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Muhamad Aly Rifai shares his journey as an early advocate for telepsychiatry, highlighting its role in addressing the U.S. mental health crisis and providing access to care in underserved areas. He delves into the obstacles posed by outdated regulations, the profound impact of the COVID-19 pandemic on telehealth adoption, and the ongoing battles with legal and administrative challenges. This episode unpacks the transformative power of telepsychiatry, its successes, and the urgent need for regulatory change.
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 discusses the KevinMD article, “The rise and fall of telepsychiatry.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai. He is a psychiatrist and internal medicine physician. Today’s KevinMD article is “The rise and fall of telepsychiatry.” Hammad, welcome back to the show.
Muhamad Aly Rifai: Thank you for having me to talk about an important topic, telehealth and telepsychiatry.
Kevin Pho: All right, tell us what this article’s about for those who didn’t get a chance to read it.
Muhamad Aly Rifai: So I am talking about the field of telehealth and telepsychiatry. I’ve been involved with telehealth and telepsychiatry since 2006. I started one of the nation’s first emergency telehealth telepsychiatry programs at a local hospital in Pennsylvania, connecting three emergency rooms together to process patients who were being boarded in the emergency room.
This was one of the early days of telehealth. The equipment was not as nice as what we have today. We started with equipment from companies where the size of the equipment was 500 pounds, and it connected three different emergency rooms. The screens were bulky, and it was—it was a different time. The quality of the connection was choppy, but we made it work. We were able to see and evaluate patients who were in different emergency rooms waiting for disposition.
This program actually gave rise, in that health system, to the inception of tele-ICU. I assisted in the inception of a tele-ICU system where, like now, most hospitals have a centralized tele-unit. Physicians are in a centralized unit and can assess, monitor, and treat patients in different intensive care units, having a great impact on their course in the hospital. The same thing with telepsychiatry: we basically evaluated and dispositioned patients who were waiting in the emergency room. We either decided on an admission, concluded they could be managed on an outpatient basis, or adjusted their medication. It was pretty impactful at that time.
Kevin Pho: All right. OK, so tell us about the role of telepsychiatry over the years. How has it evolved, especially during the pandemic? Whenever I talk to behavioral health specialists like yourself, people always say that there is a shortage of clinicians, and telepsychiatry is one of the ways we could increase access. Tell me about the evolution of telepsychiatry since you first became involved with it back in 2006.
Muhamad Aly Rifai: Sure, sure. So, I think with the shortage of psychiatrists and the shortage of physicians in rural areas, Congress was wise to enact legislation that allowed the Centers for Medicare Services to agree to pay for services provided via telehealth to individuals who live in shortage areas, in rural areas, for psychiatric services. Medicare would pay for that if it was provided by telehealth.
This started in 2009 in Pennsylvania. Medicaid also agreed to pay for telehealth services because most of Pennsylvania is rural, and we were able to get paid for telehealth services if someone lived in an underserved area. Underserved area means fewer physicians and fewer psychiatrists. The majority of Americans live in areas where the available number of psychiatrists only meets about 30 percent of the psychiatric needs in that area. This is for the majority of the 350 million Americans—they get only about 30 percent of what’s needed in terms of psychiatric resources.
So, doing telehealth allows complex cases to tap into psychiatrists who are not in rural areas. Also, psychiatrists can provide consultation services to primary care doctors in rural areas by offering help with difficult cases and managing patients who are in need of psychiatric services.
Kevin Pho: And tell us some of the challenges you face while doing telepsychiatry, especially for patients in rural areas. Was it difficult for you?
Muhamad Aly Rifai: It was—it was very difficult. We started initially with providing services to individuals who were in rural nursing homes. We had the logistical support of the staff at those nursing homes. These are mostly individuals who are severely mentally ill, who have a lot of psychiatric issues, and they’re residents of nursing homes.
That actually created a significant positive impact because it reduced the utilization of antipsychotic medications that were very heavily used in nursing homes, as well as the use of other psychotropic medications. It also reduced the frequency of psychiatric hospitalizations. We connected with primary care practices that were seeing these patients with severe psychiatric illness and the significant burden that imposed on primary care doctors. So we assisted those physicians.
Now, there were significant challenges. The regulatory challenges and the billing rules were not clear. The guidelines were not clear. And basically, in its usual pattern of different government bodies fighting with each other, the Drug Enforcement Agency passed something called the Ryan Haight Act, which prevented the prescription of controlled substances through the internet—which, by fiat, included telehealth—until the COVID pandemic happened and they waived the implementation of the Ryan Haight Act. But the Ryan Haight Act was passed in 2008, and from 2008 to 2020, the Drug Enforcement Agency never had guidelines or rules about how to implement this law. They had promised they were going to do guidelines and rules, and in 12 years nothing happened. So it was just unclear. There were significant obstacles, especially in terms of Medicare billing rules and guidelines. With all of the flexibilities that happened with COVID, many of those rules were significantly relaxed.
