Practice Management

PRACTICE MANAGEMENT

By Shawn P. Parker, JD, MPA NCAFP General Counsel & Chief of Staff

A Review of Key Elements of NCMBs' Telehealth Position Statement with Post-Pandemic Considerations

Over the past decade, significant advancements in medical and communications technologies have contributed to the increased use of telemedicine as a component of the practice of medicine. Its use throughout the COVID-19 pandemic helped expand access-to-care, reduce disease exposure to medical professionals and patients, and allowed for screening and management of persons who needed clinical care but would not come in person in compliance with state-issued travel restrictions, individual reluctance out of fear of potential exposure to COVID or otherwise had difficulty accessing in-person care.

In an effort to make telemedicine more widely available during the public health emergency, both state and federal authorities made substantive modifications to many laws, rules, policies, and other regulations that govern the delivery of health care through telemedicine technologies. The changes significantly contributed to the growth in its use. Prior to the pandemic, telemedicine visits accounted for a small percentage of total care visits, but within the first six months of the declared public health emergency, total telemedicine visits increased by more than 2,000 percent. Since that time, the number of total telemedicine visits may have waned since the early stages of the pandemic, however, the increased familiarity with telemedicine for patients and providers alike signal significant continued use beyond the pandemic.

North Carolina Medical Board Position Statement 5.4.1 Telemedicine serves as guidance to licensees and others on the appropriate use of telemedicine technologies for the delivery of medical care to patients located in the State of North Carolina. The Statement provides that the Board is cognizant that technological advances have made it possible for licensees to provide medical care to patients separated by a geographical distance if doing so is consistent with the applicable standard of care. And while standards of care continually shift based on the context in which medicine is practiced, the position statement clearly articulates those licensees providing care via telemedicine will be held to the same standard for care delivered through this modality as if the care was delivered in traditional in-person medical settings. The Board reviewed the Position Statement in March of 2021 made no substantive changes deeming the guidance to be sufficient in light of the growth in popularity and use during the COVID 19 public health emergency.

Licensure- As provided in the Position Statement, [t]he Board deems the practice of medicine to occur in the state where the patient is located. Therefore, any licensee using telemedicine to regularly provide medical services to patients located in North Carolina should be licensed to practice medicine in North Carolina. Licensees need not reside in North Carolina if they have a valid, current North Carolina license.

Care delivered via telemedicine is considered to be rendered at the physical location of the patient, and therefore, a provider to be appropriately licensed in state where the patient is located. Typically, there is an exception for episodic or follow-up care delivered to an established patient regardless of their location, as well as exceptions for consulting with physicians licensed in the patient’s location or special assessments prior to establishing the physician-patient relationship. A few states have adopted special telehealth licenses and during the pandemic many states have made specific excep-

tions that allow an out-of-state provider to render services via telemedicine through a temporary license. North Carolina utilizes a time-limited emergency license for qualified providers during state-designated emergencies.

There are two efforts worth noting which are working to address the use of telemedicine technologies across state lines. The first is the Interstate Medical Compact which provides uniform expedited licensure among the participating states. As of this writing, the compact is comprised of 34 states, the District of Columbia, and the territory of Guam. North Carolina is currently not a member but does have legislation (SB 380) introduced in the State Senate.

The second is the Uniform Law Commission’s effort to establish state law to be adopted universally that creates a registration system for out-of-state practitioners. The effort proposes to allow the state board to decline to register a practitioner if it would also decline to license the practitioner. It further proposes to subject the registrant to disciplinary actions within the state of registration.

Licensee-Patient Relationship- The physician-patient relationship is fundamental to the provision of medical care. It is the expectation that physicians recognize the obligations, responsibilities, and patient rights associated with establishing and maintaining a physician-patient relationship. The Position Statement stresses the importance of proper patient identification prior to any telemedicine encounter. The licensee using telemedicine should verify the identity and location of the patient. Furthermore, the licensee’s name, location, and professional credentials should be provided to the patient.

Critical to establishing the physician-patient relationship is obtaining appropriate consents from requesting patients which needs to include disclosures regarding any limitations regarding the use of telemedicine technologies. Appropriate informed consent acknowledges the risks, limitations, alter-

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UNC Family Medicine Center Inpatient Service Moves to the New UNC Hospital Hillsborough Campus

On January 7, 2022, the UNC Family Medicine Center Inpatient Service moved into its new unit on the first floor of the new UNC Hospital Hillsborough Campus. Hillsborough Hospital is poised to continue growing, with more services locating there over the next five years. The Family Medicine inpatient service provides hospital care for Family Medicine patients as well as those from Piedmont Health Services, and services local primary care practices. It is a full-spectrum service for adult inpatient care and a rich training environment for its residents, medical students, pharmacy students, and other health professionals.

