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Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Tuesday, September 27, 2016

ICD-10 Changes

I know it's been forever. I have actually been super busy. I still am, but since this is timely and important, I thought I'd post something.

There are ICD-10 changes that go into effect on October 1st. These are intended to correspond to recent changes in DSM-5. I suppose it should now be called DSM-5.1.

These are the changes:



I hope this is helpful.

Friday, August 5, 2016

Laziness






I'm very curious about the idea of laziness. "Lazy" is one of those words we throw around as though everyone understands what it means and agrees on its definition. Kind of like, "Love". But I don't think anyone honestly knows what lazy means. I'm not sure it even has a meaning. I think what is really meant by, "He's so lazy," is, "I don't understand why he's not doing the things I think he should be motivated to do, or that I would be doing in his position."

I'm hard pressed to think of an instance in which the word lazy is used in a non-pejorative way. At least in reference to a person or an animal. Rivers and summer days are exempt from this criticism.

I searched Pep-Web to see if the concept is addressed in the analytic literature, and there were a lot of hits for "laziness" (343) and "lazy" (806), but none in a title, and while I didn't go through every one, the ones I did look at all seemed to be either quoting someone speaking about himself or someone else, or describing someone, and all with the assumption that no elaboration was needed as to what was meant by "laziness" or "lazy".

I'll share a multilayered thought I just had. I generally make an effort to write correctly, which means that there's a comma before quotes, and the first word of a quote is capitalized, and the ending punctuation is within the quotes, even though that's weird. Or, "That's weird." Not, "that's weird". But it's not always clear to me what to do when I'm referring to an individual term. Do I place a comma before, "Lazy?" Do I always need to put quotes around, "Lazy?" Do I capitalize , "Lazy," if I use it over and over again? Do I place the punctuation within the quotes if it's just a word I'm defining, like, "Lazy"?

I assume I should do the same thing with "lazy" that I do with longer quotes, but I don't always do so. And my thought was, I'm just too lazy to bother.

Then I thought about Frank McCourt in Angela's Ashes, where he doesn't bother to use quotes, but he manages to write in such a way that you're never confused about who's saying what. Presumably, he's mimicking Joyce. So who cares whether I get the punctuation right or not? The whole purpose of punctuation is to make yourself understood, and if readers know what I mean, what difference does it make?

I'm impressed by how easily I fell into using the catchall term, "Lazy," to explain why I don't always punctuate correctly. But I'll get back to this.

I Googled, "What is Laziness?" and after the definition: the quality of being unwilling to work or use energy; idleness, I linked to an article by Neel Burton, MD, in Psychology Today, The Causes of Laziness.

It's not a bad article, but the explanations are a bit simplistic: We haven't evolved enough past our ancestral need to conserve energy and to assume life will be short so why plan for the future; We prefer immediate gratification to long-term goals; We can't see the purpose of our work; We're afraid of success; We're afraid of failure so we don't try.

Now back to my previous point. I don't think anyone knows much about why she does what she does. Even less about why someone else does what he does. You can get at some unconscious content in analysis, but there will always be mysterious actions and thoughts.

What I do notice is that when I have to make a decision about how to punctuate, it causes a slight twinge of anxiety. Am I doing this right? Is my meaning clear if I don't do it right? Why do I care? Do I care?

Clearly, I do.

I'm reminded of Otto Fenichel's paper, On the Psychology of Boredom. Fenichel describes a particular kind of boredom, a sort of ennui, in which the bored person can never settle into any particular activity. Fenichel's understanding of this is that it reflects a warded off, unacceptable wish. So the bored person wants something, but is unable to allow himself to know what it is he wants, because he's conflicted about it, and it makes him anxious. So instead, he searches for something to satisfy the wish, but of course, nothing does, because he doesn't consciously know what he's wishing for.

Laziness is not directly related to boredom, though obviously it can be, in some instances. The common thread here is anxiety generated by unconscious content-likely conflict. And it's hard to assess motivation when there's all sorts of unconscious fermentation going on.