Kevin Pho: So what’s the current state today? COVID has become endemic now. Where are we in terms of the suspension of the regulations? Where are we with the Ryan Haight Act today at the beginning of 2025?
Muhamad Aly Rifai: At the beginning of 2025, the Ryan Haight Act is still a law on the books. The Drug Enforcement Agency has decided to extend the suspension of the implementation of the Ryan Haight Act until the end of 2025.
In terms of the flexibilities that Medicare implemented during COVID—those looser guidelines that allowed some flexibility—those were set to expire on December 31, 2024. Congress, at the last moment, gave a 90-day extension. So here we are, January 2025, operating on a 90-day extension until the end of March 2025. We don’t know what’s going to happen afterward. Is Congress—this new Congress—going to write these flexibilities into law so that they become permanent? Medicare can’t do anything until Congress acts, so we’re in a period where Medicare could come back at any time and say these flexibilities are done and everyone must go back to seeing patients in the office. No more telehealth, except for individuals who live in rural areas. That’s where telehealth would still be allowed.
Kevin Pho: So it sounds like the lack of clarity regarding these regulations can really hamstring the growth and spread of telepsychiatry.
Muhamad Aly Rifai: Absolutely. I mean, there are companies that were founded during the COVID era where they only saw patients by telehealth. What’s going to happen now if, come March, Congress says, “Well, we can’t agree on what we’re going to do,” and all of these telehealth flexibilities are gone, forcing everyone back to seeing patients in the office? All of these companies that have been providing telehealth services to people out there—those services are going to go away.
So it’s an urgent situation that Congress act to extend these flexibilities, but this also comes with a significant burden on practices. I personally have been at the brunt of regulatory issues, and I was on the receiving end of a federal prosecution related to telehealth issues. I prevailed, and I was found not guilty, but I can attest that there is very little understanding of these complex issues. We need help from Congress to extend these flexibilities.
Kevin Pho: As one of the pioneers in telepsychiatry, in your ideal world, what would you like to see happen?
Muhamad Aly Rifai: I think there is room for extending these flexibilities and allowing most visits to be available by telehealth for doctors seeing patients, understanding that there are patients who really do need to be seen in the office. There are patients for whom you need to lay hands on them, examine them physically. We know that for those patients, telehealth is not effective and not appropriate.
I also like to see patients in person for the first visit. Having that personal contact is very helpful—even if you continue after that to see them through telehealth—so that you understand who this person is and can serve them better, arriving at a better diagnostic approach.
There have also been a lot of new tools becoming available to us as psychiatrists. For example, artificial intelligence for video conferencing. I’m working on some AI tools for psychiatrists, tools that examine a patient’s facial features to ascertain the presence of anxiety, mood issues, or any movement disorders that might be a side effect of the medications we use. There are AI tools being validated that correlate facial features with the severity of depression and anxiety, or analyze just the sound of the voice, volume, and intonations. Some AI tools can tell you whether a person is in distress and can assign a value for depression and anxiety scores just based on speech patterns.
Telehealth is here to stay. We must be very cognizant of whether it’s appropriate for each patient versus an in-person visit. I think an expansion of telehealth services would be very helpful for our patients and for the health care system, as long as we choose the right patient for it.
Kevin Pho: I had a guest on a few weeks ago who talked about this exact issue from the patient perspective. For those listening to you on this show who want to extend some of these regulatory pauses for telehealth and telepsychiatry, what can they do to make a difference?
Muhamad Aly Rifai: I think just advocating and talking to their patients. We need our patients to advocate. We need our patients to write to Congress. I think it’s very positive that we’re going to have a fellow physician, Dr. Mehmet Oz, as the administrator for the Centers for Medicare Services. As a physician, he understands what we go through and probably would be a great advocate for continuing these flexibilities. But we need Congress to act to extend them—it has to be enshrined in a law that makes these changes permanent.
Especially important is the prescribing of controlled substances through telehealth. We’re going to face the same situation at the end of 2025 if there is no clarity and no permanent law. Congress has a big job to do, and our patients need to write to their elected representatives to codify these changes as laws.
Kevin Pho: We’re talking to Muhamad Aly Rifai. He’s an internal medicine physician and psychiatrist. Today’s KevinMD article is “The rise and fall of telepsychiatry.” Muhamad, as always, let’s end with some take-home messages you want to leave with the KevinMD audience.
Muhamad Aly Rifai: Telehealth is here to stay. Our patients are demanding it. Physicians feel that it’s an appropriate assessment and treatment modality for their patients, as long as the appropriate patient is selected for telehealth encounters. Patients find that it’s very, very helpful to them and want it to stay. I encourage all physicians and patients to write to their elected representatives so we can have permanent changes regarding the implementation of telehealth in our health care system.
Kevin Pho: Muhamad, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Muhamad Aly Rifai: Thank you very much.
