I'm Eric Jarman, I'm moderator for the Telepsychiatry Coverage Advocacy. Will 2024 be a breakout year? I'll introduce the speakers and give you a brief overview of this session. Dr. Peter Yelolis is the CEO of Async Health and Distinguished Emeritus Professor of Psychiatry at UC Davis. He's a pioneer in telemedicine and an international advocate for physician wellness. He has published over 250 papers and eight books on topics including psychiatry, telemedicine, physician burnout, and digital health. He has over 30 years of experience in treating patients, leading healthcare organizations, and championing clinical well-being, clinician well-being. Dr. Shabana Khan is a child psychiatrist, assistant professor in the Department of Child and Adolescent Psychiatry at NYU Grossman School of Medicine just across town, and the director of Child and Adolescent Telepsychiatry at NYU Langone Health. And Dr. Christian Moser is a psychiatrist at MedStar Montgomery Medical Center and is a congressional fellow at the American Psychiatric Association. The presenters are deeply involved with advocacy for telepsychiatry and will present their wide range of personal experiences in this panel session while also covering the history of telepsychiatry advocacy going back 30 years. The session will commence with a discussion of the current status and scope of telepsychiatry policies and the federal and state levels as they affect clinical care reimbursement licensure and prescribing of controlled substances. The APA has a very active policy advocacy structure, staff, and set of processes, and this will be described demonstrating how individual interested psychiatrists with a passion for the area can be supported and assisted to make changes at the federal and state levels. Finally, lessons learned by the presenters and hopes for the future of psychiatric care will be discussed, especially the dramatic changes to psychiatry as a profession during and after the COVID-19 public health emergency and how these can be captured and continue to ensure that the provision of hybrid care, both in person and online, can become the future standard of care delivered by most psychiatrists. The Centers for Medicare and Medicaid Services, or CMS, has also been invited to present about how physicians can support CMS in establishing coverage policy and reflects standard of care and the needs of patients. So with that, I'll leave it to our presenters. Thanks indeed. I'm P.D. Oles, and unfortunately CMS actually couldn't come. They were invited, but they're not here. So look, first of all, it's great to see you all. Thanks for coming, and we look forward to an interactive session here. We'd really like your questions as we go through, if you can. So just put your hand up and ask a question, or you can come down to the middle. If you ask a question from where you are, we'll just repeat it because this is a session that's being recorded for other people to listen to. So just to get going, let me just move this forward. We're all involved in the industry for telehealth on a daily basis. Now we're covering sort of two areas really today, both telemedicine and advocacy, and I'm interested just first of all, could you put up your hands if you're interested primarily in advocacy versus primarily in telemedicine? Okay, so that gives us an idea as to what the area is, and obviously the telemedicine issues are very significant and have changed dramatically with COVID, and we're fortunate that both Shabana and Christian are going to go through that process and really give you the correct sort of current situation as to what we can and can't do. Now we've got three learning objectives to identify opportunities for policy advocacy to support coverage of telehealth service, to describe current federal and state policies and priorities around telepsychiatry, and understand regulatory and legal considerations associated with providing telepsychiatry across different patient populations and state lines. And as you all know, COVID has changed the way we all practice. This is data that's just come out from EPIC fairly recently. Now it covers 475 million medical encounters from 222 EPIC systems across 220 million patients. And whilst it's hopefully possible for you to read some of this, what it shows is the use of telehealth across all disciplines over the last three and a half years since COVID began. And you can see the mental health line is much higher than the others, and you can just about see it on that screen there. And at the beginning of COVID, about 65% of EPIC-run outpatient consultations were actually done within mental health. I mean, a huge proportion. That's since cut down to about 35%, which is where it is now. But that still means a third of our patients in EPIC systems around this country, and EPIC's obviously the largest EMR, a third of our patients at an outpatient level are being seen by telemedicine. That's compared with the overall average across all disciplines of about 9%. And that's obviously come down over time. So it's pretty clear that in our discipline, in mental health generally, there's been a dramatic change to our practice. And that this change has persisted and is likely to continue. And I think it's a pretty sure bet that we'll continue going on seeing at least a third of our patients across the system on video, potentially on the phone, and using a number of other different technologies. So what are the implications of this? Well, I'm going to leave that to Shabana. She's going to talk about the current regulatory situation. Thank you so much. Great to see everyone. I chair the APA Telepsychiatry Committee, and