My final association:  I read a story when I was a kid, and I still don't quite understand it. It was a Chinese fable about a lazy boy who never did anything his mother asked. He never helped out at home. He never did any kind of work. He was just a lazy good-for-nothing. Then one day, there was some kind of threat to his family, and the boy got up and deftly handled the situation, and saved the day.

The End.


Wednesday, July 27, 2016

Good and Bad Ideas

Today, NY State sent a letter to insurance companies, telling them they better comply with parity laws, and that they'll be checking up to make sure the insurers are keeping in line. Specifically, the letter was written to "remind" insurers that

MHPAEA (Mental Health Parity and Addiction Equity Act) prohibits issuers whose
policies or contracts provide medical and surgical benefits and MH/SUD benefits from applying
financial requirements, quantitative treatment limitations (“QTLs”), and NQTLs to MH/SUD
benefits that are more restrictive than the predominant financial requirements or treatment
limitations that are applied to substantially all medical and surgical benefits covered by the plan...

...state regulators [will] further review the processes, strategies, evidentiary standards, or other factors used inapplying the NQTL to both MH/SUD and medical and surgical benefits to determine parity compliance:

• preauthorization and pre-service notice requirements;
• fail-first protocols;
• probability of improvement requirements;
• written treatment plan requirement; and
• other requirements, such as patient non-compliance rules, residential treatment limits,
geographical limitations, and licensure requirements.

Accordingly, issuers are advised that the Department of Financial Services will be reviewing
issuers’ NQTLs and QTLs to ensure that issuers fully comply with MHPAEA and will take
necessary action in the event of any non-compliance.

Some additional NQTLs are:

"...treatment limitations based on geography, facility type, provider specialty, and the criteria limiting the scope or duration of benefits or services."

This is a good idea, enforcing rules for insurance companies.  But I worry about certain bad ideas. In fact, I have a sneaking suspicion that insurance companies pay lawyers or others so inclined large sums of money to sit around all day and come up with new bad ideas by finding ways to comply with parity laws, but still hinder or delay reimbursement.

I've written previously about one of these bad ideas, namely, an insurance company's demand that I provide proof that my patient requires out of network services. I almost fell for this and started researching articles on continuity of treatment, etc., until Dinah from Shrink Rap pointed out that the insurance company doesn't need to cover out of network services, but if they do cover out of network, the patient doesn't need to justify not using in-network care.

Other egregious examples are stalling and finally informing the patient that the claims were never submitted, or that they were lost, and then sometimes even more egregiously, when the claims are resubmitted, the insurance company comes back and says it's too late to submit.

Or prior authorization. I tried to get Brintellix, now Trintellix (because Brintellix sounds too much like some other drug) approved, got rejected, appealed by filling out a long form that met every criterion for approval, got rejected again, and finally decided it's a crappy drug anyway, and not worth the effort.

A recent gem involved asking the patient's spouse, who is the primary insured, to call the insurance company to verify or "prove" that the patient has no other insurance (Doesn't, never did).

And I'm quite convinced that these stalling tactics are effective overall, because some percentage of them will not be pursued by patients. That percentage is a gold mine for insurance companies. And mental health patients are perhaps more susceptible than most to this hindrance, since things like depression, psychosis, and anxiety can get in the way of accomplishing tiresome, long, and frustrating tasks like talking to insurance companies.

Anyone else have insurance horror stories?

Thursday, July 21, 2016

The Gene Genie

In response to my recent post, In the Genes?, I got the following email message:

Dear PsychPractice,
I am a genetic counselor for Assurex Health, the company behind GeneSight. We read your recent blog post comparing Genesight, the Genecept Assay, and Genelex with interest, and I wanted to reach out to you concerning a couple items that you may not have run across in your search of GeneSight.  While much of what you wrote about GeneSight is accurate, some of it is outdated. For example, GeneSight Psychotropic now includes 12 genes, not 5.  Based on the images of the report in your blog, I wonder if perhaps you pulled the images from our Pine Rest (Winner et al, 2013) study?  This study was published in 2013, at a time when GeneSight had 5 genes.  GeneSight has since been updated and currently includes 12 genes.  Additionally, 4 other studies on GeneSight have been published, as well as 2 meta-analyses of these data, all of which were statistically significant. 

