The Telepsychiatry Advantage: Episode 6
Ryan Haight Act: The Law That Changed Telepsychiatry.
Part 1
Hi, everyone. Welcome to The Telepsychiatry Advantage. I’m your host, doctor Edward Kafterian. And I’m the chairman and CEO of Orbit Health Telepsychiatry. The longest running telepsychiatry company in the world.
The goal of The Telepsychiatry Advantage is simple: Raise the Standard. For clinicians, for systems, and ultimately for patients. So let’s dive in.
Today we are kicking off a special four part series on a piece of legislation that has dominated the telepsychiatry conversation for years. The Ryan Haight Act. If you prescribe controlled substances, you need to intimately understand this law and its history.
Disclaimer.
Before we jump into the details, I need to make a very important and clear disclaimer. I’m a physician, not an attorney. The information provided in this podcast is for educational and informational purposes only, and does not constitute legal advice. The regulatory landscape for prescribing controlled substances is incredibly complex, and state laws often differ significantly from federal regulations. Please consult a qualified health care attorney to ensure that your telemedicine practice is fully compliant with all applicable local, state, and federal laws.
Now that we got that out of the way, let’s talk about the origins of the act. The tragic story of Ryan Haight. To understand the complex regulations we deal with today, we have to go back to the beginning.
The Ryan Haight Online Pharmacy Consumer Protection Act of 2008.
That amended the Federal Controlled Substances Act.
The legislation was named after Ryan Haight, an 18 year old high school honor student and varsity athlete from California. In early 2001, Ryan had been experiencing back pain. Looking for relief, he went online and easily ordered the highly addictive opioid Vicodin. On February 12th, 2001, Ryan’s mother tragically found him lifeless in his bed. He had died from an overdose of the medication.
The ensuing DEA investigation revealed a shocking system. Ryan was prescribed the drugs by a doctor he had never met and was never examined by. The medication was then delivered directly to Ryan’s home by an internet pharmacy operator. Both men had made millions to this operation, and both were eventually prosecuted and sentenced to 20 years in federal prison for their roles in what was essentially a massive drug dealing enterprise.
The era of the pill mill.
At the time the law was designated with a very specific target in mind to combat rogue internet pharmacies that were unlawfully dispensing controlled substances with zero medical oversight. These sites fueled a new, digitized era of pill mills. Now, when we hear the term pill mill, we often think of physical brick and mortar operations in the late 1990s and 2000 these were notorious cash only clinics with lines out the door, armed security guards and unscrupulous doctors handing out stacks of narcotic prescriptions after spending maybe 30 seconds with the patient conducting minimal to no actual physical exam. The internet effectively took that predatory model and digitized it. It allowed bad doctors to prescribe highly addictive, controlled substances on a massive scale without any preexisting, bonafide doctor patient relationship.
The core requirement: The in-person medical evaluation
To shut down these internet pill mills. The federal government instituted a strict baseline rule. Under the Ryan Haight Act, a practitioner generally cannot issue a valid prescription for a controlled substance via the internet, which explicitly includes telemedicine technologies without first conducting at least one in-person medical evaluation of the patient.
Here’s what that practically means for psychiatrists.
You must be in the physical presence of the patient to conduct that initial medical evaluation. Once you have conducted that first in-person evaluation, the Ryan Haight Act itself does not mandate an expiration period or require a specific frequency for subsequent in-person visits.
For a while, when people didn’t understand the Ryan Haight Act, there were rumors and misinformation out there saying that you need to see the patient every two years. I’m not sure how that rumor came into effect, but that’s not true. You must always remember that states maintain their own authority to regulate the practice of medicine. While the federal DEA requirement might not demand routine follow up in-person visits, many individual states have enacted much stricter physical exam requirements.
So what we’re talking about here is the Ryan Haight Act and the requirements. We’re not talking about the state requirements. And in order to fully be compliant, you need to be compliant with federal, state and local rules around controlled substances.
The seven practices of telemedicine exceptions.
Now, the Ryan Haight Act did not completely ban telemedicine prescribing. The legislation outlines specific exemptions where a provider does not need to conduct an initial in-person exam. To understand exactly how narrow these carve outs are, let’s look at the seven distinct exceptions defining the practice of telemedicine using the exact language from the Controlled Substances Act, 21 U.S.C. 802 54
The in-person requirement does not apply or in the practice of telemedicine in the following situations:
Number One.
Telemedicine is being conducted while the patient is being treated by and physically located in a hospital clinic registered under section 823 of this title.
Number Two.
The in-person requirement does not apply when the practice of telemedicine is being conducted, while the patient is being treated by and in the physical presence of a practitioner registered under section 823 F
Number Three.
The in-person requirement does not apply when the practice of telemedicine is being conducted by a practitioner who is an employee or contractor of the Indian Health Service, or is working for an Indian tribe or tribal organization.
Number Four.
The in-person requirement does not apply when the practice of telemedicine is being conducted during a public health emergency declared by the Secretary of Health and Human Services.
Number Five.
The in-person requirement does not apply when the practice of telemedicine is being conducted by a practitioner who is obtained from the Attorney General. A special registration under section 831 H of this title.
Number Six.
The in-person requirement does not apply when the practice of telemedicine is being conducted in a medical emergency situation, specifically regarding veterans, Health Administration practitioners, and strictly defined medical emergencies.
Number Seven.
The in-person requirement does not apply when the practice of telemedicine is being conducted under any other circumstances that the Attorney General and the Secretary have jointly, by regulation, determined to be consistent with effective controls against diversion and otherwise consistent with the public health and safety.
I want to circle back to number four, which is that the in-person requirement does not apply when the practice of telemedicine is being conducted during the public health emergency declared by the Secretary of Health and Human Services. So you see the words public health emergency. And you probably think pandemic, the Covid 19 pandemic. If you’re practicing telepsychiatry prior to 2020, you know firsthand how limited these exceptions were for general community practice and for over a decade, the Ryan Haight Act in-person rule severely restricted the scalability of telepsychiatry for high acuity patients who needed controlled medications. But as we all know, everything changed in 2020. The Covid 19 pandemic triggered the fourth exception on the list: the public health emergency, temporarily stripping away the in-person requirement and fundamentally altering how behavioral health care is delivered.
What’s Next.
In episode two, we’re going to dive into the current regulatory reality. We’ll discuss the DEA’s temporary extensions and how we are practicing today, and how to safely navigate the runway leading up to December 2026.
Whether you’re already practicing remotely, thinking about starting or building telepsychiatry programs in your system, and you’re wondering how to incorporate controlled medication prescribing, I’m glad you’re here.
Thanks for listening to The Telepsychiatry Advantage. And until next time, keep raising the standard.
