Medical Waivers: A Game Changer

Dartmouth-Hitchcock’s Telehealth technology in use. Courtesy photo.

As unprecedented resources are brought to bear against the COVID-19 pandemic, a loosening of regulatory hurdles in the medical arena is opening opportunities for remote patient care and providing flexibility to tackle the workforce shortage that existed long before.

Within his emergency declaration, Gov. Chris Sununu granted authority to the commissioner of the NH Department of Health and Human Services to waive any licensing or credentialing requirements to improve access to treatment while protecting public health and safety.

This led to an immediate increase in telehealth, where medical practitioners connect via a computer video system or a cellphone. For someone with a chronic illness, who needs frequent office visits, telehealth is reassuring, but for those dealing with substance use disorder or behavioral health issues it can be a lifeline.

“We know a lot about what works,” says William Torrey, professor and vice chair of clinical services for the department of psychiatry at Dartmouth-Hitchcock in Lebanon. “I’ve been doing this work for 30 years and the headway we’ve made in knowing how to help people with psycho-social interventions and medicines has grown tremendously. The main challenge, historically, has been taking what we know works and getting it to the people.”

Waivers have increased flexibility in billing for telehealth services, which he says addresses the immediate challenge posed by COVID-19 to limit exposure and also allows cross-border practice, increasing the workforce exponentially.

He says the loosening of licensing rules means everyone has access to more providers at a time when the need will continue to grow, not just through COVID-19 infections but through all related health effects.

“No one asks to have a psychiatric illness, whether it’s a substance use difficulty or a depression, anxiety, or psychotic illness. People don’t sign up for these,” Torrey says. “COVID-19 is an enormous stressor for people. It’s traumatic to have your whole sense of safety and the way the world works suddenly change. It’s like an earthquake where the ground of your life has been shaken.”

Stories about otherwise healthy, young people dying from COVID-19 increase anxiety about health, while lost jobs or lost retirement savings create economic anxiety. When combined with social isolation, this anxiety can lead to psychiatric difficulty, Torrey says. He and his colleagues are hearing from patients with substance use disorders who are relapsing and trying to get into treatment.

Prior to the pandemic, the rule that limited the number of recovery coaches one doctor could oversee was loosened, adding to the workforce, says Torrey. But, for those on the front lines, it did not go far enough. Ashley Desrochers, Strafford County Public Health Network prevention coordinator, says the requirement that only 50% of training to become a certified recovery support worker can be done online is problematic.

“We need an official order stating that 100% virtual training counts toward certifications,” Desrochers says. “There are many emergency-specific job opportunities that could provide gainful employment opportunities later on. It creates the possibility to respond more efficiently and effectively in the short term and the long term.”

Scott Schuler, COVID-19 public health IMT incident commander for Strafford County Public Health Network, says access to treatment needs to be a priority all the time. “Our treatment access in New Hampshire has never been great compared to other states. Just like other aspects of our health care system, the financial incentives are commonly not aligned with long-term health outcomes,” he says. “As priorities shift to prepare and respond to the health care needs of COVID-19, so can funding.  It’s important we also think about long-term planning.”  

He adds that funding for behavioral health and substance misuse must remain a priority and if the current disaster responses are working efficiently, they should inform permanent policy direction.

Desrochers and Schuler says it is unclear what effect the waivers are having as many agencies engaged in the opioid crisis are slowing down, furloughing employees and even closing their doors, including recovery housing, just as demand for such
services increases.

“We are already anticipating the need for increased behavioral health and substance misuse services for our communities due to decreased services to people during the event, provider burnout, and PTSD,” Desrochers says. “Many treatment services are closing and we are unsure if they will re-open after the pandemic.”

She adds that there’s a higher risk of overdose as the disruption to illicit drug distribution could lead to new dealers offering less-safe substances.

Lukas Kolm, medical director for department of emergency medicine at Wentworth-Douglass Hospital in Dover, says the pandemic has made it harder to access resources. He says people are still coming to the emergency department looking for buprenorphine (a drug to treat addiction) and to be connected with a counselor.

Both Kolm and Torrey say it doesn’t seem logical that doctors can prescribe pain medications and drugs, such as morphine and fentanyl typically associated with addiction, but must take a special course to prescribe the treatment drugs.  

“It is a time-intensive hurdle for health care organizations,” says Kolm. “I think they wanted to [stop] people who would do it in a nefarious way to monetize [medication assisted] treatment…but I think you can regulate the prescribing practices with the online physician drug monitoring system.”

Kolm says the state has loosened the regulations in so many other areas, this ought to be a time to make sure people dealing with addiction can get the treatment they need.

Torrey agrees the pandemic response is a learning opportunity. “The COVID-19 crisis has led us to do care differently. Some of what we are learning will be extremely helpful over time. We have a tremendous workforce shortage in New Hampshire. It has been very hard to get people through the licensing [process] especially the psychology and social work boards. The suicide rate has been going up and the substance use disorders continue to be a big issue as well. Having more providers would certainly help,” Torrey says.

This article is being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.