At Astral Codex Ten, Scott Alexander reacts to the US government’s new moves to make telehealth less useful for as many people as possible:
Telemedicine is when you see a doctor (or nurse, PA, etc) over a video call. Medical regulators hate new things, so for its first decade they ensured telemedicine was hard and inconvenient.
Then came COVID-19. Suddenly important politicians were paying attention to questions about whether people could get medical care without leaving their homes. They yelled at the regulators, and the regulators grudgingly agreed to temporarily make telemedicine easy and convenient.
They say “nothing is as permanent as a temporary government program”, but this only applies to government programs that make your life worse. Government programs that make your life better are ephemeral and can disappear at any moment. So a few months ago, the medical regulators woke up, realized the pandemic was over, and started plotting ways to make telemedicine hard and inconvenient again.
The first fruit of their labor is DEA-407, which makes it hard for telemedicine doctors to prescribe controlled substances. Controlled substances are drugs like Adderall, Ritalin, Xanax, or Ambien that the government has declared to be potentially addictive. The new rules say that telemedicine doctors can no longer prescribe these (or, in some cases, can prescribe them one time in an emergency).
Why don’t I like this decision? I am a telepsychiatrist. I work with about a hundred psychiatric patients who, for one reason or another, prefer online to physical appointments:
- Some live in small towns that don’t have psychiatrists of their own
- Some have agoraphobia, chronic pain, or some other condition that makes it hard for them to go to an office.
- Some move around a lot and like to be able to see their psychiatrist whether they’re in LA or SF.
- Some live hundreds of miles away from me, but know and trust me for some reason, and would rather see me than someone closer to them.
- Some appreciate the fact that I charge lower rates than psychiatrists who have offices, because I don’t have to pay for Bay Area commercial real estate and pass those costs on to my patients.
- Some work during work hours, and like being able to see me from their office instead of taking half the day off to travel to my location.
- Some like convenience and dislike inconvenience
As a psychiatrist, a big part of my job is prescribing controlled substances. For example, most guidelines agrees that the first-line treatment for severe ADHD is stimulant medications (eg Adderall or Ritalin). And although psychiatrists hate to admit it, the first-line treatment for temporary crisis anxiety, especially when it’s so bad that the patient isn’t able to listen to your clever plans to solve it with therapy, is benzodiazepines (eg Valium or Klonopin). You can’t be a good well-rounded psychiatrist without the option to sometimes prescribe these drugs.
“Well, your patients will have to find a different psychiatrist, or transition off of them”. Nobody ever finds different psychiatrists. Some of my patients are a bad match for my style or areas of expertise, and I’ve tried very hard to find them different psychiatrists, and it never works. Maybe there are no other psychiatrists in their area. Maybe the psychiatrists in their area don’t take the right insurance, or are too far away from mass transit. Maybe the psychiatrists have six month long wait lists. Sometimes it’s just that my ADHD patients get distracted and forget they were supposed to find new psychiatrists, and I can’t hold their hand literally all the time. As for transitioning off the medications, some patients absolutely cannot function at all without them. Did I mention that if you come off of some of them too quickly, you can literally die?
