other thing I just wanted to highlight was the way in which telemedicine can expand the limited access that we have as palliative care specialists to places that may not have access at all to palliative care. I’m working for a startup called Devoted Health, and we have a fully virtual palliative care model and Devoted Health is in 13 states, and so our palliative care program is set to serve those members living in those states. Some of those are in Miami, Florida, some of those patients are in Miami, Florida, and they may be able to go to a local academic medical center and receive really good outpatient palliative care. But a lot of those patients are in a lot more rural areas of Florida or Ohio where we’re really able to bring the care into their living room and they’re able to have access to high quality specialty palliative care services through telemedicine where they wouldn’t have potentially any access otherwise.

Alex: Yeah, these are great points.

Carly: I might just add to that, Brook, this won’t be relevant for everyone because I think medical aid and dying is now legal in 16 or 17 states slash territories, whatever we call Washington DC these days. But in California where I practice medical aid and dying is legal and similar to other issues that are controversial in some places, many physicians do not prescribe or do visits for medical aid and dying consultations. And so since what Brook was talking about access, there are lots of patients in California who do live near their oncologist or who live near an outpatient palliative care practice or a place where you could theoretically have access to that, but the providers in that area may or may not actually choose to participate in medical aid and dying. And similar to the hospice patients, because it’s the same prognostic qualifying estimated prognosis of six months or less, lots of those patients are among the sickest have the shortest prognosis or the least able to travel somewhere and truly may not have access to someone within four to eight hours of them who can prescribe medical aid and dying medications. And so lots of our patients would not have access to that without video telemedicine. And there are lots of discussions and have been lawsuits about access to that in general. We would make access to that worse if [inaudible 00:19:18].

Eric: Yeah, I feel like that’s a whole nother podcast we got to do around that too and potential ethical issues.

Carly: Yeah, yeah.

Joe: But if I could loop back though to access …

Alex: Joe’s not going to touch that. [laughter]

Joe: No, I’m not. I’m not discouraging conversation about that. What I’m doing though is kind of, I don’t want to lose palliative care in this and that is to acknowledge that before there was a pandemic, before telehealth became the rule, instead of the exception, we already had access issues to palliative care. We have limited workforce. If you look at just the latest statistics in terms of how many hospitals have a dedicated palliative care service, it’s increased and grown over time. But particularly in some states, I think there are some states in the southeast where only a third of the hospitals actually have a palliative care service. So it’s always been spotty in terms of geography. You’ve got a better chance of getting palliative care if you go to a big academic hospital than if you go to a small rural hospital. In other words, if our goal is to say, “You should get this good care for your serious illness, it shouldn’t matter where you live.” Then we have access issues that have predated the pandemic. And this is one way from a patient-centered standpoint, not the convenience of the clinician, but from the patient-centered standpoint, we can get care to people who otherwise have no access.

I’m going to give a very unrelated example if I can. It’s been a little while since I did direct patient care. I’ve been focused on this association role, but I went to a recent gala for our local hospice and a woman came across room. She sought me out to come and tell me a story because about 10 years earlier, she and her family, their loved one was dying in a hospital in Florida and they tried to access palliative care and they couldn’t get the doctor to refer them to palliative care. They couldn’t get a case manager to refer them in palliative care. They lived in a place where palliative care exists, but they couldn’t get access to it.

And so I’m a friend of a friend, they called me and said, “Would I have a phone call with them?” There’s not even an in-person thing here. They’re in Florida, I’m in Louisville, and we’re talking over the phone and all I did was listen to them, hear their questions, validate that they’re asking the right questions. They told me what they thought they would do, and I say, “That sounds reasonable to me. I think you’re a loving family doing the best you can.” And that had such an impact that 10 years later I was basically accosted at this party by this person who said, “That phone call we had with you changed the whole experience for us.” I’m not going to pretend that that was palliative care, but what I am saying is there’s a desert sometimes even in places that look like they have palliative care and if there are more ways to access it, that’s better for patients.

