The Future of PHE Remains Uncertain
If we’ve learned anything in the last few years, it’s that making addiction care as accessible as possible saves lives. Nothing has underscored this more than the rule changes that came about from the declaration of the public health emergency (PHE) in January 2020. Instituted by the Secretary of Health and Human Services during the early days of COVID-19, the PHE included many pandemic-related health measures, notably expanding Medicaid coverage and telehealth services.
While COVID-19 served to broadly illuminate the injustices and gaps in care already pervading society, the PHE’s loosening of regulations around the delivery of virtual care had a number of positive effects.
Given the shutdowns that kept the country largely inside during this time, the original goal was to help bring care to those who were no longer able to go to their doctors’ offices and visit clinics. While COVID-19 served to broadly illuminate the injustices and gaps in care already pervading society, the PHE’s loosening of regulations around the delivery of virtual care had a number of positive effects. It helped meet many of those persistent gaps head on, improving access for people who never had it.
Regulations before PHE had a tangled history that made Medications for Addiction Treatment (MAT) highly challenging for providers to prescribe and for patients to utilize. But the changes in regulation made it possible for people who had substance use disorder (SUD) to receive treatment in a way they simply weren’t able to before. The PHE removed burdensome in-person requirements and allowed patients to get completely online addiction treatment, support, and medications. This included prescription support for buprenorphine products like Suboxone to help transition off of opioids. Suddenly, these life-saving treatments became much easier to reach.
Boulder Care, originally founded in 2017, was among the few virtual addiction care providers who were already doing vital work in treating people with substance use disorder prior to the pandemic. However, the allowances of the PHE have meant more people are able to access and remain in care than ever before. Over the course of 2020-22, Boulder has been able to reach more than four thousand people in multiple states, delivering care entirely online. During that time, we have seen how important it is to empower patients with choices around how and where they want to access treatment, including from the privacy of their own homes on a schedule that works with their lives.
Reversing the new rules that became standard under the PHE would put people who use drugs, a population that is already vulnerable and used to being left behind by the medical system, at even greater risk.
Reversing the new rules that became standard under the PHE would put people who use drugs, a population that is already vulnerable and used to being left behind by the medical system, at even greater risk. This is especially true at a time when death from overdose is at an all-time high. It also defies all of the positive learnings about the effectiveness of telehealth that the medical community has gathered over the course of the pandemic. This includes a recent study that indicated OUD-related telehealth was associated with improved retention rate and lower risk of overdose.
Like many other telehealth providers and partners in the healthcare industry, we have been watching closely what will unfold when the PHE expires. Since its initial implementation, HHS has extended the PHE every 90 days, with the most recent extension scheduled to end January 11, 2023. HHS has indicated that they will provide at least 60 days notice before any future expiration date. The department has not given such notice yet, so we can reasonably expect the PHE to last until at least March. But the uncertainty still looms.
Boulder has been preparing for the end of the PHE to ensure continuity of care for our current and future patients, and is determined to fight and advocate for better regulations to help all people who use drugs.
What Changing Regulations Could Mean For Helping Patients With SUD
Ending the PHE could bring two major changes to the way telemedicine provider groups like Boulder Care have been delivering substance use disorder treatment. Both will end waivers that cleared the path to make treatment more accessible:
- Prescriber registration waivers will expire: Registrations with the DEA to prescribe controlled substances, including buprenorphine, an evidence-based treatment for opioid use disorder (OUD), have traditionally been required in each state in which a provider is treating patients.
During the PHE: Registering with the DEA in one state is sufficient to treat and prescribe medication to patients in other states, subject to applicable state law.
- The Ryan Haight Act waiver will expire: The Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which took effect in 2009, was intended to prevent unscrupulous online pharmacies from dispensing controlled substances. The regulations require a provider to conduct at least one in-person medical evaluation of a patient before remotely prescribing any controlled substances, including buprenorphine, the gold-standard medicine used to treat OUD. Once the provider has conducted one in-person evaluation, the regulations do not set a requirement for subsequent re-examinations.
During the PHE: There is no requirement for an initial in-person evaluation before prescribing any controlled substance, enabling providers like Boulder Care to commence a patient’s treatment exclusively via a telemedicine visit. On August 31, 2022, the Biden administration and DEA announced their intention to permanently waive the in-person evaluation requirement specifically with respect to medications for OUD, such as Suboxone. This would permanently establish the ability of providers like Boulder Care to operate as we have been since 2020.