I am at NYU Langone. So as Dr. Yelolis mentioned, I'll start by giving an overview of the telehealth landscape. With telehealth policy, it is helpful to think about what the components are. So there's going to be laws, regulations. There might be guidances. So for example, CMS might put out a bulletin for providers. So there may be guidances. And then cases as well. The court cases we don't always think about. But sometimes court cases can also impact policy, including telehealth policy. And I'll highlight one of those today, specifically related to licensure. And then with telehealth policy, we also want to think about particular issues. Is it relevant at the federal level, at the state level, both? And I'll give some examples of those. So we'll start with federal level. The most relevant would be Medicare. At the federal level, there were a lot of changes during the pandemic, during the public health emergency, that allowed for us to be able to provide telehealth for our patients. With Medicare, prior to COVID-19, there were significant restrictions. So there were only about eight different types of practitioners that could provide telehealth for Medicare beneficiaries. There were only seven or eight different types of sites that patients had to be located in. Patients had to be in a rural area outside of a metropolitan statistical area. Patients could not be seen in home outside of maybe one or two exceptions. All of this changed. So at the federal level, geography restriction, that rural restriction was removed. The sites that patients could be seen in, that also changed. We could see patients in home. The types and modalities that could be used. So for Medicare specifically, allowing audio only, and I'll talk about which of these changes have been made permanent. And then the types of practitioners that can provide telehealth for Medicare, significant expansion of services, licensure as well. At the federal level, CMS did say that they're going to waive some licensure requirements, but you do have to look at what the state requires, because it's generally a state issue. And then supervision, I'll talk about that, providing supervision to trainees, what flexibilities we've seen at the federal level with Medicare specifically. Visit limits with certain types of settings, and then more codes eligible for phone expansion, like I said, of practitioners, physical therapy, occupational, speech language. So a lot of changes. Many of the big ones have been extended through the physician fee schedule, at least through the 2024. At the state level, some similar things, the most common telehealth changes that we saw, and it varies state by state, the types and modalities that can be used, location of the patient and the practitioner, informed consent for telehealth, the types of services, practitioners, and licensure. Most if not all of the licensure flexibilities that we had during COVID-19 have expired, so generally you would have to be licensed. Where the patient is, some states might have a special registration. So for example, Florida has a telehealth out-of-state registration, where you can practice in that state without a full Florida license, so you do have to go state by state and review. So telehealth policy after COVID-19, like I said, some things were made permanent, some expired, some were extended through the end of this year. So patients' home as an eligible site for Medicare when you're conducting telehealth, that actually, this is a really big and positive change that's been made permanent, specifically for mental health and substance use disorders. We are able to see patients when they're in their home for Medicare, and that is permanent for mental health. Removal of geographic, like I said, the rural requirement, geographic and patient site restrictions, specifically for mental health and substance use disorders, again, a very positive and significant change, that removal of those requirements has been made permanent in Medicare. For other, for non-mental health and non-substance use disorder services, that's been extended through 2024, but for us, it's permanent. And then allowing audio only for telehealth has been made permanent, specifically for mental health and substance use disorders. Some things that were extended through 2024, I mentioned supervision, so the virtual supervision of residents, this was also a big change. One caveat, though, is that the care that the trainee provides has to be virtual. So if a trainee is seeing a patient through telehealth, then they're attending, their supervisor can supervise them by video. But if that trainee, we're seeing, when it comes to Medicare, but if a trainee were seeing a patient in person, then their supervisor, supervising physician cannot virtually supervise them unless they're in a rural area. So there's been a lot of advocacy, which we'll talk about through APA, to try to advocate to allow that virtual supervision, not just for virtual care, but for in-person care as well. Deferral of Medicare in-person requirements for mental health services, that flexibility has been extended through this year as well. Because of the Consolidated Appropriations Act, there is a requirement that was put into place that says that in order for us to be able to provide telehealth care for Medicare beneficiaries, we have to conduct at least one in-person examination first before that telehealth. Because of the public health emergency, that was deferred, and through, CMS has further deferred that through end of 2024. But unless some action is taken, and that would require legislative action, statutory change in order for that to be