If you are interested in receiving any of these studies, please let me know and I will send them to you.  You may also be interested in white papers on GeneSight genes that outline all current research in the context of psychiatric pharmacogenomics.  We have also created white papers on genes we choose not to add to GeneSight due to lack of clinical utility. 

Somehow, I thought I had gotten the image I used, with the list of genes, from the Genesight site. So I went there to look for it again, and I couldn't find it. So then I tracked down where I found the image, by scrolling through my browser history, and it was here:

Winner, Joel G; A prospective, Randomized, Double-Blind Study Assessing the Clinical Impact of Integrated Pharmacogenomic Testing for Major Depressive Disorder; Discovery Medicine; ISSN: 1539-6509; Discov Med 16(89):219-227, November 2013.

I guess it was from the Pine Rest study, and yes, I suppose it is outdated. And I'm pretty sure I looked up the paper because I couldn't find much information about which genes Genesight uses on their site.

I checked again just now, and it took a while for me to find it, but they do have a description of all the genes they're testing, including four new ones.

Pharmacokinetic:

UGT2B15
CYP2D6
CYP2C19
CYP2C9
UGT1A4
CYP3A4
CYP2B6
CYP1A2

Pharmacodynamic:

HLA-A*3101
HLA-B*1502
HTR2A
SLC6A4

The UGTs and HLAs are the new ones.

So now we've got that straightened out. My apologies to Genesight for propagating outdated information.

That said, since publishing that last post, I have used Genesight. Yes, I have. I chose it partially for reasons having to do with insurance coverage.

I had to meet with a rep. I tried to tell him, via email, that all I needed was a test kit. He insisted that we had to meet in person, and that it would only take 15 minutes. We scheduled and rescheduled, mostly because I was annoyed about the waste of my time so I didn't prioritize the time slot. Maybe that sounds obnoxious, but I felt I was giving up my time, and therefore money, so he and his company could make more money. I was paying to make him money.

He asked if he should just bring along a lunch. I flat out said no. When he got to my office, he had a bag with lunch, from Panera. I refused it, and I'm really proud of this fact because I was super hungry.

The meeting took closer to 40 minutes, with most of my time spent sitting quietly and waiting while the rep talked on the phone to his IT people, to figure out the new tablet system they were using. When the rep did talk to me, there was emphasis on the fact that the tests are covered by medicare. Maybe that makes them more respectable. I don't know. I was also told I'd be receiving 10 more kits in the mail shortly. I was encouraged to use them on new patients, and asked about when I do my chart review, in the mornings or evenings. I tried to explain that I don't have a high volume practice, and it doesn't work that way. He also mentioned something about my EMR, and looked a bit nonplussed when I nodded towards my file cabinet and said, "I don't use one."

I did the test on a Monday. You do two buccal swabs-1 per cheek, 10 seconds each. Then you put the swabs in an envelope and seal it. You add a consent form and the swab envelope to a larger envelope, seal that, and send it out via Fedex-it's already labeled and paid for overnight shipment. This sounded easy, but I wanted it sent off that day, my doorman wasn't sure when or whether Fedex would be in the building, and the closest Fedex drop box had been shut down some time ago. So I wandered around a bit til I found a place. More lost time and money. I had tried to contact Fedex to come pick it up, but their site didn't work properly, so I had to wander.

Also, it was a little confusing, because you don't include an order form. Instead, you login to your Genesight account and order the test there (You can print out and use an order form, but only if you don't use the online system). They give you an order number, but there's nowhere to record it on anything you mail in. I wrote it on the swab envelope, anyway.

