Telepsychiatry is a private audio (telephony) or video (video with sound) conference connection through which most psychiatric services can be provided to patients. I have been an early adopter and advocate for providing services, through telepsychiatry, to our patients who are experiencing mental health issues and psychiatric illnesses. The road leading to where we are right now in the field of telehealth has been treacherous and filled with regulatory landmines and obstacles. I believe telepsychiatry is here to stay because it is being demanded by patients. The road was quickly paved by the lockdown during the COVID-19 pandemic, yet it remains shifty and unpredictable.
In 2006 the Commonwealth of Pennsylvania approved the reimbursement of telepsychiatry services to provide mental health access to individuals in rural areas of Pennsylvania. I was one of the first group of psychiatrists to provide services in rural Pennsylvania by telepsychiatry. In 2007, I assisted a local hospital system in Pennsylvania in developing a telepsychiatry connection between its emergency rooms on several campuses to evaluate patients needing psychiatric services. The goal was to provide a disposition to those severely ill psychiatric patients who were boarding in the emergency department awaiting psychiatric beds. We also helped with initiating early treatment for psychiatric illness and preventing further decompensation by providing those patients with a telepsychiatry evaluation to assist in the diagnosis and early treatment. This program is active to this day and was featured by the American Hospital Association as a model for telehealth early adoption. This telepsychiatry program was later utilized as a stepping stone for this hospital system to establish its tele ICU program in 2010, an expanded program that proved lifesaving during the COVID-19 pandemic.
In 2009 the practice of telepsychiatry expanded further when the Center for Medicare Services (CMS) approved the use of telepsychiatry to provide psychiatric care to Medicare beneficiaries residing in federally underserved and designated rural areas in the United States. In Pennsylvania, that included many counties and their residents (42 out of 67 counties in Pennsylvania). Simultaneously, in 2008, the United States Department of Justice (DOJ) and the Drug Enforcement Administration (DEA) advocated for the establishment and passing of the Ryan Haight Act, legislating that no controlled substance may be delivered, distributed, or dispensed by means of the internet (telepsychiatry). Since 2008 the DEA was mandated by Congress to establish procedures for implementing the Ryan Haight Act, which the DEA has failed to implement to this moment, even during the suspension of the implementation of this act during the COVID-19 public health emergency. The DEA has extended for the third year in a row the suspension of the Ryan Haight Act and the continuation of flexibilities around prescribing controlled substances that were implemented during the COVID-19 public health emergency (PHE).
As the US faces a significant mental health crisis and a shortage of psychiatrists, the practice of telepsychiatry flourished between 2012 and 2020 until it became mainstream during the COVID-19 PHE. The number of adults with any psychiatric illness increased by nearly 30 percent during the same period, increasing from 40 million to 52 million, and these numbers continued to increase during the COVID-19 pandemic. Furthermore, the United States is experiencing a significant shortage in the number of psychiatrists, as only 30 percent of people in the US live in an area with enough psychiatrists available to meet the needs of the population of the area. There is voluminous evidence-based peer-reviewed research on the utility of telepsychiatry in the treatment of psychiatric illness and its equivalence to face-to-face encounters. Additionally, patients in rural areas in the United States with limited internet access benefited from the flexibilities of allowing telephonic encounters for providing much-needed psychiatric care in patients who suffer from severe mental illness and who have little access to transportation. Despite this tremendous need, CMS and Congress have failed to act, and the flexibility that was implemented during the COVID-19 PHE is set to expire at the end of 2024. There will no longer be reimbursement for telephonic visits with indigent Medicare beneficiaries in rural areas. These patients will have to arrange transportation to see their psychiatrist face-to-face. Many of the psychiatric clinics that were established during the COVID-19 PHE remain virtual with no brick-and-mortar clinic locations for the patients to visit.
I can tell you firsthand that the implementation of telepsychiatry has been mired with administrative obstacles and legal landmines. In 2022 I was indicted and faced trial on federal health care fraud charges related to telepsychiatry services I provided in 2017. I went to trial in 2024 and was found not guilty, and it was evident during the trial that the government, including the DOJ and the Office of Inspector General for the Department of Health and Human Services, lacked a basic understanding of telepsychiatry services, their rules, relevant legislation, and the implementation of psychiatric services through telehealth. Over the past two years, many other physicians and companies that provided telepsychiatry services have faced criminal legal charges, as well as civil enforcement actions from government prosecutors who present experts who lack a basic understanding of the service of telepsychiatry and its rules and regulations.
The COVID-19 pandemic has transformed telepsychiatry from an alternative backup model of care reserved only for rural and underserved areas to a mainstream necessity utilized across the field of mental health. And while the DOJ, the DEA, and other regulatory bodies remain wary of telepsychiatry due to concerns about fraud, waste, and abuse, as well as concerns about non-efficacy, telepsychiatry is here to stay. The impact of telepsychiatry is undeniable. The American Psychiatric Association data shows that most psychiatric encounters continue to be conducted through telepsychiatry, bringing much-needed psychiatric services to underserved areas. Practicing psychiatrists continue to deploy telepsychiatry to meet patients for their convenience with good clinical reliability and improved patient-psychiatrist satisfaction. Patients, on their part, still prefer telepsychiatry for its convenience, privacy, efficiency, and reduced stigma. The hope is that regulatory bodies (CMS) will realize this and reverse course in their action to end telepsychiatry flexibilities, as they are set to mandate in-office visits for reimbursement of psychiatric visits starting in 2025.
Muhamad Aly Rifai is a practicing internist and psychiatrist in the Greater Lehigh Valley, Pennsylvania. He is the CEO, chief psychiatrist and internist of Blue Mountain Psychiatry. He holds the Lehigh Valley Endowed Chair of Addiction Medicine. Dr. Rifai is board-certified in internal medicine, psychiatry, addiction medicine, and psychosomatic medicine. He is a fellow of the American College of Physicians, the Academy of Psychosomatic Medicine, and the American Psychiatric Association. He is the former president of the Lehigh Valley Psychiatric Society.
He can be reached on LinkedIn, Facebook, X @muhamadalyrifai, YouTube, and his website. You can also read his Wikipedia entry and publications.
