Vivian B. Pender, MD

 had become a household word. From March 2020 to June 2020, 30% of all outpatient care was delivered via telehealth, versus 0.8% in 2019.

 Today, telehealth is becoming a standard tool in care delivery as health care clinicians strike an appropriate balance of in-person and virtual care. Moving forward, we expect telehealth to account for 20% to 30% of care delivery.

Fortunately, Congress passed a provision in the Consolidated Appropriations Act in 2020 to increase access to telemental health services by permanently waiving historical Medicare restrictions like the geographic requirement for these services. However, the provision included an unexpected and unnecessary in-person requirement: Physicians must see their patients in-person at least 6 months prior to their telemental visit before Medicare will reimburse for the telehealth visit.

The American Telemedicine Association (ATA) strongly opposes statutory in-person requirements, as they create arbitrary and clinically unsupported barriers to accessing affordable, quality health care.

 Requirements such as these could negatively impact those in underserved communities who may not be able to procure an in-person exam due to provider shortages, work, lack of childcare, and/or other resources.

There is no clinical evidence for an arbitrary in-person requirement before a patient can access telehealth services. In fact, evidence has demonstrated that telemental services like telepsychiatry are just as effective as in-person visits.

 Further, there is clear consensus that a provider can establish a relationship with a patient via a telehealth visit.

The Federation of State Medical Boards, the association of state regulators that oversees standards of medical care, stated that “the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised health care practitioner) and patient.”

Even before the COVID-19 public health emergency, the health care system in the United States was in crisis, with dramatic provider shortages, an aging population that required more and more health care services, and the explosion of chronic diseases. Although the numbers of aging and chronically ill patients continues to grow, the deficit of health care clinicians is expected to reach a quarter of a million by 2030.

As demonstrated during the pandemic, telehealth increased the capacity of health care providers across the country by removing geographic and other physical barriers. Telehealth was a lifeline for clinicians and patients during the public health emergency; this could be arbitrarily and instantly severed if the in-person requirement is enacted.

Furthermore, recent data from the Centers for Disease Prevention and Control demonstrated that 23% of American adults do not have an existing relationship with a health care provider, a statistic that is alarmingly high in minority populations.

 In the case of telemental health, explicitly denying a patient’s access to care based on their inability to find a scarce mental health clinician is simply unreasonable.

Supporting a Hybrid Approach to Quality Care Delivery

Simply put, the in-person requirement for telehealth services is at odds with the direction telehealth policy has moved over the past decade. Medicare, historically, has remained deferential to state laws on professional practice requirements and clinical standards of care. Today, no state practice of medicine law in the United States requires a prior in-person visit.

We as a society must support the availability of life-saving care for all Americans, regardless of whether they have an established relationship with a medical provider. The ATA urges Congress to ensure telemental health services continue post-pandemic and defer to states and individual payers to determine telehealth prerequisites. For the Medicare program, Congress should work with the Department of Health and Human Services (HHS) to ensure the HHS Secretary has the authority at the regulatory level to implement any appropriate health care requirements. By explicitly limiting care in statute, legislators will unnecessarily stifle innovation and tie the hands of regulators, providers, and patients.

It is important to note that there will always be an important role for in-person care. Telehealth is simply another tool for clinicians, within the requirements of their license and the appropriate standard of care, to deliver quality care to patients where and when they need it, and it should be regulated accordingly.

Over the past 18 months, it has become clear that there must be a 2-channel system of care delivery, appropriately balancing in-person and virtual care. A hybrid approach to care delivery is the only way our health care system will survive, and the only way all Americans will receive quality, affordable, and convenient care in a post-COVID world.

is chair of the board of the American Telemedicine Association, and the editor of 

. He is also a professor at Harvard Medical School and 

senior advisor of Virtual Care at Mass General Brigham. 

is president of the American Psychiatric Association and clinical professor of psychiatry at Weill Cornell Medical College.

1. HealthLeaders. ATA-Chair:-Telemedicine-Choices-In-Next-Few-Months-Will-Shape-The-Next-Decade. Accessed September 9, 2021. 

https://www.healthleadersmedia.com/technology/ata-chair-telemedicine-choices-next-few-months-will-shape-next-decade

2. ATA. ATA-Overview-of-In-Person-Requirements. Accessed September 8, 2021. 

https://www.americantelemed.org/wp-content/uploads/2021/06/ATA-Overview-of-In-Person-Requirements-1.pdf

3. American Psychological Association. How-well-is-telepsychology-working? Accessed September 9, 2021. 

https://www.apa.org/monitor/2020/07/cover-telepsychology

4. Federation of State Medical Boards. Model-Policy-for-the-Appropriate-Use-of-Telemedicine-Technologies-in-the-Practice-of-Medicine. Accessed September 9, 2021. 