Eric: Well, let me ask you this. Can we just review some of the big changes? Because pre-pandemic, right, there was issues with you had to be boarded in the state, right? You were doing medicine and what changed during the pandemic?

Brook: So during the pandemic, they waived those cross state. You could see people across state if you needed to. For me, let’s say now in Massachusetts, I could care for somebody in New Hampshire or Maine who was getting their oncologic treatment at Mass General, and I could see them. Those rules have since gone away now with the pandemic getting better, I don’t know if that’s the right term terminology, but evolving.

Eric: The emergency has been ended, right?

Brook: Has been lifted. The emergency rules have been lifted. And so we spend a good deal of time in Boston then because we do care for patients in multiple different states, scrambling to get licenses in the states, neighboring Massachusetts so that we could continue to provide care.

Alex: Wow. So you have to get licensed in all of New England essentially.

Eric: And if you’re seeing someone in Florida, you have to be licensed in Florida.

Brook: So with my work, I’m going to end up… I mean, I don’t even want to think about it, but-

Eric: 13 states.

Brook: … probably carrying at least 15 licenses and my mom makes me keep my California license just in case, so add one more.

Carly: That sounds expensive.

Joe: Well, there’s a whole industry around that. I mean, just keeping tabs on what needs to be renewed and when probably some of those states have different CME requirements. Like if you’re in Kentucky, you’d have to take the domestic violence required course, but you probably have a different one if you’re in Indiana. So that would be a big job to maintain a lot of licenses.

Eric: And it also sounds like prescribing opioids have changed, so you didn’t need face-to-face. You can use telemedicine telehealth to prescribe opioids-

Alex: During the pandemic.

Eric: … during the pandemic. Any other big things that end now? Well, let’s hold off for now. I won’t get to now. Well, we talked about now with the other one. So where are we now with that with the whole Ryan Haight face-to-face?

Carly: I just add one quick thing, which is that in the last few years, five years, maybe this happened earlier in other places, but now we also have e-prescribing of controlled substances, which has made it much easier to go along with video telemedicine that we’re not mailing triplicates through the mail that can be tampered with and lost, and then it’s obviously the wrong thing and you have to resend it five times. We have other things that have helped us expand telemedicine within or across state lines too that we can take advantage of.

Joe: Yeah, so I’m willing to give a bit of a summary of where I think we are with the PA and the prescribing of controlled substances through telemedicine means. So recognizing that the public health emergency was going to be declared over and all those temporary waivers were going to expire, the DEA actually put out a request for information about should it go back to life as it was, or should they potentially have some new rules or new flexibilities? The Academy and many other people responded and…

Eric: And they have proposed rule changes, right? The DEA?

Joe: Well, the proposed rule changes would’ve included, for example, that you have to have a face-to-face encounter with a patient in order to prescribe over telemedicine, or you have to have received a referral from someone who did have a face-to-face, and they also would’ve had to be DEA certified. And how are you going to know that when you’re just getting random referrals from teaching hospitals, for example?

Eric: The proposal is actually that the person that’s referring you to palliative care had to have a DEA regis-… Yeah. How would you do that?

Joe: If you weren’t going to go and have your own in-person visit, if you were going to do a telemedicine prescription without having yourself seen the patient, you would have to have received a referral from a clinician who did do a face-to-face visit with that person. So it developed all this issue around what is a qualifying referral that would allow me to do telehealth prescribing? What I can tell you is, it was… I hate to use the word unprecedented. We hear that all the time now. Everything’s unprecedented. The DEA themselves said, “We received an unprecedented 38,000 comments.” And I could tell you that’s a lot for a government agency to hear. And so the immediate response to that was to say, we’re going to kick the can for six months, so we will put a six months extension on all the flexibilities that exist now, and during that six months, we will work on a proposed rule to address some of your concerns. So the clock’s already ticking on that, but we got a six-month reprieve and it was by far the most comments I’ve ever seen submitted for anything.