The results came in at 10pm on Wednesday night, which is probably within the 36 hour turnover time. I can't get into the clinical details, but the test results were about as helpful as I expected. The pharmacokinetic stuff was fair. They suggested some dose adjustments that might be helpful. They also yellow-boxed, meaning use, but with caution, a couple meds that have caused serious side effects in this patient, in the past.

The pharmacodynamic stuff was not particularly good. Meds were recommended that have been of little or no use in the past, or have actually had deleterious effects. I didn't expect much of this aspect, so I wasn't too disappointed. I already knew that genetic testing that's supposed to predict which drugs will be helpful is not ready for prime time, yet.

The best I can say for Genesight, so far, is that it made one potentially useful suggestion, and it seems to be covered by insurance, or if it isn't, it has a decent financial assistance plan, with patients who make less than $50K per year paying $20 for testing. Will I use it again? Hard to say.


David Bowie: The Jean Genie







Wednesday, July 6, 2016

Keeping Mum

Hippocrates

This post was prompted by an article written by Ben Goldacre in The Guardian, Care.Data is in Chaos. It Breaks My Heart. The article is about the Health and Social Care Information Centre (HSCIC, in the UK), which, "admitted giving the insurance industry the coded hospital records of millions of patients." These records, according to Goldacre, were line for line, and could be decoded by anyone with an inclination to do so. The purpose of this "gift", by the way, was for the insurance companies' actuaries to figure out premiums, based on likelihood of death (or illness, I assume).

Useless Fun Fact: Years ago, in another professional trajectory, I passed the first of the however many actuarial exams.

Anyway, then the HSCIC said it couldn't share documentation on this release of information, presumably because it's more important to protect insurance company privacy than patient privacy.

Summarily, in Goldacre's words, "...a government body handed over parts of my medical records to people I've never met, outside the NHS and medical research community, but it is refusing to tell me what it handed over, or who it gave it to, and the minister is now incorrectly claiming that it never happened anyway."

So I started to think about patient privacy, including a long-ago post, What, Exactly, Is HIPAA?, where I wrote that I would follow-up with more information about privacy, and I never did. Incidentally, I've looked, and I still haven't found any contradictory information about what constitutes a HIPAA covered entity, and I'm still convinced that I'm not one, because I don't bill patients electronically.

So I was wondering, what is the difference between privacy and confidentiality, as they relate to patients? And I found this article (Prater), which was helpful.

Basically, confidentiality is the, "...obligation of professionals who have access to patient records or communication to hold that information in confidence," while privacy is the, "...right of the individual client or patient to be let alone and to make decisions about how personal information is shared."

In other words, confidentiality is my professional, or at least ethical obligation to my patients, while privacy is a patient right I need to respect. From this I infer that technically, my patients do not have a right to confidentiality, and I don't have an obligation to protect patient privacy.

Here are some more details.

Confidentiality

Confidentiality goes back, at least, to the Hippocratic Oath:

And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

It is a cornerstone of professional association codes of ethics. The AMA's code of Ethics, Opinion 5.05, states:

The information disclosed to a physician by a patient should be held in confidence. The patient should feel free to make a full disclosure of information to the physician in order that the physician may most effectively provide needed services. The patient should be able to make this disclosure with the knowledge that the physician will respect the confidential nature of the communication. The physician should not reveal confidential information without the express consent of the patient, subject to certain exceptions which are ethically justified because of overriding considerations.

And don't forget about postmortem confidentiality:

All medically related confidences disclosed by a patient to a physician and information contained within a deceased patient’s medical record, including information entered postmortem, should be kept confidential to the greatest possible degree...At their strongest, confidentiality protections after death would be equal to those in force during a patient’s life. Thus, if information about a patient may be ethically disclosed during life, it likewise may be disclosed after the patient has died.

In reading this stuff, I also found that the AMA has a slightly different slant on the definitions of privacy and confidentiality:

In the context of health care, emphasis has been given to confidentiality, which is defined as information told in confidence or imparted in secret. However, physicians also should be mindful of patient privacy, which encompasses information that is concealed from others outside of the patient-physician relationship.