https://www.fsmb.org/siteassets/advocacy/policies/fsmb_telemedicine_policy.pdf

5. Behavior Health + Economic Networks. Addressing-the-Behavioral-Health-Workforce-Shortage. Accessed September 9, 2021. 

https://www.bhecon.org/wp-content/uploads/2016/09/BHECON-Behavioral-Health-Workforce-Fact-Sheet-2018.pdf

6. Kaiser Family Foundation. Adults-Who-Report-Not-Having-a-Personal-Doctor/-Health-Care-Provider-by-Race/-Ethnicity. Accessed September 9, 2021. 

https://www.kff.org/other/state-indicator/percent-of-adults-reporting-not-having-a-personal-doctor-by-raceethnicity/?currentTimeframe=0&selectedDistributions=all-adults--white--black--hispanic--asian-native-hawaiian-or-pacific-islander--american-indian-alaska-native--other&sortModel=%7B%22colId%22:%22All%20Adults%22,%22sort%22:%22desc%22%7D

 Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

Articles

Medicare's in-person requirement threatens access to quality care. 

Clinically Based Policy Decisions: In-Person Requirements for Telehealth Create Unnecessary Barriers 

Slideshows

In the spirit of Human Trafficking Awareness Month, we hope this short quiz raises awareness when considering clinical vulnerability in victims.

Human Trafficking Training in Health Care

Although it is estimated that up to 50% of victims will see a health care professional while in captivity, frequently there is no intervention or assessment.

 Moreover, only about 40% of health care professionals have received any information, education, or training about human trafficking.

It may be difficult to determine whether the victim is being held against his or her will. When victims are seen by a health care professional, they are frequently accompanied by their abuser. The victim may be afraid and intimidated, or she may be extremely defensive, loud, and uncooperative. It is important to distinguish her behavior with and without her pimp.

When assessing the patient, be aware that in the presence of the abuser-who will often try to speak for the patient-the victim may appear depressed, anxious, fearful, or submissive. There is likely to be poor eye contact and a scripted robotic story. When you ask for clarification, the narrative will often become incoherent. She may dissociate, become confused, and have poor concentration and a short attention span. Frequently, a victim will be unable to give a coherent history.

Recognizing and Treating Victims and Survivors of Human Trafficking

 Stevens M, Berishai K. The anatomy of human trafficking: learning about the blues. 

 Becker HJ, Bechtel KI. Recognizing victims of human trafficking in the pediatric emergency department. 

 Beck ME, Lineer MM, Melzer-Lange M, et al. Medical providers’ understanding of sex trafficking and their experience with at-risk patients. 

Poll

Is taking a medical history from a victim of human trafficking similar to taking a history from any other patient? Find out in this quiz.

Mini Quiz: Human Trafficking

Sex trafficking of an adult is legally defined as the use of force, fraud, or coercion for the procurement of commercial sexual services. Sex trafficking of a minor is by statute illegal and must be reported: force, fraud, or coercion does not have to be shown in these cases.

The Nordic model-a human rights and gender equality based approach also known as the Swedish model-is an effective approach to preventing trafficking and exploitation.

 This set of laws and policies penalizes the demand for commercial sex while decriminalizing individuals in prostitution and providing them with support services, including help for those who wish to exit prostitution. Based on an approach first adopted in Sweden in 1999 and followed by Norway and Iceland, the 2 main goals of this model are to curb the demand for commercial sex that fuels sex trafficking and to promote equality between men and women.

The internationally accepted definition of trafficking is contained in the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children.

 Among the key tenets of the UN Trafficking Protocol:

• Trafficking does not require movement

• Means include threat or use of force or other forms of coercion, abduction, fraud, deception, the abuse of power, or a position of vulnerability

• The consent of victims of trafficking is irrelevant

The US Trafficking Victims Protection Act was passed in 2000.

 Subsequently, the New York State 2008 Safe Harbor Act I was enacted, making New York the first state to adopt this type of law.

 It mandates the removal of minor victims aged up to 16 years from the criminal justice and juvenile delinquency systems and provides them with specialized services. The 2013 Safe Harbor Act II closed the loophole for victims of trafficking aged 16 and 17 years. Finally, the 2015 New York Trafficking of Victims Protection and Justice Act:

• Aligned the penalties for buying sex from a minor with those for statutory rape

• Established sex trafficking as an affirmative defense to prostitution

• Provided a civil remedy for victims to recover damages and reasonable attorney’s fees from their exploiters

• Developed protocols to increase law enforcement’s awareness to better identify and assist human trafficking victims

• Eliminated the stigmatizing word “prostitute” used in the New York Penal Code and replaced it with the term “person used for prostitution”

Fraudulent advertising that promises jobs such as modeling, acting, waitressing, or bartending is used to lure victims. The victims are mostly women and children who come from all socio-economic levels and urban, suburban, and rural settings. Victims who come into contact with those who can help them (eg, law enforcement, shelter providers, health care providers, and outreach workers) often remain unidentified because victims do not identify themselves as such; and others do not always view victims as victims.