Eric: What are they, do you know what they’re doing these six months? Are they reaching out to organizations like HPM, AGS, AMA?

Joe: I suspect they’re reading those comments that were submitted. I mean, the Academy’s was like 12 pages long and that’s one of 38,000. So they probably have a lot of input to process here going into this now.

Eric: What were the big recommendations from the Academy to the DEA? Do you remember?

Joe: Yeah.

Eric: The ones that come to your mind.

Joe: Okay. So kind of going back to my comment that let’s not forget that hospice and hospice practice in this one of our requests was that you may get explicit that there is an exception for patients enrolled in a hospice program. And by the way, we have really good reason for that because this isn’t like a prescribing clinician within a clinic or an outpatient clinic or something. This is a hospice that is sending people to your home doing comprehensive assessments, having team meetings to go over your care plan every two weeks. It’s a very integrated, different model of care, and that physician should be able to work with the team and not have to make a face-to-face visit.

Eric: Wait, before we go move on for that. Can I ask a really stupid question, Joe?

Joe: Sure.

Eric: If the rules just revert back to they were pre-pandemic, what’s different for hospice?

Joe: There doesn’t have to be anything different for hospice. But that model I described of you have a lot of patients they’re having involving care needs, a nurse goes and makes an emergency visit calls, the hospice medical director says, “Can you give me an electronic prescription to meet this patient’s need?” Under the new rules if no exception were made for hospice, they would either have to say, “We assume there’s an exception and practice like we always did.” Or we’d have to say,” I’ve got to get a doctor to go see this person.”

Eric: So prior there was assumption?

Joe: Yeah.

Eric: Okay. So now to make that assumption explicit.

Joe: Yes. And we believe that it was a valid assumption and we believe there are very many good reasons to recognize that prescribing under hospice care is a very different model than what they are primarily concerned about. But one of the things we would ask for is don’t make us guess. Don’t give us an ulcer. Just tell us that that is in fact an exception and it’s okay to practice the way that we always have. So that would be one. We also really had concerns about any of these rules that would require the prescriber to do all this checking up on whoever referred the patient. First of all, I might not know who referred the patient. It may have come to a care manager. It may have been written by the hospitalist, but the other doctor I’m working with is really the person I would call.

We have to recognize that people don’t practice in solo practices, they practice in integrated groups. And so this idea that you would need to go and say, “Who was the referring physician? What’s their NPI number? What state are they in? What’s their address? Do they have a valid DEA certificate?” We don’t have a mechanism to do all that, so either we’re going to assume the referral was okay or we’re going to be afraid to prescribe unless we make a face-to-face visit. And that face-to-face visit, as we’ve pointed out, becomes an access issue for the patient because I’d be doing it to meet a DEA role, but I wouldn’t be doing it because it’s good for my patient to have to travel those four hours. That lady on the 10 liters per minute of oxygen doesn’t need to go out and breathe the Canada wildfire smoke for four hours coming to my clinic just so I can write a prescription.

Eric: Yeah.

Carly: And I think a prescription that we had considered to be safe to give her for the last three years, that it would be so helpful if the DEA could be really explicit about what they are trying to accomplish with these rules so that when we find ourselves in the position of considering is there an assumption about an exception or something else, we know what the spirit of the law is in addition to the letter. I think it’s really unclear what they are hoping or expecting that checking someone’s NPI number or having this patient have a face-to-face visit with someone else is protecting people against.

Joe: Yeah. I’ll just add one other thing that we would ask for, and it really was in the Ryan Haight Act and that is that there was supposed to be a mechanism to get a special certificate that would allow you to prescribe through telehealth without a face-to-face that was supposed to happen before the pandemic was never implemented. And we’re just happy that you don’t always need an X waiver now just to prescribe buprenorphine. So this idea of another waiver may strike you as why would you ask for that? But if we don’t see a lot of these flexibilities extended into the future, if we don’t get confirmation that hospice is an exception, then for you to have something you could do as a prescriber, even if it’s jumping through an extra hoop or two to know that you’re on the right side of the DEA would be worthwhile.