NC AHEC Practice Operational Assessments

NC AHEC Practice Support provides 1:1 practice support coaching at no cost to independent family medicine practices, FQHCs, rural health centers and health departments with primary care services. This includes practice operational assessments that are available to help practices identify potential gaps or opportunities related to human resources, financial management, quality management, care access, and health information technology. Coaches will work 1:1 with your leadership and staff to perform this analysis and help you address or close these gaps. Practice support coaches have extensive experience in practice facilitation, practice management, quality improvement, health information technology, and clinical workflow redesign. If you are interested and accept Medicaid, please contact NC AHEC Practice Support at practicesupport@ncahec.net.

natives, and benefits of the telemedicine encounter and should be included.

Evaluations and Examinations- Licensees using telemedicine technologies to provide care to patients located in North Carolina must provide, or rely upon, an appropriate evaluation prior to diagnosing and/or treating the patient. Evaluations via telemedicine require you to exercise clinical judgment as to your ability to facilitate aspects of the patient assessment needed to render care. “If it is possible to gather sufficient clinical information from the patient during a telemedicine consultation to provide care that meets at least the minimum accepted standards of care, then the Board considers it appropriate to use telemedicine.” The evaluation should include collection of relevant clinical history to identify underlying conditions or possible contraindications to the treatment recommended.

Prescribing- According to the NCMB’s COVID-19 Telemedicine FAQs, “if it is possible to gather sufficient clinical information during a telemedicine encounter to provide care that meets at least the minimum accepted standards of care, NCMB considers it appropriate to prescribe [controlled substances] following that encounter.” The guidance further notes this exception may be linked to a shifting standard during the public health emergency. For the duration of the declared federal state-of-emergency related to the coronavirus pandemic, DEA has waived the requirement for an in-person medical evaluation for both established and non-established patients prior to prescribing controlled substances as long as certain conditions are met. One condition is the encounter must be conducted using an audio-visual, real-time, two-way interactive communication system. Prior to the Pandemic, the DEA was directed by Congress to create a special registration for telemedicine. Those regulations have not yet been enacted, possibly for the lack of necessity due to the public health emergency exception.

Medical Records- Documentation requirements for a telemedicine service are the same as for a faceto-face encounter. The information about the visit, the history, review of systems, consultative notes, or any information used to make a medical decision about the patient must be documented along with a note that the service was provided through telemedicine. Of note, the Position Statement includes the following: "Licensees practicing via telemedicine will be held to the same standards of professionalism concerning the transfer of medical records and communications with the patient’s primary care provider and medical home as those licensees practicing via traditional means. These records should be readily accessible in a format for future patient use."

Training of Staff- Staff involved in the telemedicine visit should be trained in the use of the technology being used to deliver care and competent in its operation. Physicians and their staff will need to have basic knowledge of technology needed for the delivery of high-quality telehealth services. This includes understanding when and why to use telehealth and how to assess patient readiness, patient safety, practice readiness, and end-user readiness.

References

Cortex C, Mansour O, Qato DM, Stafford R, Alexander C. Changes in Short-term, Long-term, and Preventative Care Delivery in US Office-Based and Telemedicine Visits During the COVID-19 Pandemic. Jama Health Forum. 2021;2(7):e211529. Doi:10.1001/jamahealthforum.2021.1529

Federation of State Medical Boards. Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. April 2014.

https://www.ncmedboard.org/resources-information/faqs/ covid-19-telemedicine-faqs

North Carolina Medical Board. Position Statement 5.4.1: Telemedicine. May 2021.

R. David Henderson, JD. NCMB Update and Telemedicine overview. Presentation to NCAFP Board of Directors. December 2, 2021.

CAREPOINTS

The Need for New Solutions to the Mental Health Tsunami of the COVID Pandemic

By: Samantha Meltzer-Brody, M.D.

Assad Meymandi Distinguished Professor & Chair,

UNC Department of Psychiatry;

Director, UNC Center for Women’s Mood Disorders

Reprinted with slight edits with permission from the NC Psychiatric Association magazine and from Dr. Metzer-Brody.

The mental health impact of the COVID-19 pandemic is enormous and constitutes a public health crisis. Both national and international data demonstrate worsening mental health globally.1 Primary drivers of worsening mental health include worry and stress of contracting COVID-19, caring for sick family members, loss of a loved one to COVID-19, disrupted employment, economic hardship, social isolation, school closures, and loss of childcare. This crisis has led to a massive need for psychiatric and behavioral health care that our U.S. health care system is not prepared to absorb.