Ironically, many do not believe that they are victims of a crime. This often results from their psychological vulnerability, experiences of abuse, lack of education and understanding of human trafficking, and lack of awareness of their rights as a victim. But according to law enforcement and service providers who have worked with victims, victims are also frequently told by their traffickers that they are to blame for their circumstances and that they are criminals who will be deported or arrested if caught. Because of their past and current experiences of abuse, many believe this portrayal of reality.

In other situations, the victim has come to depend on her trafficker and views the trafficker as her protector/boyfriend. Service providers equate this to the Stockholm syndrome experienced by prisoners of war. In these cases, victims not only do not see themselves as victims, but they do not believe their trafficker has done anything wrong. When victims don’t see themselves as such, the interactions with law enforcement and others trying to help them are often negative and sometimes even hostile. According to law enforcement and some shelter providers, this is especially the case with minor victims of sex trafficking.

Ironically, many do not believe that they are victims of a crime.

Moreover, law enforcement may see victims as illegal immigrants or as prostitutes (even in cases involving minors). These cases reinforce the message that victims will be treated as criminals if they come to the attention of authorities and buttress the perception that they are to blame, which enhances the power and control that traffickers have over them.

It may be difficult to determine whether the victim is being held against his or her will. When victims are seen by a health care professional, they are frequently accompanied by their abuser. The victim may be afraid and intimidated, or she may be extremely defensive, loud, and uncooperative. It is important to distinguish her behavior with and without her pimp. The questions in 

Physical examination that reveals injuries, signs of abuse, tattoos or branding, and poor general health as well as untreated STDs and multiple pregnancies is often indicative of victimization. Other signals to note are the use of terminology of the game (eg, “Daddy,” “Wifey,” “in the life”); working in a strip club; or inability to remember when or where events took place.

 Not all of these need to be present simultaneously, but the more that are, the higher the likelihood that the person is a victim of trafficking.

While the criminal and hidden nature of the crime is a major obstacle, law enforcement and service providers acknowledge that a lack of awareness confounds the problem. That is, even if victims were more visible, most of the general public would not recognize a victim if they saw one. The experiences in the field suggest that, across communities, most people do not believe that human trafficking exists in today’s society and, in particular, in their communities. Even in those areas where attempts have been made to raise awareness, there remains confusion regarding who is a victim.

“A” grew up in the suburbs. She was 6 years old when an older boy raped her. Although the police were notified, the boy was never arrested. At age 12, she became involved with a neighbor who befriended her and then raped her repeatedly over a 3-year period. At age 15, the neighbor’s cousin became her pimp. He threatened that he would rape her sister if she told anyone. She lived at home and graduated high school. On weekends, she would have sex with up to 20 men a night. She did not run away. She felt invisible and hoped that someone would notice.

“B” grew up in a Midwestern rural setting. Her parents were always fighting and separated when she was 13 years old. She and her siblings lived in poverty with her mother, who worked as a waitress in a local restaurant. “B” began abusing alcohol and drugs and dropped out of high school. She doesn’t remember her first sexual encounter with an older man who introduced her to the commercial sex trade at age 14.

“C” grew up in a big sprawling city. Gangs, guns, and violence surrounded him. Not uncommonly, he witnessed murders that affected him deeply. He could not abide all the violence and decided it would be better if he were a girl. When he attempted a sex change, he was bullied and beaten. And then he was raped. After years of this, he left the US and became a transgender sex worker. He belongs to the International Union of Sex Workers, a trade union based in the UK.

Victims of sex trafficking are often found in the streets or working in establishments that offer commercial sex acts (eg, brothels, strip clubs, pornography production houses). Such establishments may operate under the guise of massage parlors, escort services, adult bookstores, modeling studios, and bars/strip clubs.

While the criminal and hidden nature of the crime is a major obstacle, law enforcement and service providers acknowledge that a lack of awareness confounds the problem.

Anyone can report suspected trafficking cases. If the victim is under 18, US professionals who work in law enforcement, health care, social care, mental health, and education are mandated to report such cases.

 If you suspect that you are seeing a victim of sex trafficking, here’s what you can do:

 Call the National Human Trafficking Resource Center at 1-888-373-7888 (24/7), the Department of Homeland Security at 1-866-347-2423 (24/7), or the US Department of Justice at 1-888-428-7581 from 9:00 am to 5:00 pm (EST). You can also submit a tip online at 

. Victims, including undocumented individuals, are eligible for services and immigration assistance.

 Contact your local FBI office; in New York contact Anthony Bivona, Supervisory Special Agent, Civil Rights/Public Corruption, Squad C-2: 212-384-2806 (office), 646-210-9831 (mobile).