An example of support for the legal status of confidentiality, as the privileged communication between patient and doctor, can be found in Jaffee v. Redmond, where the, "...U.S. Supreme Court upheld a therapist’s refusal to disclose sensitive client information during trial." (Prater)


Effective psychotherapy...depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories, and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment or disgrace. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment. (p.10, Jaffee v. Redmond)


Privacy

There is no constitutional right to medical privacy. Rather, healthcare privacy rights, "...have been outlined in court decisions, in federal and state statutes, accrediting organization guidelines and professional codes of ethics." (Prater)

The big example is HIPAA. Subject to HIPAA, "Individuals are provided some elements of control, such as the right to access their own health information in most cases and the right to request amendment of inaccurate health information...However, in [the] attempt to strike a balance, the Rule provides numerous exceptions to use and disclosure of protected health information without patient authorization, including for treatment, payment, health organization operations and for certain public health activities..."(Prater)

I've been trying to read through the relevant parts of this ponderous document about HIPAA, and on pages 757 and following, in part Squiggle164.512, Uses or Disclosures for which an Authorization or Opportunity to Agree or Object is not Required, I found what appear to be a number of these exceptions to the "privacy" provided by HIPAA. I think. I'm not a lawyer. Such as:

a) required by law
b) public health activities
c) victims of abuse, neglect, or domestic violence
d) health oversight activities
e) judicial and administrative proceedings
f) law enforcement purposes
g) about decedents, i.e. coroners, ME's, funeral directors
h) cadaveric organ, eye, or tissue donation purposes
i) research purposes
j) aversion to serious threat to health or safety
k) specialized government functions
j) worker's compensation

There are many specifics, including disclosing information to a patient's employer, but I'll leave those as an exercise for the reader.

Point being, HIPAA does little to protect patient privacy. I think the value of HIPAA is that it attempts to delineate what patient privacy rights are, and that it has succeeded in making people aware that the privacy of their medical information is vulnerable. It does not solve this difficulty, which becomes hugely magnified by the use of electronic health records. This leads to consideration of one more important term, security, or the means by which patient information is protected, such as a locked filing cabinet, or encrypted data.

What I glean from all this is that there is at least a notion of a patient's right to privacy, which I should try to respect. But that my standards for protecting patient information are much higher than anything HIPAA has to say.









Wednesday, June 29, 2016

In the genes?




I'm starting to look into genetic testing to help my work with patients who have not responded well to multiple psychotropic medications. It feels like a desperate bid, but I'm not sure what other help I can offer.

There are three main testing products, that I could find:

Genesight

Genecept Assay

and

Genelex


I have three main questions about these products:

1. What do they tell me?

2. How accurate/helpful are they?

3. How easy are they to use?


Genesight

Genesight seems to be the one mentioned most by people I asked. Practically speaking, it involves a buccal swab sent to Genesight via prepaid FedEx, with access to results online 36 hours after the sample is received. They are covered by some insurance plans, and have a financial assistance program. And it looks like, in order to try out the test, you need to speak with one of their representatives-there's no way to order online.

In terms of how well it works, their claim is, "Patients with uncontrolled symptoms who switch off of genetically discordant medications show the greatest reduction in depressive symptoms."

They also claim that, "70% of patients who have failed at least one medication are currently taking a genetically sub-optimal medication," and that, "GeneSight testing may help avoid drug-drug interactions and compounding side effects."

Finally, for patients younger than 18, Genesight can help in decisions about efficacy, tolerability, and dosing.

