A traveling doctor who treats medical cannabis patients is fighting new state rules that she claims discriminate against disabled, rural and low-income patients.

Dr. Mary Callison crisscrosses the state and uses video conferencing to certify and care for hundreds of medical marijuana patients in their own homes. A few times a week, Callison leaves her house in Hollis at first light and makes a daylong swing through one of Maine’s far-flung corners to sit with patients at their kitchen tables, in nursing homes or in a private room at a local community center.

Some of Callison’s patients are too sick to travel to see one of the Maine doctors willing to certify medical marijuana patients. Every county now has at least one medical provider who will certify patients, according to the state, but some of Callison’s patients are too sick to even get out of bed. Some don’t have a car or somebody who can drive them. Others can’t afford to hire a babysitter, take time off from work or pay a different doctor’s high marijuana certification fees.

“Everybody’s got a story, but in the end, many of these people will not receive appropriate medical care unless it comes to them,” Callison said. “I believe doctors have a responsibility to heal the sick. All the sick. If they can’t come to me, I’ll go to them. I’ll sit in their living rooms. I’ll talk cannabis. That does not make me less of a doctor. It makes me better. Just because it doesn’t happen in a doctor’s office, just because it involves cannabis, doesn’t mean it’s not good medicine.”

But Callison and other health care providers and advocates believe a new rule from the state Department of Health and Human Services will deprive patients like hers of their access to medical marijuana and outlaw the heart of her medical practice. The new rules that will go into effect Feb. 1 require a physical exam before a doctor can certify a medical marijuana patient they are meeting for the first time. The question is about how and where that exam must take place.

The rule seems to contradict itself. In one section, it specifically says nothing in the rule prohibits remote health care certification. In another, it outlines how the doctor must conduct a physical exam similar to an office visit or outpatient treatment in terms of site, extent, duration and frequency at a clinicilly appropriate permanent location. DHHS has issued statements on its website saying telemedicine is safe, but those who use the services say the rule needs to be clear.

“Those are just words,” said Tammie Snow, Callison’s lawyer. “If my client ends up in court one day, I want to cite state statute in her defense, not a departmental FAQ.”

NEW MEDICAL METHODS

Maine has a strong telemedicine parity law, first adopted in 2009 and strengthened by rule changes in 2016, that requires health care providers to be reimbursed for any service delivered by telemedicine at the same rate as those delivered in person. Under last year’s telemedicine rule changes, a telemedical provider can use information technology, like real-time visual telecommunications, to diagnose, monitor or treat a patient, as long as the provider deems it medically appropriate.

Dustin Sulak, a Falmouth doctor who specializes in medical cannabis, said the fact that there have only been a handful of licensure disciplinary actions against doctors in a field of medicine that has been legal in Maine since 2009 is a sign that the industry is a good one. DHHS should rely on the medical boards to do their jobs, Sulak said, rather than jeopardize the safety of Maine’s most vulnerable patients by using its rules to try to police providers.

Sulak said he thinks some medical marijuana patients must be seen in person, in a clinical setting, but others are served well by telemedicine or home visits.

“There are ways to do telemedicine right,” Sulak said. “If we certify a patient over the phone, we require that patient to have been seen by the primary care provider in the last month, including a physical exam. We have them send their note to our offices before so we know what’s going on with the patient even if we can’t see it. Specialists relying on primary care providers is very common in medicine, especially when there is a lack of specialty services, like we see in the field of medical cannabis.”

It’s a rigorous screening process, Sulak said. Most people who aren’t really sick never even make it past the front desk screening.

Medical marijuana advocates such as Hillary Lister, the former director of Medical Marijuana Caregivers of Maine, say it is wrong for Maine, which adopted telemedicine as a way to increase health care access to its aging, far-flung population, to single out medical cannabis for telemedicine exclusion. She ticked off examples of the homebound people in remote parts of the state she knows who are enduring life-threatening illnesses with the help of cannabis treatment monitored by telemedicine and home visits.

“If this rule goes into effect as it is written, it would represent a huge step backward for health care access in Maine,” Lister said. “It would literally hurt people.”

REACHING RURAL PATIENTS

One of those potential victims is Micheline Clavette. The 54-year-old Madawaska woman said medical cannabis creams, tinctures and smokeable flower have brought her relief from the pain of degenerative joint disease and PTSD that she hadn’t been able to achieve despite 20 years of doctor prescriptions. She said that she hasn’t taken a pill in the seven years since obtaining her medical marijuana certification.

It took Clavette, who is disabled, almost four years to save up the $200 she needed to pay the doctor to get that first certification, she said. At the time, no doctors in her area would certify a medical marijuana patient, so for the next five years, Clavette would drive more than 300 miles once a year to see a certifying doctor in Hallowell or Falmouth. But two years ago, Clavette found her old car unable to make the drive and herself unable to pay the fee.