Eric: I’m going to think about a slightly different perspective. What precautions would you put in place to protect the population from, let’s say the original reason for we had the Ryan Haight Act was like these pill mills prescribing to people they’ve never met or met for 30 seconds to give them this opioid so they can make a quick dollar. What are the reasonable kind of precautions that you would think the DEA should take? That’s open to anybody.

Carly: I was actually just thinking, and we talked about this in the op-ed, that at least in California we have the CURES Act, which requires you to review people’s opioid use history within a certain period of time. So if not every time, at least every four months when my EHR prompts me to do so, I review the frequency with which people have filled their opioid prescriptions. At what pharmacy did they get them? Who prescribed that? When was the last time they filled it? So that you really can pick up on whether somebody is getting them from other places, having other kinds of concerning behaviors. And I will confess that I haven’t actually used this, but recently in our CURES database, there’s the option to run an intrastate check. And so presumably in California I can see what people have filled in Oregon and Nevada and Arizona as well. Not perfect, but does give you the chance to pick up on obviously worrisome behavior where people are getting prescriptions from multiple people or filling them in a way that is more frequent than it’s been prescribed.

Joe: And Carly, I’m so glad you dove in. I was doing that seven second palliative pause to see if anybody would jump in and you did it. Thank you. I think one way to think about this is what’s so magic about it being through telemedicine rather than through in-person. I mean people can walk to your office and you can have all kinds of problems recorded to your prescription just because they came to your office rather than you looked at them on a computer screen doesn’t really change. So I might say, what can we apply the same things? Go ahead Eric. I’m sorry.

Eric: Joe, I mean the frequency is an issue. It is so much easier to scale up an online pill mill than an office-based pill mill, especially when it’s interstate and you have… There is this worry. We know we’ve seen it with other things too.

Joe: Oh yeah, well look, we’ve been arguing pretty passionately for flexibility to use telemedicine and that’s partly because one of the overriding issues is that there is such poor access right now to care people really need, but that needs to be balanced of course against the quality of the care we’re providing. Are we getting quality outcomes? Is it a good experience for the patient, the costs, and the safety? And one thing that none of us want is to have a system that’s easy to gain and that’s going to hurt people. I’m simply pointing out that all the things we do to make an in-person visit safe, there are ways we could apply similar rules, telehealth visits. We can look at things like, did you look at your prescription medicine monitoring system? Did you query it? I would expect that the DEA or the state medical boards would be looking at volumes of prescriptions.

If one provider is providing 50,000 prescriptions a quarter, I would say that’s pretty obvious, but the best telehealth you can do, that’s still too much. So what I would say is rather than get hung up on, “Oh, telehealth is dangerous.” Why don’t we say, “All of healthcare is dangerous.” The things we’ve learned that make it safer, let’s find ways to apply that through telehealth just like we would apply it in any other way. I think there’s this idea that if I see you in person, I’ll be able to tell that you’re gaming me or that you’re lying to me or something. We should not be trying to guess whether our patients are lying to us. We need to have better tools than that.

Eric: Yeah, I always thought it was just a roadblock, not that it improves quality, but it kind of slows things down. Brook, you were going to say something? You were going to push back on something I said.

Brook: Well, yeah. Just to offer something I’ve been thinking about, so in the current proposed rule or as far as I can tell, maybe the plan moving forward, it’s a little hard to tell and there’s a chainsaw in the background, so let me know. They’re cutting down a tree. It’s like telemedicine best practices-

Carly: Never fails.

Brook: … 101 is don’t have a chainsaw in the background. But one of the things I’ve been thinking about is which appears to be right now, at least as they’ve stated, a potential requirement to have a referral. And I do think if that process could be… That would add work and there would always be those people that had called a palliative care program and didn’t have a referring provider, but really needed help that would be a challenge there. But I mean, I don’t think that that’s a totally bad idea.