They site a paper, A prospective, randomized, double-blind study assessing the clinical impact of integrated pharmacogenomic testing for major depressive disorder, the results of which were:

Between-group trends were observed with greater than double the likelihood of response and remission in the GeneSight group measured by HAMD-17 at week 10. Mean percent improvement in depressive symptoms on HAMD-17 was higher for the GeneSight group over TAU (30.8% vs 20.7%; p=0.28). TAU subjects who had been prescribed medications at baseline that were contraindicated based on the individual subject's genotype (i.e., red bin) had almost no improvement (0.8%) in depressive symptoms measured by HAMD-17 at week 10, which was far less than the 33.1% improvement (p=0.06) in the pharmacogenomic guided subjects who started on a red bin medication and the 26.4% improvement in GeneSight subjects overall (p=0.08).

You'll notice that they talk about "trends" without any statistics, and mean percent improvement showed no significant difference (p=0.28), even though they point out that improvement in the Genesight group was higher. Recall that p=0.28 means there is a 28% chance that the differences they found were due to chance alone.

The "red bin" is a reference to the way Genesight presents its results, which I find easy to understand, if not entirely illuminating. This is an example:




I don't get the impression that the results give me information about which drugs will be helpful, as much as which drugs won't be harmful.

How does the test work? Genesight measures polymorphisms among 5 genes, CYP2D6; CYP2C19; CYP1A2; the serotonin transporter gene, SLC6A4; and the serotonin 2A receptor gene, HTR2A.

The CYP genes are clearly measures of rates of metabolism. A repeat length polymorphism in the promoter of SLC6A4 has been shown to affect the rate of serotonin uptake. The implications of this fact are not clear to me, but according to Wikipedia, genetic variations in the SLC6A4 gene have resulted in phenotypic changes in mice, including increased anxiety. HTR2A influences serotonin transporter binding potential, and variations in the gene have been associated with variations in outcome in treatment with citalopram.

So the answers to my three questions, for Genesight, are:

1. It tells me which drugs are more and less safe and tolerable to use. And if I accept their conclusion that patients switched off red bin drugs improved significantly, then perhaps it tells me which drugs will be effective, but I'm skeptical about this part.

2. The results are less impressive than they'd like me to think.

3. Results are clear and easy to read.  Turnover time is good. Getting hold of a test is not that easy.



Genecept Assay

The genecept FAQ page is much more informative than the Genesight pages. The test can be ordered online or by phone. It's covered by most insurance and they have a patient assistance program. Turnaround time is 3-5 business days from receipt of the sample, also a buccal swab, and they provide expert staff to help interpret results.

The online order form also gives you the option of becoming a "Preferred Provider", which means they'll send patients who are looking for genetic testing to you.

As for function:

The Genecept Assay® report is intended to aid clinicians in making personalized treatment decisions tailored to a patient’s genetic background and helps to inform psychiatric treatments that:

Are more likely to be effective
Have lower risk for side effects and adverse events
Are dosed appropriately

The report consists of two pages, and looks like this:



So they look at more genes than Genesight, and they provide one report about what's safe to use, and another about what's potentially helpful.  And in all honesty, I don't have the energy right now to look up how believable their first page markers are in terms of efficacy, and I think I would need their help to interpret these results, but they do provide more information than Genesight.

Answers:

1. Safety, tolerability, and efficacy

2. I'm too tired to check

3. Easy to get the test, harder to interpret results


Genelex

Genelex allows you to order tests online, too. They claim there is some insurance coverage (See *, below), they have some fancy software that's supposed to be helpful, in addition to their report, and they have a 3-5 day turnaround time.

Genelex restricts itself to CYP450 genes, but it includes three that Genesight doesn't, 3A4, 3A5, and 2C9, but doesn't include 1A2. This is a link to a sample result, which is too long to include as an image. And like Genesight, it's mainly about what is and isn't safe or tolerable to take.*

*Actually, I just learned on the FAQ page that Genelex also includes CYP1A2; NAT2;DPD Enzyme; UGT1A1; 5HTT; and HLA-B*5701, but that these are generally not covered by insurance. I also couldn't figure out what data these additional tests provide.

Answers:

1. Safety, tolerability, maybe efficacy?

2. For the CYP tests, same as above, for others, I don't know

3. The software seems like overkill. The report is clear and moderately informative. You can order the test online.


That's it for this topic, for now, for me. I have yet to decide whether I'm going to use any testing.




