The world is a year into the Covid-19 pandemic, and much of daily life has changed during the past year. Almost all of those changes were radical, affecting how individuals spend their days working, learning, worshiping, and just living. Medicine is not only toiling on the front line of the pandemic but has also been radically transformed by it, and one of the most profound changes is the necessity-driven boom in telemedicine services.
But a simple shift from in-person clinic visits to Zoom visits is not really all that simple, as a perspective published online by New England Journal of Medicine details.
“The rapid growth of telemedicine during the Covid-19 pandemic has focused renewed attention on the debate over physician licensure,” write Ateev Mehtrota, MD, Alok Nimgaonkar, BA, and Barak Richman, JD, PhD, of Harvard, Tufts, and Duke respectively. “Before the pandemic, states typically licensed physicians according to policies outlined in each state’s medical practice act, which dictate that physicians must be licensed in the state where the patient is located. This requirement creates substantial administrative and financial hurdles for physicians hoping to use telemedicine to treat out-of-state patients.”
To their credit, many states moved quickly in the early days of the pandemic to issue temporary orders that permitted out-of-state clinicians to treat in-state patients via telemedicine. At the same time, Medicare and Medicaid temporarily waived their requirement that physicians must be licensed in the state where the patient lives.
Many in medicine point to the surge in telemedicine as a silver-lining to the pandemic; however, turning that silver lining into an ironclad advance will require licensure reforms, which may be a heavy lift since licensure authority rests with the states.
How heavy is the lift? Well, it required a ruling from the Federal Trade Commission to get North Caroline to allow nondentists to provide teeth-whitening services—a ruling that was cited in a U.S. Supreme Court case that challenged the Texas licensure limits on telemedicine.
There is precedent for the federal government to provide a remedy as it did with “… the VA MISSION Act of 2018 requires states to allow out-of-state clinicians to practice telemedicine within the Veterans Affairs (VA) system. The growth of interstate telemedicine has created another opportunity for the federal government to intervene,” Mehtrota et al wrote.
In the perspective, the authors review four potential reforms to address the licensure issue:
- The already existing Interstate Medical Licensure Compact that is “a mutual agreement currently among 28 states and Guam to expedite the traditional process for physicians to obtain additional state licenses.” For a fee of $700 an individual physician can join the compact and then pay an additional fee (ranging from $75 to $790) to the state in which he or she is seeking a license. Congress could legislate wider participation by states in this compact, but practically speaking the compact has not attracted wide use since its inception in 2017 through March 2020 only 2,591 physicians signed up.
- Reciprocity among states—automatically recognizing the licensure of another state—is another option, and it is already used for physicians who practice in the VA system.
- Currently licensing is based on the patient’s location but flipping this so the licensure is based on the physician’s location is another option that has gained some legislative support.
- Another option, and this one would be a truly radical change for medical licensure, is a federal-issued, national medical license. Clinicians who want to practice across state lines could get a national license in addition to a state-issued license.
The authors note that a national license may be a non-starter because “… it overlooks more than a century of experience with state-based licensure systems. Boards also play an important role in disciplinary activity and take action in the cases of thousands of physicians each year. Switching to a federal licensure system could undermine state-based disciplinary authority. Moreover, both physicians who provide predominantly in-person care and state medical boards have a vested interest in maintaining state-based licensure systems to limit competition from out-of-state providers, and they would probably try to derail such reform.”
The best solutions, they wrote, are probably those that integrate the state licensure authority, such as reciprocity agreements.
Mehrotra, et al concluded that “The Covid-19 pandemic has raised questions about the utility of the existing licensure framework, and it’s become increasingly clear that a system that relies on telemedicine deserves a new regime. Potential models abound, and the degree of change involved ranges from incremental to categorical. We believe that building off the existing state licensure system but encouraging reciprocity among states presents the most practical path forward.”
Peggy Peck, Editor-in-Chief, BreakingMED™
Mehrotra disclosed receiving speaker fees from Excellu and Optum, as well as grant support from the National Institutes of Health.
Cat ID: 150
Topic ID: 88,150,508,509,510,556,192,150,151,463,590,60,61,925