Telemedicine should be able to cross state lines

With pandemic easing, state licensing boards are balking

IN THE EARLY DAYS of the pandemic, state licensing boards waived restrictions and gave doctors the freedom to provide virtual medical care to patients regardless of location. Telemedicine’s value was proven when millions received medical care safely in their homes during a raging pandemic, yet state licensing boards are now returning to a Luddite mentality.

As states have eased up on activities like indoor dining and travel, licensing boards in six states and the District of Columbia have effectively closed their borders to out-of-state physicians practicing telemedicine, with more expected to follow suit this summer. We need to start thinking differently about how to support and regulate telemedicine so that it’s covered by insurance, available to physicians, and doesn’t cause undue hardship for patients.

Bridgette has been a patient in my practice for over 10 years and would make the one hour drive from Rhode Island to attend appointments. She has multiple chronic medical problems including diabetes, high blood pressure, and a history of breast cancer, all of which require regular doctor’s visits. During the pandemic, traveling across state lines and entering a medical center was extremely risky for a patient with her comorbidities. Telemedicine, and a waiver to practice in the state of Rhode Island, allowed me to manage her blood pressure while she remained safely at home.

Now we can’t do this. I had to call Bridgette to see if she would be willing to drive from her home in Rhode Island to a parking lot over the border in Massachusetts for our upcoming appointment. To her surprise, despite the fact that she is an established patient of mine, my employer no longer allows me to see her via telemedicine while she is physically outside of the Commonwealth of Massachusetts.

Technically, I could have seen Bridgette virtually because Rhode Island and Massachusetts still have waivers in place. Mass General Brigham did this because administrators know what’s coming. Many of the flexibilities put in place by state licensing boards are tied to emergency declarations, and with successful vaccination efforts many states are eying the finish line.

There’s some hope but it may come too late. Physicians and other stakeholders have been providing feedback to the Massachusetts Division of Insurance about how to regulate telemedicine, but that investigation is expected to take until at least the fall, at which point pay parity will be lost for medical visits that do not fall under the umbrella of mental health or chronic disease management.

To add to the confusion, these rapidly changing developments only affect insurers in Massachusetts, including MassHealth. It does not affect Medicare support for telemedicine, which is tied to the national state of emergency. The Biden administration has extended the public health emergency until July 20, but many believe it will be further extended through the end of the year.

Telemedicine was initially covered by Medicare for patients in rural areas that had inadequate access to medical care. The location of the patient was fundamental to establishing eligibility. In response to the public health emergency, Medicare expanded coverage broadly, allowing physicians to offer telemedicine to all patients.

Patient location has become paramount and its role in eligibility and coverage has endured, despite the fact that telemedicine has outgrown that limitation. Now anyone can use it, proving that the location of the patient shouldn’t be the determining factor anymore in whether insurance covers telemedicine.

State medical licensing boards need to adapt to the new landscape of healthcare delivery where the vast majority of patients expect telemedicine to remain an option. Making Bridgette drive across state lines to participate in a virtual visit is a preposterous solution. There must be a better way.

Implementing a federal license to practice medicine would probably be the best fix, at least for telemedicine. But states may not like this, despite the fact that it is an elegant and simple solution.

It would seem that approaching this legislatively might prove tricky as it involves the physician licensing systems of 50 individual states and the District of Columbia. Each of them would have to change their licensing laws to reach this goal. As the pandemic proved, from mask mandates to lockdowns to voting accommodations, getting all 50 states to react in a timely manner to an important issue is difficult.

Since 2017, states have been discussing whether or not they will join an Interstate Physician Licensure Compact (IPLC) that promises to streamline traditional medical-license application processes and allow doctors to be licensed in more than one state and accomplish that quickly. So far, 29 states have fully joined the compact. On May 18, Gov. Charlie Baker proposed that Massachusetts join the IPLC.

While the IPLC offers an attractive option, a deeper look exposes yet another burdensome and expensive process. Joining the compact costs $700 and each additional state license can cost up to $790. Few physicians have taken advantage of this so far. Anticipating which states I may need to be licensed in for my patients who are on vacation, visiting family, or away at college is Sisyphean – and paying for it could get expensive.

Creating a telemedicine-only license would likely solve this problem. It’s not unheard of. The Veteran’s Administration has done it already to allow providers who were using telemedicine in its early days, after a study showed that the costs of requiring healthcare providers to have to be licensed in additional states would have outweighed any benefit.

If states saw enough promise in waiving licensing restrictions then they should see the value of creating a telemedicine-only license. The only thing that will have changed in late 2021 is the risk of COVID infection has gone down. The physicians who were waived in to provide care will still have the same training and credentials.

Meet the Author

Stephanie Titus

Primary care physician, Affiliated with Mass General Hospital
Telemedicine has been an invaluable tool during the pandemic. Letting antiquated licensing structures roll back the advances we have made in health care delivery is a bad idea if delivery care matters.

Stephanie Titus is a primary care physician affiliated with Massachusetts General Hospital