Thursday, June 23, 2016

Virtually Certified

A while back, I wrote about HealthTap, a platform that allows people to ask doctors questions in almost real time. The company was also developing a system for virtual care, and I recently received an email suggesting I take an online course, worth 2 CME credits, to be certified in said virtual care.

I was curious about the progress in this field, so I did take the course, and am now officially certified. I also accidentally clicked an  "okay" button, thinking it would allow me to print out my certificates. But it was the wrong button. The button I wanted said, "certificate only", but I didn't see it in time. The "okay" button indicated that I was allowing myself to be part of the HealthTap network of physicians. I didn't really want that, but I suppose it doesn't matter since I'm not going to do anything with it. So watch out for this if you decide to try it.

What I was mainly interested in, in the course, were the legal and regulatory issues related to virtual care. And I did learn a couple things. For instance, you do need to be licensed in your patient's state in order to provide virtual care. I don't know if that means the state where the patient resides, or just the state the patient is in when seeing you. I would guess the latter, since I can treat patients, in person, who live in neighboring New Jersey or Connecticut for example, where I'm not licensed, as long as they see me in my New York office.

Incidentally, you don't need to be licensed in any particular state to virtually treat patients outside the US.

The course referenced the Interstate Medical Licensure Compact, which, "Creates a new pathway to expedite the licensing of physicians seeking to practice medicine in multiple states. States participating in the Compact agree to share information with each other and work together in new ways to significantly streamline the licensing process."

A number of states have already enacted legislature that will allow this expedited pathway to proceed, and other states have introduced such legislation. Still others, such as New York, have done neither. One interesting point I noted is that in order to use this expedited system, you need to be primarily licensed in a state that has already enacted the legislature. So if I want to virtually care for patients in Montana, which has enacted this legislature, I can't, because I'm licensed in New York, which hasn't.

That point is irrelevant, though, since there is currently no administrative process for applying for this pathway, although they state that there, "...will be soon."

The video mentioned that there are CPT codes for virtual care, ranging from 99441 for a 5-10 minute telephone Eval/Management consultation, to a 99444 for an online E/M, to a 99446 inter-professional 5-10 minute consult, to a 99490 > 20 minutes of chronic care management. But most virtual care billing is done using the same CPT codes that would be used for a regular office visit, with a GT modifier, e.g. 99213 GT.

Most importantly, 25 states with parity laws, plus Washington DC, have enacted "...legislation requiring private insurers to pay for Virtual Care at the same level as equivalent in-person services, provided the care is deemed medically necessary."

According to this document, in New York, "The law requires telehealth parity under private insurance, Medicaid, and state employee health plans. The law does restrict the patient setting as a condition of payment."

This image depicts which states make it easy to provide virtual care (A is best), and which make it difficult (I'm not sure what the * means):




Aside from that, the course touts the virtues of virtual care, claiming that in some ways, it's superior to in-person care, and giving examples, such as the fact that patients have quicker access to virtual care. They also claim that many, if not most, common complaints can be treated virtually, and a lot of monitoring can be done at a distance, e.g. glucose. In addition, they mention the use of wearable devices for tracking activity, etc., and the up and coming virtual examination tools, like stethoscopes.

The video is careful to note situations which require in-person treatment, such as a wheezing infant, or chest and jaw pain in a 68 year old man.

A bit comical were the presentations. For a company that's promoting care via video-conferencing, they should probably have gotten better people to present in their video. One guy had shifty eyes, another had drooping eyelids and looked like he was falling asleep and forgetting what he needed to say, yet another guy looked like his shoulders were hiked up to the point of having no neck.

While I definitely prefer in-person work, I can see where psychiatry, and especially psychotherapy, are amenable to virtual care, probably more-so than specialties that require a physical examination. But given the regulatory and legal limitations, I'm not ready to go there, yet.