She talked to her local caregiver, who referred her to Callison. A few days later, after sending her medical records and talking to Callison on a video conference call, she was certified. It cost her $75 instead of $200. Callison spent more time with her during the initial certification exam, asking her about each of her three qualifying medical conditions, than the doctors that certified her in their offices. And she calls back between appointments to check up on her, too.

“I actually cried after my first exam with Dr. Mary,” Clavette said. “It was amazing! Why couldn’t I have found this five years ago! It would’ve saved me a thousand dollars. Don’t forget, insurance doesn’t cover my marijuana. I have to pay for that out of pocket. So the lower fee, the convenience, it all meant so much. Telemedicine saved me time, money, anxiety, wear and tear on a very old vehicle, but most of all, it helps me get my medicine, and the medicine, it’s saved my life.”

John Engler has found telemedicine to be a convenient way to renew his own medical marijuana certification, but the 34-year-old owner of High Sail Cannabis in Auburn said he knows that some of his medical marijuana patients can’t afford the annual $200 fee that many physicians charge for in-office certifications. Engler doesn’t mind a face-to-face exam requirement for a first-time certification, but said renewals should be easy and affordable, and telemedicine makes that possible.

Engler, who moved back home to Maine to launch a caregiving business, began recommending telemedicine renewals shortly after opening High Sail in July 2016.

“For people using cannabis to treat a lifelong debilitating condition, an in-person visit on top of all the medical costs and the time off from work and the rest is expensive, and in some cases, prohibitive,” Engler said. “It’s a structural cost built into the system, none of which is covered by insurance. Doctors have to cover their overhead, the office staff, the rent. I get it. But for some patients, that’s just too much. Low income, fixed income, they need the lower telemedicine fees.”

CLARITY AND COMPLIANCE

While some patients and providers lament the murkiness of the new telemedicine rule, the department has taken steps to try to reassure the community and outline how it will interpret and enforce its new rules. It amended its rules to add in the telemedicine protection statement after concern was raised at a public hearing in June. And it also issued a departmental FAQ to its website that further expanded upon the telemedicine rule, among others.

In response to a query from the Press Herald, DHHS spokeswoman Emily Spencer further clarified, saying the physical exam that will be required to establish a bonafide doctor-patient relationship can be a visual assessment that is done through technology. That statement, and the additional language included in the FAQ, seem to clear a path for Callison to continue her video and at-home certifications, but her lawyer, Snow, said the department should amend the rule itself to include all those protections.

The department said it needed to add the telemedicine rule, and expand on the definition of a bonafide doctor-patient relationship, after consultation with its stakeholders, state medical licensing boards, and subject matter experts to provide a “fuller understanding of clinical responsibilities related to a written certification, and around patient safety and compliance,” in written response to public testimony delivered in a June hearing on the proposed rules.

A few Maine doctors have gotten in trouble for improper medical marijuana certifications.

In 2014, a Lewiston gynecologist, Keng-cheong Leong, surrendered his medical license for certifying patients without appropriate record keeping or examinations, some of which were conducted in “unorthodox locations,” including a marijuana dispensary.

Also in 2014, Maine reprimanded William Ortiz and fined the Caribou doctor $2,000 for unprofessional conduct for issuing 44 certifications without exams after conducting a weekend-long marijuana seminar at two Orono hotels.

Some states, such as Washington and Colorado, have adopted legislation that requires physicans to conduct in-person examinations or changed their telehealth rules to ban medical marijuana certifications or treatment. Last summer, Florida adopted legislation that bans doctors from using telemedicine to issue a cannabis prescription. Some states, like California, allow it, as long as the examination meets the acceptable standard of care.

Lister said it is understandable that DHHS wanted to take steps to keep certifications from happening at hotels or festivals, but said the rule change goes beyond what is needed to stop 3 a.m. certifications like the ones that Ortiz was conducting at the University Motor Inn and has unintended consequences for homebound people in rural Maine who can’t travel to get their medical cannabis.

PETITIONING FOR CHANGE

The new rule goes far beyond a minor technical change, which is how DHHS billed it, and changes Maine policy, something that should only be done through legislation, said Lister, who lobbies the Legislature on medical marijuana, among other issues. The Legislature will consider a host of medical marijuana bills this session, with initial hearings starting this month, that could offer state lawmakers an opportunity to amend the telemedicine rule.

But Callison doesn’t want to wait. She is petitioning DHHS to rewrite the rule to allow certifications and treatment to occur at all doctor’s offices, remote locations where both the provider and patient are present, or by telemedicine, as long as relevant physical exams are conducted as needed to address the patient’s debilitating condition. She has collected about 100 petition signatures in three weeks. She needs at least 150 if she wants to force DHHS to officially consider the petition.

Even if she succeeds, the new medical marijuana rules would probably go into effect before DHHS considers her petition. So Callison has Snow, who has represented a number of caregivers in civil and criminal court across the state, ready to go to court to stop DHHS from enacting the rules until after it addresses Callison’s petition.