removed. But for now, that's been extended through 2024. So we don't have that initial in-person requirement for mental health services for Medicare. Business address instead of home address. So before COVID, the general rule was that for Medicare telehealth, if the practitioner is going to be at home while they're seeing their patients through telehealth, so if you're as a clinician at home, Medicare required that you provide your home address for enrollment, for claim forms. And during COVID, that was waived to allow for telehealth to be used more. And practitioners were allowed to, instead of using their home address, they could use their business practice address, even if they're at home during these visits. This has been extended through 2024, so you don't have to list your home address. But unless something changes come 2025, if you're at home during these telehealth visits as a practitioner, you would have to list your home address. The problem here is that often these things are online. These are publicly available. So patients, anyone could see your home address. So there are some potential privacy safety risks associated with this. It's unclear what the value is. So there's some advocacy that's being done by APA and other organizations in that area to try to make this permanent, where you don't have to list your home address. And then telemedicine-controlled substance prescribing, we'll talk about the flexibilities that have been extended through this year. So Medicare, as I mentioned, is at the federal level. And then Medicaid plans and private payers, commercial payers, that would be at the state level. And every state is different. So it's hard to speak to specific payers. You really do have to review individual payers. Medicare Relative is a little bit easier because it's at the federal level. It applies to all. But with Medicaid, you would have to look at individual Medicaid plans. Generally, if we look broadly, so audio only is covered by Medicaid in 43 states and D.C., but every single state is different in terms of what they're covering, whether it's for a particular diagnosis, particular specialty. So there are nuances. And then live video, broadly, is covered by all 50 states and D.C.'s Medicaid plans. But again, you have to look at the specific plan. Remote patient monitoring is covered in 37 states for Medicaid. And then store-and-forward or asynchronous, not-in-real-time technologies are covered by 33 states in their Medicaid plans. And a great resource for this, I listed it here, the Center for Connected Health Policy does regular updates looking at individual states and at the federal level, and they provide excellent summaries on their website. So telemedicine and licensure, like I mentioned, the general rule is that you have to be licensed in the state where the patient is located at the time of the visit. And it's not just licensure, but in addition to licensure, you also have to comply with each state's medical practice act or the equivalent of a medical practice act and then practice standards. So for example, patient examinations, how do you establish that doctor-patient relationship, what technologies can be used, and also part of that medical practice act may be things like remote prescribing. There are some special exceptions, so for licensure there's some special rules for the VA. So if you're a healthcare practitioner that's part of the VA and you're seeing a patient through the VA system, you don't have to be licensed in every state. As long as you have one license, you can see patients through the VA in other states. There may be special rules for U.S. military as well when a patient is on a base. There's some exceptions relevant to telemedicine, so consultations for example, if you're not taking on care of the patient, not establishing that doctor-patient relationship, but you're just serving as a consultant to a doctor in another state, you may not need to be licensed in that state, but every single state is different in terms of how they define that consultation. So you would have, if you wanted to do this, you would want your malpractice legal risk management to provide guidance there. I mentioned special registration, so Florida for example, so that's another exception that's relevant to telemedicine. A lot of professions have licensure compacts that can facilitate the practice of that profession across state lines. The medical one, you still have to have your principal state licensure, but then you also have to get the full license in the other compact states. So it doesn't make that easier, but it might make it a little bit quicker to get that license in the other compact state. There's also an administrative fee associated with this, so maybe not as ideal a model as some of the other professions licensure compacts where you don't have to get the full license in the other state. By mutual recognition, as long as you're licensed in one state for these other professions, you can practice in another compact state as long as that's approved through that compact. So the medical one, you do have to get a separate license in each compact state. There's about 40, 41 states that are part of the medical licensure compact. Our states are not, so the big states, New York and California, for example, are really holding out on this. Very, very hesitant to be a part of such a compact. In general, a lot of states were hesitant because they want to be able to regulate the practice of medicine within their jurisdiction, but New York is not a part of this. New Jersey, I believe, just joined a couple of months ago. And then I wanted to highlight this case. This