The following sobering statistics paint the story of the magnitude of the need. Population data estimates from the Household Pulse Survey, a partnership of the National Center for Health Statistics (NCHS) with the Census Bureau, show 4 in 10 adults had clinically significant symptoms of anxiety and/or depression in January 2021, a marked increase compared to a similar time period in 2019 (pre-pandemic).2 Communities of color have been disproportionately impacted; 48% of non-Hispanic black adults report symptoms of anxiety and/or depressive disorders, compared to non-Hispanic white adults (41%).4, 5 Data from the March 2021 Kaiser Family Foundation (KFF) report demonstrates that younger people and women, including mothers, have been those who are hardest hit by the mental health impact of the pandemic.

The impact of the pandemic on our youth

If we look specifically at the impact on our children and teens, the pandemic has been particularly cruel. Between March and October 2020, the percentage of emergency department visits for children with mental health emergencies rose by 24 percent for children 5 to 11 years old and by 31 percent for children and teens 12 to 17 years old (CDC).3 There has also been a devastating 50 percent surge in emergency department visits for suspected suicide attempts among girls 12 to 17 years old. Suspected suicide attempts climbed in boys by 3.7 percent.7 New data from the 2022 Mental Health in America Report confirms and expands the CDC data: more than 2.5 million youth (10.6%) have severe major depression, and 15.7% of youth experienced a major depressive episode in the past year.

In North Carolina specifically, the chronic under-funding of child and adolescent mental health services has led to a dire situation across the state. North Carolina is near the very bottom of all 50 states in terms of funding for child and adolescent mental health services.6

This egregious situation has caused our emergency rooms to be filled with our youth requiring care, there is a horrendous lack of inpatient psychiatry beds for children and adolescents. Parents (and primary care physicians) are unable to find outpatient clinicians for mental health care of these children. It is simply unacceptable.

The path forward

Innovative approaches are needed to address the mental health crisis. This will require new resources, widespread collaboration, and a financial investment from all stakeholders, including federal, state, and local entities. It will also require a robust and coordinated effort to make meaningful change.

I want to share an example of what UNC is doing to tackle the impact of the mental health crisis. UNC Health and the Department of Psychiatry are significantly expanding the scope of clinical services to address the ever-growing need across the state in all aspects: inpatient beds, outpatient services, scope of our training mission, and expanded research programs. We are building our capacity to expand the reach of telepsychiatry services across UNC Health entities in North Carolina, many in rural areas.

At the university, in response to three tragic deaths of students from suicide over a one-month period, the Chancellor called for a November 15th Mental Health

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Summit for the UNC Community. The goal of the Summit was to educate, engage, and foster discussion among faculty, staff, and students, and included opportunities to hear diverse voices and perspectives from students, faculty, and parents, learn from national leaders, and hear from campus working groups focused on prevention, crisis response, and campus culture. The discussions will help distill a set of recommended action items to augment new initiatives already in process and being deployed.

The UNC Mental Health Summit is the beginning of a conversation about where we are now and where we need to go next. It is a great model of what needs to be happening in North Carolina, at all levels, to discuss the mental health landscape.

Primary Care Collaborating with Psychiatry (Added for NCAFP with permission) - This is not just a concern for psychiatrists, but for primary care physicians as well. Psychiatry knows how critical family physicians and pediatricians are to caring for patients with mental illness.

One of the potential benefits of moving to Medicaid Managed care is once again allowing primary care to provide services to individuals with mild to moderate behavioral health issues, thereby integrating mental health care back into primary care rather than carving it out to the state’s LME/MCOs. As the state moves to tailored plans at the end of this year, LME/MCOs will change their focus and will be concentrating on whole-person care for persons with severe and persistent behavioral health issues. These changes provide an opportunity for mental health and primary care professionals and organizations to work together more closely to provide whole-person care in the medical home.

The Collaborative Care Model is one evidence-based way to do just that, using behavioral health care managers working with a primary care physician and a consulting psychiatrist. We are seeing how this is working in the UNC system and across the state. This is particularly timely, as behavioral health issues related to COVID are significantly stressing the current system. Together, our specialties—Family Medicine and Psychiatry—can and must do great work to build new solutions for mental health care.

Editorial Note:

The NC Psychiatric Association (NCPA) and the NC Academy of Family Physicians, along with others, are already in discussions on how we can better collaborate to combat this growing crisis. The NCPA, NCAFP, NC Pediatric Society, NC AHEC Program and Community Care of NC, have a history of collaborating to try to address behavioral health issues going back at least 15 years. More recently, the organizations have been discussing how to work to better integrate behavioral health into primary care through the Collaborative Care Model and other efforts.

