Another expected extension for virtual prescription, same uncertainty

In November, the Office of Management and Budget (OMB) indicated that the DEA may soon propose a fourth expansion of telehealth e-prescribing flexibilities. Over the past 5 years since the start of Covid PHE, temporary extensions have been essential for patients who have been prescribed controlled medications via telehealth and for whom in-person requirements create serious barriers to continuity of care. While another extension beyond the last day of 2025 would certainly be welcomed by providers and patients who have been caught in a multi-year cycle of uncertainty surrounding electronic prescribing of controlled substances in telehealth, we hope that 2026 will be the year that the DEA finalizes meaningful and permanent regulatory policy around electronic prescribing benefits in telehealth.

It is important to take a moment here to review the current situation. The central issue remains that DEA exceptions allowing electronic prescribing of controlled substances via telehealth without an initial in-person visit are about to expire again. Although the Ryan Haight Act of 2008 was designed by Congress and the DEA to clarify policy regarding electronic prescribing benefits for telehealth, it has been fraught with misinterpretations, confusion, and a lack of alignment of federal and state legislation and prescribing flexibilities.

Clinicians have relied on federal and state telehealth flexibilities to prescribe critical treatments for ADHD, anxiety disorders, depression and other serious behavioral health conditions – medications that help patients maintain stability, function and safety. For many patients, these medications are an essential part of treatment in psychiatry, family medicine and pediatrics, not a luxury. Interruptions in access often lead to destabilization, safety risks and worsening symptoms.

The cycle continues, still no clarity

While another extension would provide temporary relief, it would not address the fact that providers, patients, and health systems still lack the ongoing regulatory clarity they need to confidently plan for care delivery in the future. From late November until Christmas, practices and pharmacies receive a wave of calls from patients and parents asking if they will still be able to access their medications, unfortunately leaving many patients and families in prescribing uncertainty. This uncertainty adds to ongoing drug shortages that are already negatively impacting patients and frustrating providers and pharmacists.

For families dealing with ADHD, anxiety, and other behavioral health issues, these medications are life-changing. Clinicians consistently point out that these medications address real physiological imbalances in brain chemistry, just as other medications address physical imbalances throughout the body. When access is interrupted, the consequences are tangible. Children struggle in school, behavior problems worsen, family stress increases, and in some cases there is an increased risk of involvement in the juvenile justice system.

Regulatory whiplash is a clinical problem

Disruptions caused by regulatory uncertainty are not limited to the prescribing of controlled substances. During the recent government shutdown, Dr. Helen Hughes, media director of the Johns Hopkins Medicine Office of Telemedicine, described the situation in Healthcare IT News: “Seeing the government shutdown block our progress on telehealth has been deeply disheartening and disruptive. As we see vital access to care disappear, we hope that Congress will act quickly to permanently restore these essential services for our patients.”

His remarks reflect what clinicians experience when telehealth policy is governed by temporary solutions. Whether it’s Medicare coverage or DEA prescribing authority, last-minute extensions directly interfere with patient care, in addition to being an administrative burden with canceled visits, delayed refills and panicked patients. Clinicians are forced to focus on managing uncertainty rather than devoting their full attention to the practice of medicine.

What it looks like in an office

The Ryan Haight Online Pharmacy Consumer Protection Act contains an in-person visit requirement that remains the legislation’s biggest source of confusion.

Service providers regularly ask:

• Will all patients need to be seen in person in the near future?
• Can care continue if another psychiatrist or clinician has seen the patient in person in recent months?
• Are prescriptions written immediately after an extension protected?

There are no clear answers. As a result, practices must rethink their schedules, document defensively rather than clinically, debate whether to bring in patients unnecessarily, and manage increased call volumes from pharmacies, parents, and schools.

Suppliers shouldn’t be left to guess

Throughout this prolonged period of ambiguity, clinicians have heard very little about DEA. Many members of the medical community consider this silence unacceptable, given the stakes for patients.

The DEA’s lack of communication is often attributed to concerns about diversion. Diversion prevention aims to reduce the misuse and illegal distribution of controlled substances. While this remains an important goal, providers stress that effective regulation should distinguish pill mills from legitimate prescribers. This should not make clinicians afraid to treat patients appropriately.

Health professionals should not be expected to decode legislation that even lawyers have difficulty interpreting. In the absence of clear rules, many rely on good faith clinical judgment informed by legal advice, documentation, and patient needs. When regulations are vague, a good faith interpretation is considered valid for clinicians acting in the best interest of the patient.

Extension is not a solution

In a MedCity News article about navigating virtual prescribing policy changes last year, I offered several practical strategies to help providers operate amid continued regulatory uncertainty.

At a high level, the guidance highlighted:

• Strengthening compliance processes
• Strengthen coordination with pharmacies and healthcare teams
• Maintain clear communication with the patient
• Carefully document clinical decision-making

I also called on policymakers to provide permanent and actionable guidance. These recommendations remain relevant today.

Extensions can delay disruptions, but they don’t solve the underlying problem. Until clear and lasting guidance from the DEA exists, the cycle will continue. Every November and December, clinicians will wait as care delivery remains vulnerable to political delays.

Photo credit: Big Stock Photo

This message appears via the MedCity Influencers program. Anyone can post their views on healthcare business and innovation on MedCity News through MedCity Influencers. Click here to find out how.