is from a few months ago. McDonald v. New Jersey State Board of Medical Examiners. This is in the US District Court for New Jersey. It was filed in December. This is the first time that medical licensure is being challenged at the federal level. So generally, states regulate the practice of medicine. You have to be licensed in each state where you're practicing. But in this case, there were two patients. So there was a pediatric patient who required a very specific expertise by a radiation oncologist. They went to that other state for the treatment, and they require follow-up visits when they're back in New Jersey. And they don't have such expertise locally, so they do really need to continue to see that doctor, but that doctor is not licensed in New Jersey. And then there was another case of a college student who went to, I believe, Pittsburgh, University of Pittsburgh, for their care with a neurosurgeon. Now they need follow-up visits with them, and they're back in New Jersey, but that doctor is not licensed in New Jersey. So this case involves those two situations, and because they're arguing the Constitution here, it's now a federal case. And over like many, many years, it's been discussed, can we challenge licensure at the federal level, but it's never been done until now. So don't know how this is going to play out, but the arguments that they're using are commerce clause. They're saying that interstate commerce is under the purview of Congress. It's at the federal level, so if you're requiring a license, that that's a violation of the Constitution. Privileges and immunities clause, which they're arguing that one of the privileges that were afforded in the Constitution is the right to have an occupation, and by requiring that that doctor have a license in New Jersey, you're interfering with that right. First Amendment, and then 14th Amendment due process clause. So interesting arguments. I believe the New Jersey State Board responded like a month ago, so we don't know what will happen here, but if, let's say, they do win this case, then it could have implications not just for New Jersey, but because New Jersey licensure laws are very similar to other states, it could impact state licensure broadly. So something for us to keep an eye out on. So controlled substance prescribing, generally before COVID, outside of very, very narrow exceptions, we do have to conduct an in-person visit with a patient before prescribing a controlled medicine. This is due to the Ryan Haidt Act of 2008. That was waived, and the exceptions are pretty limited, like I said. So patient would have to, in order for you to not have to do the in-person exam, patient would have to be in a DEA-registered hospital or clinic, or they would have to be in the physical presence of a DEA-registered practitioner during the telehealth encounter or services through the VA in an emergency. If you're providing care for tribal organizations, those were some exceptions. One of the exceptions was a public health emergency, which was put into place in March 2020. So because of that, that in-person exam was waived, as long as you're prescribing for a legitimate medical purpose within your usual course of practice, and you're using live video for that visit, and then of course, it's not just about federal. This is one example where you have Ryan Haidt at the federal level, you have these waivers at the federal level, but each state is different, so you also have to look at your state and what they say about controlled substance prescribing. So as long as you're acting in accordance with federal and state law. The other thing that was waived, one of the other things that was waived prior to COVID, you did have to have a separate DEA registration and a practice address in each state where you're prescribing controlled medicines, that was waived. It's still waived, all of these things for controlled substance prescribing at the federal level are waived through December 2024, and we are still waiting to hear about what, how this is going to end up, what the DEA is going to do. They're supposed to put out something, and they did indicate that they plan on opening it up for public comment before it's finalized, so a great opportunity for us as APA members, as psychiatrists, to advocate since this has such a huge impact on our field. I will hand it over to Dr. Mosher. Are there any questions up to this point? I mean, the issues that Shabana has just gone over will affect everyone in the room, and, you know, particularly, you know, which sort of, you know, licensure and registrations will continue after the end of this year, but hopefully, if you're not sure, you can look at our slides, which are available on the app, and that has all of these details on them. All right, well, thank you, Dr. Kahn, for the introduction. So, I'm going to talk a bit about what the APA has done so far this year, some big wins that we've had, then I'll get into talking about what are our goals in general, and then I'll give you a little bit of background on what is the current lay of the land in Congress, what legislation has been proposed, where do those bills stand, and I can talk a little bit about what does advocacy look like on the inside, when somebody comes to Congress and meets with legislative staff or with a senator or congressperson, what happens after that? I'll get to that in a bit. So, the wins the APA has had this year, we have successfully lobbied to have legislation introduced that would remove that six-month in-person requirement for telehealth services, so it's not been implemented. Okay, can you hear me now? Okay, just move it up a