If we can make it easier, I do think it’s a good idea for… So I’ll just think about my practice with the startup. I do think it’s a good idea that a primary care doc or an oncologist is bought in to the fact that I am going to be the one prescribing controlled substances, and one way to do that is with a referral. But you’ve got to make it simple and it can’t be to sort of one individual, it needs to be to a practice and that sort of thing. But I mean I do want, if that’s one sort of harm reduction method, and it also sort of accomplishes what I think is another important goal is trying to coordinate care for these really complex people and in terms of controlled substance safety, making sure that it’s clear about who’s going to be doing the prescribing.

Joe: I think that’s great, Brook. And again, I’ll say that’s kind of the way that many hospices actually operate. So the hospice referring physician may continue as the hospice attending of record, but then they’re working with the medical director and the hospice physician. Ideally, it’s great to have that referring doctor stay involved in the care. In Medicare’s case, they would say, “We like having two doctors certifying that eligibility for hospice.” And you could say, “This would be another example. If I have a clear referral in that’s two physicians agreeing this patient should be in my clinic and considered for opioids.” So I can see the strength of that. What it can also tell you just from the hospice experience is it’s not always the case that the local physicians actually want to engage that much after the patient gets to you.

Alex: I have a question. Let’s say our listeners want to rise up and they’re fired up about this issue and they want to do something about it. What can our listeners do to advocate for these proposals that we’re discussing today?

Joe: I can tell you one thing they did is they wrote comments to the DEA. So maybe there is something there. If we can get enough people to write 10-page letters to regulators, that is one way to really get attention for something. I’ll point out that we’ve been focusing on the prescribing aspect and we’ve been thinking back to the DEA’s proposed rule, which got kicked for six months and the editorial. But there are other aspects just in general about telemedicine, whether you’re prescribing opioids or not, that were flexibilities built in during the pandemic and then they expired and then some of those were then extended through the end of next year as part of that big final budget package that consolidated appropriations at the end of last year in the lame duck Congress. Some of those were extended through another year, but they’re not permanently extended. So there’s another bill called the Connect for Health Act, which really gets more broadly at making permanent some of those things. For example, that we should not have geographic restrictions. It shouldn’t matter what state or county we’re in, whether it’s urban or rural, it should be patient centered, not place centered.

Eric: Well, can I ask about that, Joe? Because that’s an interesting one because we were talking about boards. So if I’m boarded in Nevada and I do consults in California, who am I responsible to from a medical boards perspective if I’m doing really bad medicine?

Joe: That’s beyond me at this moment to know I would suspect possibly both. My sense is, and we were talking earlier about…

Eric: This is the problem without national warrants …

Joe: Brook has 13 licenses. Generally you want to be licensed in the state where your patient is receiving care and you might be licensed in multiple states. I believe it’s where your patient is. That’s going to be where your accountability lies, but that may also vary by state, and I’m not an attorney.

Eric: Because it’s fascinating. If you’re not board in that state, what can they do? You’re not board. They can’t take away your boards in a state that you’re not boarded in. Brook, what are your thoughts on that?

Brook: I mean, I’m just thinking about the comment that was made earlier just from a very practical perspective when it comes to this cross-state licensure issue is thinking about everyone’s best and highest use and also to the point that was made earlier in this call, what is the DEA trying to do or what is the purpose, right? From a clinical perspective, it makes no difference. If my patient is in New Hampshire or Massachusetts or Maine or Ohio or Florida, I’m going to care for them and provide good care and the amount of work that it’s creating. If you even just take one person or one program or one company or one hospital to then if you think about the whole country and the amount of work and the distracting effort that’s going into that without necessarily a totally clear clinical purpose, I mean I think that that’s a big deal that I’m hoping in telemedicine 2.0 we’re able to solve for in a meaningful way.

Joe: Yeah, yeah. Go ahead. Sorry.

