How Telehealth Changed Prescribing Patterns Post-COVID

The COVID-19 pandemic didn't just change how we see doctors — it fundamentally altered how medications are prescribed in the United States. When the DEA issued emergency waivers allowing practitioners to prescribe controlled substances via telehealth without an in-person evaluation, it opened a door that has proven remarkably difficult to close. The consequences are visible in Medicare Part D data: shifts in prescribing volumes, geographic patterns, and a new category of fraud risk that regulators are still learning to detect.

The Great Telehealth Experiment

Before March 2020, the DEA required an in-person medical evaluation before a practitioner could prescribe Schedule II-V controlled substances. The Ryan Haight Online Pharmacy Consumer Protection Act (2008) was designed to prevent exactly the kind of remote prescribing that became standard practice almost overnight.

When the public health emergency was declared, the DEA issued blanket waivers under 21 USC §802(54)(D). Suddenly, a psychiatrist in New York could prescribe Adderall to a patient in Florida they'd never met in person. A pain management specialist could continue opioid prescriptions via video call. The barriers that had taken years to establish evaporated in days.

What the Data Shows

Prescribing Volume Shifts by State

While CMS doesn't directly flag telehealth prescriptions in Part D data, we can identify proxy signals. States with traditionally lower provider-to-patient ratios saw disproportionate increases in prescribing activity from out-of-state providers — a hallmark of telehealth. The states with the highest cost per claim often reflect expensive specialty drugs prescribed remotely:

Psychiatry Led the Telehealth Revolution

Mental health was the specialty most transformed by telehealth. Psychiatrists and psychiatric nurse practitioners adapted quickly to video consultations, and their prescribing patterns show it. Among the specialties most associated with telehealth adoption:

Controlled Substances via Telehealth: The Risk Landscape

The DEA Waiver Timeline

The trajectory of controlled substance telehealth policy has been a regulatory rollercoaster:

• March 2020: DEA issues blanket waiver for telehealth prescribing of all scheduled substances
• 2020-2022: Telehealth controlled substance prescriptions surge, particularly for stimulants and benzodiazepines
• November 2023: DEA proposes new rules requiring at least one in-person visit for Schedule II substances
• 2024: Rules delayed after backlash from telehealth industry and patient advocates
• 2025: Temporary extensions continue — the "permanent temporary" waiver

Stimulant Prescribing Explosion

Perhaps no drug category was more affected by telehealth than ADHD stimulants. Companies like Cerebral, Done, and Ahead built entire business models around remote ADHD diagnosis and stimulant prescribing. The DEA and DOJ eventually took action — Cerebral's CEO faced charges, and Done's founders were indicted — but the broader pattern persists.

In Medicare specifically, stimulant prescriptions for the 65+ population are relatively rare, but the telehealth infrastructure built for younger patients has spillover effects on Medicare prescribing patterns. Providers who established high-volume telehealth practices for commercial patients often also see Medicare patients.

Geographic Implications

States Most Vulnerable to Telehealth Prescribing Risks

States with the highest baseline opioid prescribing rates face compounded risk when telehealth is added to the equation. If a state already has high opioid rates from in-person visits, remote prescribing from out-of-state providers can layer additional risk on top:

Cross-Border Prescribing Patterns

One of the most significant changes telehealth introduced is the erosion of geographic prescribing boundaries. Historically, a provider in Alabama prescribed to patients in Alabama. Telehealth broke this link. We see evidence of this in the data: providers with patient panels spanning multiple states, prescribing patterns that don't match their physical location's demographics, and cost-per-claim figures that suggest specialty drug prescribing far from traditional specialty centers.

The Regulatory Response

What the DEA Wants

The DEA has proposed a framework that would require:

• At least one in-person evaluation before prescribing Schedule II controlled substances via telehealth
• Mandatory PDMP checks across all states where the patient has resided in the past year
• Registration in the state where the patient is located, not just the provider's home state
• Quantity limits for initial telehealth prescriptions (30-day supply for Schedule II)

What Providers and Patients Want

The pushback against stricter rules comes from legitimate concerns:

• Rural access: Patients in underserved areas finally have access to specialists via telehealth
• Mental health: The psychiatrist shortage means many patients can only access care remotely
• Continuity: Patients who established telehealth relationships during COVID don't want to be forced back to in-person
• Disability: Homebound patients rely on telehealth for essential medication management

Identifying Telehealth-Related Fraud Risk

Red Flags in the Data

While we can't definitively identify telehealth prescriptions in Medicare Part D claims data, several proxy indicators suggest high-volume telehealth prescribing that warrants scrutiny:

The Telehealth-Fraud Nexus: Case Studies

Operation Rubber Stamp (2023)

The DOJ's largest telehealth fraud takedown charged 193 defendants with $2.75 billion in fraud. The scheme involved telehealth companies that paid doctors to order medically unnecessary genetic tests, durable medical equipment, and prescription medications based on brief or nonexistent telehealth encounters. Many of the prescriptions appeared in Medicare Part D data as legitimate claims.

The Cerebral/Done Cases (2022-2024)

Digital health startups Cerebral and Done were accused of prescribing controlled substances (primarily stimulants) with inadequate evaluation. While primarily affecting commercial insurance, the cases highlighted how telehealth platforms could operate as high-volume prescribing operations with minimal clinical oversight. Done's founder was charged with conspiring to distribute controlled substances.

Medicare Advantage Telehealth Schemes

Multiple cases have involved telehealth companies that arranged brief phone calls with Medicare beneficiaries, then billed for comprehensive office visits and generated prescriptions and orders for expensive medications, braces, and genetic tests. The prescriptions from these encounters flow through Part D.

Policy Recommendations

Looking Ahead

Telehealth prescribing isn't going away — nor should it. The access benefits, particularly for rural and underserved populations, are real and significant. But the current regulatory framework was designed for an era when prescribing required physical proximity, and it hasn't caught up to the reality of remote healthcare delivery.

The challenge is finding the balance: maintaining access for the vast majority of patients who benefit from telehealth while detecting and preventing the minority of cases where remote prescribing enables fraud, overprescribing, or patient harm. The data infrastructure to do this exists — it just needs to be better connected and more consistently applied.

Among the 1,380,665 prescribers in our Medicare Part D dataset, the telehealth revolution represents perhaps the most significant structural change in prescribing practice since the advent of electronic health records. Understanding its impact — and its risks — is essential for anyone trying to make sense of modern prescribing data.

Explore Related Analysis

• Anatomy of a Pill Mill: What Medicare Data Reveals
• The Controlled Substance Pipeline: Beyond Opioids
• Geographic Hotspots for Opioid Prescribing
• How We Score Prescribing Risk
• Rural America's Prescribing Problem