little bit. How's that? Okay, so we've had some wins this year. One of the big ones is that we got some legislation introduced that would get rid of the six-month in-person requirement for telemental health services. I'll give you a little bit more information on that one later. We have also had some success when working with CMS, that's Medicare Medicaid, to remove the requirement that we would need to report our home address when we're delivering telemental health services from home, we could report a business address instead. Aetna had planned to terminate its telemental health services, and we successfully lobbied through sending a letter to them, along with other mental health organizations, and they ended up announcing that they would instead expand their telehealth policy. And then, finally, through our successful advocacy, DEA, in coordination with the Department of Health and Human Services, it announced that it would extend COVID-19 telehealth or telemedicine flexibilities for prescription of controlled medications through the end of this year. All right, now, in general, this is what APA's agenda looks like when it comes to telepsych. So, the common theme here, we are in favor of eliminating that in-person requirement for mental health services. We advocate that the allowance for residents to deliver telehealth under virtual supervision be made permanent, and that the virtual supervision be extended to include residents delivering in-person care in any geographic location. So, Dr. Khan touched on that earlier, just allowing for virtual supervision. That's a big push of ours. We recommend that telemedicine and psychiatry should be reimbursed by payers, public and private, for all covered psychiatric services at parity with in-person delivery, including for audio-only visits. In short, we want mental health parity and telehealth parity. Okay, and finally, this May, coming up in the next couple of weeks, APA is going to be hosting a congressional briefing to urge members of Congress to take immediate action to address all of these. So, we have a big push coming in the next couple of weeks here. Okay, so, these are a couple of bills that APA has endorsed. I'm not going to read this to you word-for-word, but generally I'll just talk about what the scope is here and what the strategy is behind it. So, this first one, the Telemental Health Care Access Act, this one is narrow in scope. It specifically is just to remove the six-month in-person requirement for telemental health services. So, that requirement has not actually gone into effect at any point, but if we don't act by the end of the year, it will go into effect, and we want to preempt that. So, this bill is narrow. It specifically focuses on mental health, where others have a broader health care focus. There are lots of telehealth bills out there this year. This one is very specific to our situation, and we make it specific so that it has a better chance of getting through Congress. If it's more narrow, there is less of a chance that somebody will find a reason to vote against it, to have a hang-up about it. Now, this next one is much more broad, the Connect for Health Act. So, it does include that getting rid of the six-month in-person requirement, but it would also do a lot of the other things that we're pushing for in general. So, it would remove those geographic requirements. It would expand originating sites. Patients could be at home and receive their care there. It would allow FQHCs and rural health clinics to furnish telehealth services. Those would become qualified originating sites, and we would be able to be reimbursed for those services. Now, the good news is the broad bill here is the one that has a lot of traction right now. As of this morning, there are about 64 co-sponsors in the Senate, so that's more than half the Senate. It still needs to get through committee. Right now, it's going to the Finance Committee, but if we have 64 co-sponsors, by the time it gets to the floor, this one should be able to pass. Okay. Now, a little bit about what happens behind the scenes. So, say you meet with your legislator, you meet with their staff. What we do after that meeting is we take the information that you bring to us, and we have to write it all up for the legislator. We have to give them a research memo, essentially. So, that's, this year, the majority of my job. I meet with these constituents. They bring me an issue, and my job is to turn around and gather all of the data that I can to give the boss a fully informed memo and give them a recommendation at the end. So, that process can involve background research. It involves reaching out to stakeholders like the APA or other health care organizations or constituents. We talk to the staff of other members in Congress to see where do they stand on this issue. Are there any legislative hurdles that we're going to run into here if we endorse or don't go along with it? And then, finally, that recommendation to the legislator, to the boss. And, at the end of the day, it is their decision to go along with it or not. We don't make the decision for them, but we give them a thumbs up or a thumbs down. So, this is a very big part of the job. We have to cover lots of different subjects every day. So, the most helpful thing that advocates can do when they come to meet with us is to give us a compelling story. Tell us about somebody who's been affected by that issue in the state that the legislator represents, and that is what we can turn around and share with other people to really change minds and hearts. Coming armed with lots of facts and figures is helpful, but often when