 Contact the US Department of Justice AMBER Alert Program if you suspect a child is being trafficked. The mission of the US Department of Justice AMBER Alert Training and Technical Assistance Program is to safely recover missing, endangered, or abducted children through the coordinated efforts of law enforcement, media, transportation, and other partners by using training and technology to enhance response capacities and capabilities and increase public participation. As of December 31, 2014, 728 abducted children have been recovered as a result of the AMBER Alert Program. Call the National Center for Missing and Exploited Children at 1-800-THE-LOST (1-800-843-5678).

 The Administration for Children & Families has the following programs. The Office of Refugee Resettlement certifies adult foreign victims of human trafficking and provides federal eligibility letters to minor foreign victims of human trafficking so that they can receive services available for human trafficking victims. The Family and Youth Services Bureau provides grants to service and technical assistance providers working with victims of trafficking through multiple runaway and homeless youth programs and family violence and prevention services.

 An excellent contact worldwide is the International Office of Migration in New York and Geneva, Switzerland.

 for ways you can help advocate to end human trafficking.

The road to recovery for human trafficking victims is intense and requires intervention and care on multiple comprehensive levels. Trafficked victims have been through extensive personal hardships that may include isolation from family members and severed relationships from their home community, as well as physical abuse and medical problems from months or years in slavery. Housing, food and clothing, medical care, legal assistance, vocational training, peer counseling, and psychological assessment and treatment are generally all necessary. Expertise in the treatment of the severest forms of trauma is important. Establishment of trust, long-term commitment, medications to alleviate symptoms, step-wise plans, and integrated care are crucial.

The stereotype regarding international sex trafficking exists not only among the general public but among some law enforcement and service providers. That is, victims are viewed as foreign-born, young females forced into prostitution. It is evident-especially when talking with providers who work with domestic runaway and homeless youths-that there is an overall lack of knowledge and understanding that human trafficking can occur. Specifically, the fact that the prostitution of US minors likely constitutes human trafficking is not well understood by most health care professionals or even law enforcement.

Popular media portrayals and high-profile cases are possible explanations for the lack of a comprehensive understanding of the crime of human trafficking and its victims. Specifically, the lack of focus on domestic victims (eg, US citizens or legal permanent residents), male victims, and labor trafficking (which significantly overlaps with sex trafficking) is recognized as a contributing factor to the misconceptions surrounding this crime.

In April 2015 a CME conference and webinar, Human Trafficking: Training Healthcare were held at Weill Cornell Medical College in New York. I spoke at the conference, as did many others, including Mark Smaller, PhD, President of the American Psychoanalytic Association; Holly Austin Smith, a public speaker and survivor of the commercial sex trade; Anthony Bivona, FBI Special Agent; US Congresswoman Carolyn Maloney; Assistant US Attorney Karine Moreno-Taxman; Weill Cornell Dean Laurie Glimcher, MD; Julia Geynisman, MD, Founder of the New York Presbyterian Survivor Clinic; Ruth Fischer, MD, Child Psychiatrist and Psychoanalyst; Adrienne Harris, PhD, Psychoanalyst; and Taina Bien-AimÃ©e, Esq, Executive Director of the Coalition Against Trafficking in Women. Many of the points discussed in this article were covered in this conference. A Vimeo link to the conference is available at 

Dr. Pender is Clinical Associate Professor of Psychiatry at Weill Cornell Medical College; Training and Supervising Psychoanalyst, Columbia University, Center for Psychoanalytic Training and Research in New York. She reports no conflicts of interest concerning the subject matter of this article.

 Equality Now. What Is the Nordic Model? 

 United Nations Office on Drugs and Crime. 

https://www.unodc.org/unodc/en/human-trafficking/

 United Nations Human Rights: Office of the High Commissioner. Optional Protocol to the Convention on the Rights of the Child on Sale of Children, Child Prostitution and Child Pornography. 

http://www.ohchr.org/EN/ProfessionalInterest/Pages/OPSCCRC.aspx

 US Department of State. Office to Monitor and Combat Trafficking in Persons. 

 Polaris: Freedom Happens Now. State Laws and Issue Briefs. 

https://polarisproject.org/state-laws-issue-briefs

 Barrows F. Human trafficking and the healthcare professional. 

 US Department of Justice. Human Trafficking. 

https://www.justice.gov/usao-cdca/human-trafficking

 Federal Bureau of Investigation. Violent Crimes Against Children. 

http://www.fbi.gov/hq/cid/cac/crimesmain.htm

 National Center for Missing and Exploited Children. 

 Baral SD, Friedman MR, Geibel S, et al. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. 

The road to recovery for human trafficking victims is intense and requires intervention and care on multiple comprehensive levels.