Telehealth providers can keep writing prescriptions for controlled substances without an office visit, the U.S. Drug Enforcement Agency (DEA) announced on May 3.
The DEA extended for an additional six months the permissive telehealth rules enacted during the COVID-19 pandemic that allow patients to receive prescriptions for controlled medical through telehealth providers.
Before the extension, patients who were receiving opioid painkillers, stimulants, and tranquilizers through telehealth were facing a potential cutoff of access to their medications until they could schedule an office visit with a primary care physician (PCP). This could have created a serious backlog of medical appointments, resulting in some patients’ prescriptions running out before they could obtain an appointment with a provider.
Despite the extension, there is an ongoing concern that a massive backlog in PCP appointment slots is unlikely to be resolved during the six-month period.
Easing the Shortage
The eventual end of the temporary telehealth rule will create serious access issues, says Jeffrey A. Singer, M.D., a senior fellow at the Cato Institute.
“The nation already has a significant shortage of health care practitioners, particularly in primary care, and with patients poised to no longer get ready access to telehealth services from out of state, health care access—particularly for people in rural and underserved areas—will only get worse,” said Singer.
Lack of a PCP varies widely by state, ranging from a low of 16 percent of Massachusetts patients to a high of 42.6 percent in Tennessee, over the 2016 to 2022 period, according to a study published by FAIR Health on March 15. Another study found that the ratio of people to each primary care practice location ranged from a low of 115 for Rochester, Minnesota to 2,760 for Zapata, Texas.
Arizona’s Telehealth Solution
When the DEA’s telehealth rule expires, state professional licensing regulations will reduce patients’ access to telehealth providers, says Singer.
“With the emergency over, obstacles to telehealth services posed by state licensing laws (will) prevent people from getting telehealth services from providers who are not licensed in the state in which the patient lives,” said Singer. “Since 2021, Arizona state law has allowed Arizonans to get telehealth services from any type of health care provider licensed in any of the 50 states and the District of Columbia,” said Singer. “But efforts to replicate the Arizona reform in other states have been met with strong opposition from entrenched incumbents who fear out-of-state competition.”
State medical market protectionism can be overcome, says Singer.
“There is, however, a federal fix,” said Singer. “Congress can define, for the sake of interstate telehealth services, the ‘locus of care’ as the state in which the provider is licensed, not the state in which the patient purchasing the service resides.”
Assistant Physician Access
A potential solution to the shortage of physicians is to increase the supply, according to Singer.
That could be done by giving patients nationwide access to assistant physicians (APs) through telehealth. Unlike Physician Assistants (PAs), APs are Medical Doctors (M.D.) and Doctors of Osteopathy (D.O.) who have not completed a residency program. Singer says expanded AP access, which could be done at the state level, would greatly ease shortfalls where they exist.
“States that pass AP laws should not require that APs work only within the premises of a supervising physician, as some have done,” said Singer. “They should follow the example of Missouri and permit them to practice in their own clinics, providing they have a ‘collaborating’ or supervising physician nearby and available 24/7. This will allow people to access primary care at more locations. In Missouri, the supply of primary physicians has increased by three percent just since the AP law was implemented in 2017.”
Texas is one state that could benefit from more flexibility, says Singer.
“If Texas were to pass an AP law—which the legislature is now considering—it would certainly help,” said Singer. “However, Texas needs to also allow allied health care practitioners to provide primary care services. For example, Texas is now among the minority of states that don’t grant full practice authority to Advanced Nurse Practitioners, such as board-certified Family Nurse Practitioners. FNPs have proven, over the decades, to provide excellent primary care services.”
Non-Physician Alternatives
APs receive two years more clinical training than PAs, and Nurse Practitioners (NPs) have been another option to ease shortages, but they receive less clinical training than physicians.
Replacing physicians with non-physicians could present some problems, says Linda Gorman, director of the Health Care Policy Center at the Independence Institute.
“We lack clear data about physician assistant abilities relative to physician abilities,” said Gorman. “Their training differs. The question is whether it matters for patients. There are also liability issues that would have to be resolved.”
While there is no clear consensus as to how to address the prescription issue moving forward or what post-emergency permanent rules will look like, Gorman said there may be a simpler solution.
“A bigger question is why we have prescription requirements at all, with the exception of those for drugs such as antibiotics or addictive drugs which generate severe externalities if they are improperly prescribed,” Gorman said.
The current DEA rule extension runs through November 11.
Kevin Stone (kevin.s.stone@gmail.com) writes from Arlington, Texas.
Internet Info:
Jeffrey A. Singer and Spencer Pratt, “Expand Access to Primary Care: Remove Barriers to Assistant Physicians,” Cato Institute, April 24, 2023: https://www.cato.org/briefing-paper/expand-access-primary-care-remove-barriers-assistant-physicians
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