we share those things in a meeting or in a hearing, something like that, that's when we start to see eyes glazing over and statistics as powerful as they can be. It's better for the in-print version. So, bring those statistics in writing. Leave them behind for the staffer to do all of their research and put into their memo, but give us a good story, okay? And then, most importantly, keep in touch with us after the meeting. We see probably 50 to 60 different constituents per week. It's hard to keep track of all of these things, so stay on top of us. We do the best that we can, but if you are in frequent contact with us, your issue is going to stay towards the top of our to-do list. The squeaky wheel gets the grease. Okay, all right. Now, this is actually a good stopping point. If anybody has any questions, I'd be happy to answer. Repeat the question. The question was whether there's any major opposition to the APA's policy agenda, especially when it comes to something like the Connect for Health Act, the one that has 64 co-sponsors right now. Typically, the major points of opposition that we run into are any bills that are going to cost a lot of money, especially in this Congress, with the House divided as narrowly as it is right now. There are a few members of Congress who have a lot of power, and they're very much against increasing the national debt in any way. So we're under a lot of pressure to make any bills budget neutral as much as possible. That being said, the APA endorsed legislation, not expensive. That's why we're seeing as much support as we are. The question was whether we have any data or studies on abuses of telehealth, inappropriate use and how common that is. That's a great question. I don't have an answer for you right now, but I can give you my contact information and get back to you. I can probably just comment on that. There aren't any actual studies. That's the first question, first answer. Having said that, there have been a number of lawsuits over the last few years directed towards people who are providing telemedicine, generally not in psychiatry, generally in other areas. As far as I know, the health insurers still see this as being a very low-risk activity. What other questions do we have before we get into the latter half of our presentation? Yes, we are. I mean, there's been a lot of people doing inpatient telepsychiatry and covering inpatient units, you know, from other states, living in different states. I mean, they're included in that group that I was talking about. Again, very few legal suits at all, but that doesn't mean to say they're actually doing it right. Yes. I don't know where it's there yet, but what about international telepsych, the one who's abroad, the one who practices in states? Is that something in discussion yet? Is it too early? So if a clinician is practicing abroad, is that the question? So a clinician is in another country, but they're seeing patients in a state where they're licensed. So the considerations there would be, first, payer level. So CMS has said that a practitioner for Medicare or Medicaid cannot be outside of the U.S., so what does your payer say? There might be private payers that might have something to that effect as well, so you would want to look at that. And then the other thing is data privacy. So just like we have HIPAA, we have high-tech, we have to adhere with other countries or other regions may have something similar around data privacy, their own regulations, and you would have to make sure that you're adhering not just with what's required here in the U.S., but there as well any time there's data transmitted. So there can be significant fines related to not adhering with that, and that's why some hospital systems or practices may be hesitant to do that. You would have to do an analysis of what regulations would be relevant there. All right, now for this part of the presentation, we wanted to give you all an idea of how each of us ended up in the advocacy world. If any of you guys are interested in becoming advocates yourself, we really wanted to highlight that there are a number of different ways to get involved, so we're just going to share our own stories. All right, now for myself, I've been interested in policy for a long time, but the specific focus in health care and mental health and telehealth, that developed over time. I started in college studying political science, knowing that I wanted to go to med school, interest in health care. I joined my local and state societies when I was a medical student, and I helped to advocate for general medical issues at the time. And then when I got to residency in Washington, D.C., I became more interested in advocating specifically for mental health issues on the local level, so I joined the Washington Psychiatric Society. From there, I got more and more involved. I worked my way up into volunteer positions with the APA, and then eventually that snowballed into a fellowship with the APA, working full-time in Congress, specifically for mental health issues, but being the only physician in the office, I cover all health care issues, really. But the biggest nugget of wisdom that I can offer is that getting involved in your local society, your state level or your city society, that is a good way to come across lots of different opportunities. I mean, they will be happy to have you join. They will often ask you to join this committee or that, and if you keep showing up, if you are committed, then it's easy for it to escalate into bigger and bigger leadership opportunities. All right, now Dr. Kahn. Thank you. So just to give you a little background, I started