A study by the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services and the National Institute on Drug Abuse suggests that telehealth expansions instated during the COVID-19 public health emergency (PHE) led to a reduced risk of opioid overdoses in adults with opioid use disorder (OUD). The telehealth expansions likely improved access to OUD-related telehealth services and were linked to improved retention of medications for opioid use disorder (MOUD) and a reduction in medically treated overdoses.
Telehealth Expansions and Opioid-Use Disorder-Related Care During the COVID-19 Pandemic
The first COVID-19 legislative package, Coronavirus Aid, Relief, and Economic Security Act (the CARES Act), was passed by Congress in March 2020. Included in the bill was the authority for CMS to waive antiquated restrictions that were limiting patient access to telehealth services. For the first time, Medicare beneficiaries no longer had to be from a designated rural area and physically in a health care setting in order to receive reimbursable telehealth services. In addition, this waiver authority allowed Medicare to pay for audio-only telehealth services and for federally qualified health centers and rural health clinics to offer telehealth. However, these flexibilities are temporary. In the omnibus legislation passed by Congress in March 2022, they were extended for 151 days after the end of the PHE, which is currently set to expire in mid-October.
Also in response to the pandemic, the Drug Enforcement Administration (DEA) allowed for the remote prescribing of controlled substances via telehealth without a prior in person visit, a loosening of a requirement under the Ryan Haight Online Pharmacy Consumer Protection Act. As a result, patients are allowed to access clinically appropriate Schedule III through Schedule V prescriptions via telehealth. MOUD, or medication-assisted treatment, coupled with counseling and behavior therapy is one of the most effective treatments for OUD, but are subject to additional regulations as scheduled drugs. Current law mandates that outside of a SAMHSA-certified opioid treatment program (OTP), qualified practitioners must obtain a special DEA waiver to provide medication-assisted treatment. As a result, only a small fraction of the eligible providers have obtained the necessary waiver to provide this treatment. During the pandemic, certain certification requirements needed to prescribe buprenorphine were exempted to help expand access to treatment.
However, this waiver — and therefore telemedicine access to controlled substances like MOUD — will expire when the COVID-19 PHE does. DEA has drafted special registration rules for telemedicine as well as a rule for audio-only telemedicine for buprenorphine initiation for treatment of OUD, but those rules have not yet been published. If the PHE ends imminently, it is highly likely that there would be a period of time during which the waivers expire but the rules are not yet finalized, and those currently benefiting from OUD treatment via telehealth would lose access to that service. The findings from the study can hopefully make a case as to why a permanent fix is needed.
The Study and Results
Researchers studied Medicare data from two cohorts of adults with OUD — pre-COVID-19 pandemic and during the pandemic — to examine receipt of telehealth services, MOUD receipt and retention, and medically treated overdoses prior to the pandemic compared to during the pandemic. Key findings from the study include:
- Individuals in the pandemic cohort received more telehealth services compared to those in the pre-pandemic cohort, with 19.6% of the pandemic cohort receiving OUD-related telehealth services compared to just 0.6% of the pre-pandemic cohort.
- Individuals in the pandemic cohort received more MOUD compared to the pre-pandemic cohort (12.6% versus 10.8%, respectively).
- When comparing individuals who received OUD-related telehealth services to those who did not within the pandemic group, MOUD treatment retention was higher, and the risk of medically treated overdoses was lower in individuals who received OUD-related telehealth services.
Telehealth Expansions Now and Beyond the COVID-19 PHE
The study results highlight the positive outcomes of the COVID-19 pandemic telehealth expansion for OUD-related care, lending support to the potential benefits of a permanent expansion. Several actions have occurred to extend telehealth expansions beyond the PHE. In July, Xavier Becerra, Secretary of Health and Human Services, extended the COVID-19 PHE to October 2022 and is expected to extend it one more time, ensuring that the telehealth expansions noted in the study will remain in place 151 days post-PHE. On the Congressional side, shortly before August recess, the House of Representatives passed the Advancing Telehealth Beyond COVID-19 Act (H.R. 4040) by a vote of 416-12 to extend COVID telehealth flexibilities in the Medicare program through the end of 2024. Though there is a crowded legislative calendar, it is possible that a telehealth bill could be included in a larger end-of-year legislative package.