How Boulder Care Is Preparing for a Post-PHE World
In the midst of potential changes to the protections offered by the PHE, it is important to reiterate that Boulder Care existed and treated patients before the pandemic, and will continue to do so. Boulder is growing our team, expanding to new states, and propelling new methods for substance use disorder treatment into the mainstream, all while keeping an eye on any potential impacts from the end of the PHE and any other regulatory changes that may come our way. To ensure that we are able to maintain uninterrupted coverage for our patients, we are already instituting the following plans:
- All of Boulder Care’s providers are and will continue to be licensed in every state in which they are treating patients. Boulder has never taken advantage of the emergency waivers that allow a clinician to practice medicine or nursing in states in which they are not licensed by the state medical or nursing board. This is a true differentiator for Boulder Care.
- All Boulder Care providers will be registered with the DEA in all states in which they prescribe, so that they may continue to care for their patient panels without interruption. This means that if the prescriber registration waiver ends with the expiration of the PHE, Boulder patients will continue care, regardless of changes to rules in the state where they reside.
- We are and will continue to be vocal advocates for change at the policy level to the Ryan Haight Act. We are participating in active discussions at the federal level with representatives from the DEA, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Office of National Drug Control Policy (a division of HHS). Our deep advocacy is not only another differentiator for Boulder Care, it also means we are able to help lead the charge to a better future for people who use drugs across many issues, and are able to help mold the future of telehealth treatment.
- In the unlikely event there is a gap between the PHE expiration and the implementation of permanent telehealth flexibility with respect to buprenorphine, we are prepared to meet the need for an initial in-person exam. By leveraging existing protocols and the strong community relationships that we’ve forged with brick-and-mortar providers of primary and specialty care, including health and hospital systems, we have plans in place to help new patients start their care in-person if required. We have consistently hired clinicians that are embedded in the communities we serve to ensure these plans can continue to be at the forefront of our contingency planning.
The Future of Addiction Care Must Include Telehealth
No matter what the future holds regarding the expiration of the PHE, it is undeniable that the past two years have taught us a tremendous amount about the value of telehealth in the addiction treatment space. Online addiction care has been delivered, tested, and appreciated by diverse patients across the socioeconomic spectrum. It is also drawing widening support from the medical profession.
Online addiction care has been delivered, tested, and appreciated by diverse patients across the socioeconomic spectrum.
According to a recent Yale survey, “more than 1,000 registered physicians who used telehealth services to treat patients with opioid-use disorder during COVID-19 found that an overwhelming majority [85%] favor making telehealth a permanent part of their practice.” The study’s lead author, Tamara Beetham, MPH, stated that, “Recent exposure to telehealth…has promoted the perspective among the physicians surveyed that it is a viable and effective treatment option for patients.” According to her, these findings could have major implications for telehealth regulations because “continued flexibility would allow more individuals to access life-saving treatment.”
We have seen this at Boulder Care firsthand. Allowing patients to access treatment through an app means they can get care from the privacy of their own homes, while on their lunch break, after their kids have been put to bed, or anywhere they need to make their recovery fit into their life. Accessible addiction care grounded in support can make all the difference between long term, successful recovery that is in patients’ hands vs treatment that is disempowering, doesn’t work, or even worse, is additionally harmful for a population that is already underserved and at high risk.
Telehealth has been truly life-changing for many, who are now able to realistically sustain the formidable work of behavior change involved in recovery. One patient even commented:
“I never could do treatment before because I have a family and full time job. I can’t just take off to rehab. I also couldn’t participate in any treatment options around here as you have to travel 49 minutes every morning to get a dose. Boulder Care has allowed me to get treatment at home and continue with my busy life discreetly– which will help so many people like me."
Boulder Looks Ahead
There are many reasons to look ahead with great optimism. The PHE has allowed a great experiment in telehealth to not only take place, but succeed. And people at all levels of the government are taking note.
Most recently, 45 state attorneys general joined advocates, addiction medicine providers, public health experts, members of the House of Representatives Bipartisan Addiction and Mental Health Task Force, and more in signing a letter to the DEA urging them to permanently implement telehealth flexibilities for buprenorphine.
We’re prepared to adjust as needed to ensure uninterrupted care for our patients, and will continue to advocate loudly for a better future for all people who use drugs.
There are numerous options legislators and regulators have at their disposal for how to make the necessary changes happen, from extending the PHE further to enacting permanent rule changes, to even de-scheduling buprenorphine. But no matter the direction the federal government or individual states head, Boulder will be here. We’re prepared to adjust as needed to ensure uninterrupted care for our patients, and will continue to advocate loudly for a better future for all people who use drugs. We will keep our community apprised as the regulatory continues to unfold. But please feel free to reach out to us with any questions or concerns.
If you’d like to join us in the fight and advocate for making PHE waivers permanent, there are two bills currently making their way through Congress, the TREATS ACT, and an amendment to the Ryan Haight Act, which set the initial in-person requirement for SUD treatment. Contact your representatives to voice your support for these efforts.