doing telepsych in 2011. That interest actually developed in residency and fellowship, and through involvement with the Telepsychiatry Committee of American Psychiatric Association and then also American Academy of Child and Adolescent Psychiatry, I then, over the years, got involved more and more with advocacy. And I don't think we get a lot of training in residency, fellowship, in advocacy, but it is so important, and it actually ended up being one of the most rewarding things that I do now. So that's why we actually were looking forward to this session, and I think the behind-the-scenes information that you gave was so helpful because sometimes we'll have these meetings and then we wonder, are they even listening? Is anything going to change? But it is really helpful to hear the other side. I think meeting with staffers, someone might think, well, it's someone who's very young. Maybe they're inexperienced. Are they actually going to help us? They're very, very knowledgeable. They're very motivated. Some of them are actually drafting the bills and the memos that go to the congressmember or the legislator. So I think taking those meetings very seriously as well is important. And I'm curious, in our audience, how many folks here have met with their legislators, either state or federal, whether it's just advocacy for anything psychiatry-related. Anyone? Yeah, so I know APA sends those out regularly since they're tracking it so closely, and I think that can be really, really helpful to extend our reach. I think you provided some nice tips on what's helpful when you are meeting with a legislator or a staffer. Through APA as well as ACAP, American Telemedicine Association, Dr. Yellowlees will talk about that. He was the president of ATA in the past, and then Center for Telehealth and eHealth Law as well. We've been able to advocate not just with Congress but with payers, so CMS, Department of Health and Human Services, DEA, especially with this flexibility trying to determine how they're going to approach it. They had a listening session, so we were able to be a part of that as well, meeting with administration, and I think the statistic I heard was of our 535 Congress members, 20 are physicians, none are psychiatrists, and they do want to hear from us with stories, de-identified patient stories. They may not want us. They know we're not going to necessarily be able to know the ins and outs of the policy and the details, but they do want to hear about how is this policy or potential policy going to impact your practice, how is it going to impact your patients who are going to be their constituents, so it kind of brings that policy to life for them. So I think there is a lot of value to this advocacy, and then there's best practices, guidance documents that we've worked on through our committees as well. Thank you. So my journey's been for about 40 years now in various different areas of advocacy. It actually started in Australia when I went out there in 1980. I discovered a large number of patients with Zernike-Korsakoff syndrome, which was related to thiamine deficiency, that were permanent members of long-term psychiatric hospitals. And I then investigated why that was and found out that Australian beer did not contain any thiamine, whereas European beers all did, and it was in the yeast. The Australians took the beer out of yeast. Took the yeast out of beer, I should say. And so I wrote an editorial for the Medical Journal of Australia recommending that yeast be added to Australian beer, or at least thiamine be added to Australian beer, and I did all the economics of it and showed what a great health idea this would be, what a simple public health intervention this was. And I got an amazing amount of feedback, mostly negative, and it was actually led by all groups, quite astonishingly to me at the time, but I was incredibly naive. It was actually led by the Australian Dieticians Association. And I would have thought they would have been on my side. Surely a good diet should include some thiamine. But they had a philosophy that you shouldn't add a good product... ..a good thing to a bad product. So, in other words, a good food to a bad product. And they somehow believed that if you added some thiamine to beer, that would turn everybody into bigger beer drinkers. I've never heard of a big beer drinker, you know, saying, I'm going to have an extra one because there's thiamine in it. So I got very interested in advocacy in that area at that time because I was just astonished by this response. And from about 1990, when I started seeing patients on video, I've been involved with telemedicine advocacy 10 years in Australia and 20 years here. And in Australia, when I started going to see people, I discovered that, essentially, the dollar was the most important thing in policy. And at that stage, I was arguing, you know, for reimbursement for telepsychiatry. And I got just simply told, no, that's never going to happen, it's going to cost more. And I said, but you've got all these rural folks who can't get any care. And quite honestly, the people in Canberra, in Australia, didn't care about that. Because it costs more, they weren't interested. Now, 10 years later, they'd actually changed their tune. The politics of the whole system had changed. And I ended up actually writing the documentation for the codes, for payment codes for Australia that came in in about 2002, working with, by then, some federal colleagues. But that took a good 10 or 12 years to do. Coming over to the States, I have been a long-standing member of the American Telemedicine Association. I was on the board for over a