In the coming months, it is expected that NCPA, NCAFP, NC Peds, NC AHEC, CCNC and others will introduce further education and assistance on this model. Both Medicaid and Medicare already pay for using collaborative care codes in primary care, and we hope our commercial insurers will do so in the near future as well. Look for additional information as it becomes available.

REFERENCES:

1. (LANCET, https://www.thelancet.com/infographics/covid-mental-health)

2. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3. htm?s_cid=mm6945a3_w

3. Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R,

Holland KM. Mental Health–Related Emergency Department

Visits Among Children Aged <18 Years During the COVID-19

Pandemic — United States, January 1–October 17, 2020. MMWR

Morb Mortal Wkly Rep 2020;69:1675–1680. DOI: http://dx.doi. org/10.15585/mmwr.mm6945a3external icon

4. Panchal N, Kamal R, Cox C, Garfield R. The Implications of

COVID-19 for Mental Health and Substance Use. Feb 10, 2021.

DOI: https://www.kff.org/coronavirus-covid-19/issue-brief/theimplications-of-covid-19-for-mental-health-and-substance-use/

5. Kearney A, Hamel L, Brodie M. Mental Health Impact of the

COVID-19 Pandemic: An Update, April 14, 2021. DOI: https:// www.kff.org/coronavirus-covid-19/poll-finding/mental-healthimpact-of-the-covid-19-pandemic/

6. Reinert, M, Fritze, D. & Nguyen, T. (October 2021). “The State of Mental Health in America 2022” Mental Health America,

Alexandria VA.

7. Yard E, Radhakrishnan L, Ballesteros MF, et al. Emergency

Department Visits for Suspected Suicide Attempts Among

Persons Aged 12–25 Years Before and During the COVID-19

Pandemic — United States, January 2019–May 2021. MMWR

Morb Mortal Wkly Rep 2021;70:888–894. DOI: http://dx.doi. org/10.15585/mmwr.mm7024e1.

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comprehensive care from the medical home and not charge a patient’s deductibles if services are delivered there. This is truly how we drive down health care costs.

The NCAFP will continue our mission of inclusion. I have been blessed to work with current and past leaders from all walks of life. Family physicians like Drs. Tamieka Howell, Rhett Brown, Jessica Triche, David Rinehart, Charlie Rhodes, and Alisa Nance, have provided amazing guidance and leadership on this subject. We will continue to advocate from the state and national level down to help ensure family physicians from all backgrounds will continue to be included in various arenas of health care. We will also continue to be inclusive within our own leadership at the NCAFP. At the end of the day, we are here to learn, respect, and support each other, as a community that celebrates diversity.

Family physicians, along with being here for each other, are also here to be voices for their patients. Patient advocacy -- as healthcare may quickly change next year -- will be a key area for the NCAFP to continue in 2022. We must continue our hard work with insurance companies and the state legislature to ensure everyone can have access to affordable healthcare. Advocating coverage for collaborative ancillary services, like nutritional, behavioral, and wellness in the primary care setting, will help improve health care outcomes.

We also must continue our efforts to reduce the administrative burdens faced by family physicians across the state and, at the same time, work to ensure that Family Medicine is valued by payers so that we can put great teams around us to assist in our efforts with the increasing complexity of our patients. Lastly, as we are hopefully coming out of this pandemic, let us not forget that what we practice is called the ‘art’ of medicine. Let’s be open minded when it comes to the ever-changing recommendations in medicine. Let’s respect one another if sometimes our medical opinions may differ. Let’s continue to engage each other, learn from our differences, learn from each other, and at the end of the day, agree that we are all here for one overall purpose: the betterment of our profession and the betterment of the health of our patients. Our patients aren’t a medical statistic or a number. Each patient has a different background, and that impacts how you strive to personalize their healthcare delivery.

That is the NCAFP, a place where for me in the last 20 plus years, I have come to learn, grow, and adapt as a family physician. Learn from your leaders, learn from colleagues, learn from your patients, learn from your families, and most importantly, as master Yoda once said, ‘pass on what you have learned…” to the future physicians of our profession. Always keep your head up, always beg the question, and always be a voice with your colleagues.

The members of this Academy are working every day in the trenches because we know how to best deliver cost-effective and phenomenal healthcare. Do not be afraid to speak up and never be afraid to challenge the status quo for the betterment of our patients and our profession. It is truly an honor to be standing here tonight, and I will do my best to uphold the oath I took tonight. Know, I am always here for you, never hesitate to reach out if you ever need anything, and above all, please take care of yourselves and each other!!

Thank you.

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