Carly: Well, for Eric and Alex, I mean you both practice at the VA, which is a national organization. I’m actually curious what happens with board regulation there. Because there is telehealth nationally, you can take care of a patient who lives in Florida within the VA, although I guess that’s technically federal property, but we do actually have a model for having a national system in which you can prescribe across state lines and that works just fine. I was thinking for law for example, there are state bars because the laws are actually different in each state, but our boards are not different in each state. The practice of medicine that we are held to and the evidence base that we have is not state-based and that’s probably a whole another process.

Eric: It’s little state based. There are requirements like Joe is saying, states, there are laws that come up as far as what physicians can even talk about in their clinic settings, whether it be in Florida.

Carly: That’s true.

Eric: Even in California.

Carly: For medical aid and dying. But the medical part, what antibiotics to give for this and those kinds of things, we’ve chosen to make the political or other things state based. But the medicine part for which we are certified is not.

Joe: So you could imagine something like national licensure to be something to consider in the future. Just to be clear, when I was saying geographic restrictions, I didn’t actually mean what states your doctorate and what state you’re in. I meant more like if you’re in a rural county, you can have telemedicine. If you’re not in a rural county, you can’t. We want to see that go away and the other thing we want to see go away is this originating site rule and that’s this thing that says the patient has to be in a certain place, they have to be in a clinic or a hospital in order for me to do telehealth with them. You actually had patients leaving their home and going somewhere in order to do telehealth with you. So we would want to say, “We don’t need that.” Whatever is convenient for the patient should be an originating site that works for this. That’s an example of what we’d like to see made permanent.

Eric: Okay. I want to be mindful of time. Each of you lightning question. You have one thing that you can change, fix or continue moving forward from here, whether it be from a clinical research education equity perspective around this issue of telehealth, telemedicine for those with serious illness, what would that be? Joe, I’m going to start off with you.

Joe: Okay. I’m going to build on a theme that we’ve been really talking about here, which is really patient-centered care. Centered on the patient’s needs, what gives equitable access to patients, what will meet their needs, what is safe and quality for them? If I could use my magic wand, I would like to see all conversations about this to begin with what is right for the patient, not what’s most convenient for the healthcare system. What allows the clinician to make the most billable visits or what makes for a good electronic health record. Now I think it should be what is the very best for our patients.

Eric: Brook?

Brook: Well, I love Joe’s response and we didn’t get a chance to talk about this, but I do think that rounding out our research and establishing some quality standards for the practice of telemedicine based palliative care is going to be important. We kind of missed a lot of that because of the pandemic and so I think it’s still important to sort of go back at our evidence base and figure out what we want things to look like and try to standardize that.

Eric: Wonderful. Carly, you’re last.

Carly: I was thinking about expanding on both of those things, so I am very much in Joe’s camp of saying what is the best thing for the patient and also creating an evidence base to show us. In the absence of evidence that something is harmful to a patient, can we really just keep that at the center? And kind of building on that evidence base, there are lots of other things that we should look into because if anything, we may find out that we should be expanding telehealth and getting rid of the state line requirements so that people can have language concordant palliative care so that a Vietnamese-speaking palliative care physician in California can see someone in Indiana or all kinds of things that we imagine but don’t necessarily know are helpful. I think we may be thinking too small in terms of the ways that we can be patient-centered and telemedicine could really help us with that as long as we have an evidence base that demonstrates that what we imagine to be true is actually true.

Eric: Well, I want to thank you all for joining us on this podcast. Alex, a little bit more, David Bowie.

Alex: (Singing).

Eric: So the DEA is ground control. Major Tom is Carly. As I listen to the song, I’m trying to put all the pieces together.

Joe: Eric, our patient is Major Tom. [laughter]

Carly: Definitely.

Joe: And Carly is ground control and the DEA is NASA or something.

Carly: Yeah.

Eric: Well, thank you all three for joining us. It was a great podcast.

Brook: Thanks so much.

Carly: Thanks everyone.

Joe: Appreciate it. It was great. Thanks.

Eric: And thank you to all of our listeners for your continued support.

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