decade, was the president in 2017. So I've had an enormous amount of activity on the advocacy front through the ATA rather than the APA. I've also worked with the APA. But that's involved going to the Hill, doing presentations, having meetings with congressmen and congresswomen, lots of meetings with people from the various different important federal and state groups like the DEA, CMS, and medical boards, the development of policy and white papers. Again, it's all very interesting stuff. And in my case, also, research and creating evidence to support what I was doing, although I have to say I liked the comment about stories being the most important thing. I think they are. So I've done an enormous amount of advocacy over the last 30 years or so. And I guess I've got four things that I've learned from it, apart from the fact that it's actually really interesting and really worthwhile. But first of all is you shouldn't be naive when you go into it. Money really does count. And ultimately, money is really important. And so you've got to address that fact when you go for any innovation or any change. Secondly is you cannot be sure who is going to support you. I mean, I learned that from the dieticians early on. It's quite astonishing. You know, you think certain groups should support you, but then at the end of the day something's happened, some other agenda has occurred, and they don't support you. So you've really got to be very careful how you, in fact, present. And you essentially get your numbers right before you go and ask for things. In this state, or in this country, the killing argument is states versus federal rights. And you saw that with some of Shabana's presentation earlier on. And telemedicine has been dramatically adversely affected because of the differences between state and federal rights in this country. You know, we would all love to have a national medical license, for instance, but that's, I think, highly unlikely to ever happen, or I've spent hours and hours and hours trying to convince people it should. As most countries have already, because basically medical boards are run by the states. And finally, change can actually happen. I mean, we're in a different world now from 20 or 30 years ago, but it takes a lot of time and a lot of effort. But it's really worthwhile. And I think as physicians we have, there really is almost a sort of ethical sort of direction to us to work in these areas to try and improve things for the wider group of patients that we're serving. And so I'd just encourage you all to get involved in advocacy in whatever way interests you most. It's something we've got the skills, we've got the intelligence, we've got the knowledge to do this. And I'd really encourage you to be involved with APA or with any of your preferred organizations or groups and try and advocate for whatever you think is really important. And at the end of the day, it is a really worthwhile procedure, but you can carry on through most of your career. I mean, this is not a quick-time solution. So please do think about that. So I'm going to finish at that stage and hand back to Dr Khan, who's just going to run through some of the advocacy resources that the APA has for telepsychiatry. Because really we've got a tremendous set of resources that have been developed over a long period of time, and that's part of advocacy. So just a couple of more slides. We'll start with advocacy resources specifically. So if you go to psychiatry.org forward slash advocacy, there's the APA Political Action Committee, which is our voice on Capitol Hill, how we get individuals elected into Congress who are advocates of our field. The Congressional Advocacy Network, which is APA's political grassroots network. And our advocates here will connect with members of Congress to ensure that legislation is informed by the psychiatrist's experience. You can sign up for action alerts. I know you had mentioned that there are those emails that are generated, a draft of an email that you can send to your local legislator, and APA can be very, very helpful for this. So action alerts, you can sign up to receive advocacy alerts, get the most up-to-date resources, tools to take action on legislation that impacts psychiatry. And then advocacy staff at APA also has a monthly newsletter, and you can contact and reach advocacy staff at advocacy at psych.org by email as well. Telehealth specifically, so on the APA website, we have the Telepsychiatry Toolkit, which is a series of videos and also includes a blog that covers key telehealth relevant topics. There's a COVID-19 and telepsychiatry FAQ on there as well. The APA Practice Management Helpline is very helpful. You can contact them by email. It's available to all APA members to assist you in resolving any practice management questions. So I know they do get a lot of telehealth-specific questions there. And then there's recorded webinars, policy and practice insight series, so things like Advocacy 101, AI in Psychiatry, HIPAA compliance, telepsychiatry reimbursement, and many more. And this is our contact information. Feel free to reach out to us. And we did want to leave time, a lot of time for questions, so we'll stick around. APPLAUSE Well, thank you very much. Anybody got any particular questions? We've got about five minutes or so left, and we'd love to keep on talking. If not, you're going to get some of your time back. OK, well, thank you very much indeed for attending. It's really good to see you here, and have a great conference.

telepsychiatry

advocacy

telemedicine

policy changes

COVID-19 impact

reimbursement parity

legislative efforts

APA

Eric Jarman