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During the Covid-19 pandemic, the rapid development of telemedicine has refocused new attention on the debate about doctors’ licensing. Prior to the pandemic, states generally issued licenses for doctors based on the policy outlined in each state’s Medical Practice Act, which stipulated that doctors must be licensed in the state where the patient is located. For doctors who wish to use telemedicine to treat patients outside of the state, this requirement creates huge administrative and financial obstacles for them.
In the early stages of the pandemic, many licensing-related obstacles were removed. Many states have issued interim statements that recognize out-of-state medical licenses. 1 At the federal level, Medicare and Medicaid Services have temporarily waived Medicare’s requirements for obtaining a clinician license in the patient’s state. 2 These temporary changes enabled the care that many patients received through telemedicine during the Covid-19 pandemic.
Certain doctors, scholars, and policy makers believe that the development of telemedicine is a glimmer of hope for the pandemic, and Congress is considering many bills to promote the use of telemedicine. We believe that licensing reform will be the key to increasing the use of these services.
Although the states have maintained the right to practise medical licenses since the late 1800s, the development of large-scale national and regional health systems and the increase in the use of telemedicine have expanded the scope of the health care market beyond national borders. Sometimes, state-based systems do not conform to common sense. We have heard stories about patients who drove several miles across the state line to participate in primary care telemedicine visits from their cars. These patients can hardly participate in the same appointment at home because their doctor is not licensed in the place of residence.
For a long time, people have also worried that the State Licensing Commission is paying too much attention to protecting its members from competition, rather than serving the public interest. In 2014, the Federal Trade Commission successfully sued the North Carolina Board of Dental Inspectors, arguing that the Commission’s arbitrary prohibition against non-dentists from providing whitening services violated antitrust laws. Later, this Supreme Court case was filed in Texas to challenge licensing regulations restricting the use of telemedicine in the state.
In addition, the Constitution gives the federal government priority, subject to state laws that interfere with interstate commerce. Congress has made certain exceptions for the state? Licensed exclusive jurisdiction, especially in federal health programs. For example, the VA Mission Act of 2018 requires states to allow out-of-state clinicians to practice telemedicine within the Veterans Affairs (VA) system. The development of interstate telemedicine provides another opportunity for the federal government to intervene.
At least four types of reforms have been proposed or introduced to promote interstate telemedicine. The first method builds on the current state-based medical permit system, but makes it easier for doctors to obtain out-of-state permits. The interstate medical license agreement was implemented in 2017. It is a mutual agreement between 28 states and Guam to speed up the traditional process of doctors obtaining traditional state licenses (see map). After paying the $700 franchise fee, doctors can obtain licenses from other participating countries, with fees ranging from $75 in Alabama or Wisconsin to $790 in Maryland. As of March 2020, only 2,591 (0.4%) of doctors in participating states have used the contract to obtain a license in another state. Congress can pass legislation to encourage the remaining states to join the contract. Although the usage rate of the system has been low, expanding the contract to all states, reducing costs and administrative burdens, and better advertising may lead to greater penetration.
Another policy option is to encourage reciprocity, under which states automatically recognize out-of-state licenses. Congress has authorized physicians practicing in the VA system to obtain mutual benefits, and during the pandemic, most states have temporarily implemented reciprocity policies. In 2013, federal legislation proposed the permanent implementation of reciprocity in the Medicare plan. 3
The third method is to practise medicine based on the location of the physician rather than the location of the patient. According to the National Defense Authorization Act of 2012, clinicians who provide care under TriCare (Military Health Program) only need to be licensed in the state where they actually live, and this policy allows interstate medical practice. Senators Ted Cruz (R-TX) and Martha Blackburn (R-TN) recently introduced the “Equal Access to Medical Services Act”, which will temporarily apply this model to telemedicine practices nationwide .
The final strategy –? And the most detailed proposal among the carefully discussed proposals – the federal practice license will be implemented. In 2012, Senator Tom Udall (D-NM) proposed (but not formally introduced) a bill to establish a serial licensing process. In this model, clinicians interested in interstate practice must apply for a state license in addition to a state license4.
Although it is conceptually appealing to consider a single federal license, such a policy may be impractical because it ignores the experience of more than a century of state-based licensing systems. The committee also plays an important role in disciplinary activities, taking action against thousands of doctors each year. 5 Switching to the federal licensing system may undermine state disciplinary powers. In addition, both doctors and state medical boards that primarily provide face-to-face care have a vested interest in maintaining a state-based licensing system to limit competition from out-of-state providers, and they may try to undermine such reforms. Granting medical care licenses based on the location of the physician is a smart solution, but it also challenges the long-standing system that regulates medical practice. Modifying the location-based strategy might also pose challenges for the board? Disciplinary activities and scope. Respect for national reforms Therefore, historical control of permits may be the best way forward.
At the same time, it seems an ineffective strategy to expect the states to take action on their own to expand the options for out-of-state licensing. Among doctors in participating countries, the use of interstate contracts is low, highlighting that administrative and financial barriers can continue to hinder interstate telemedicine. Considering internal resistance, it is unlikely that states will enact permanent reciprocity laws on their own.
Perhaps the most promising strategy is to use federal authorities to encourage reciprocity. Congress can require permission for reciprocity in the context of another federal program, Medicare, based on previous legislation regulating physicians in the VA system and TriCare. As long as they have a valid medical license, they can allow physicians to provide telemedicine services to Medicare beneficiaries in any state. Such a policy is likely to accelerate the passage of national legislation on reciprocity, which will also affect patients who use other forms of insurance.
The Covid-19 pandemic has raised questions about the usefulness of the existing licensing framework, and it has become increasingly clear that systems that rely on telemedicine are worthy of a new system. Potential models abound, and the degree of change involved ranges from incremental to classification. We believe that establishing the existing national licensing system, but encouraging reciprocity between countries is the most realistic way forward.
From Harvard Medical School and Beth Israel Deaconess Medical Center (AM), and Tufts University School of Medicine (AN) –? Both are in Boston; and Duke University School of Law (BR) in Durham, North Carolina.
1. The Federation of National Medical Councils. U.S. states and territories have revised their doctor’s license requirements based on COVID-19. February 1, 2021 (https://www.fsmb.org/siteassets/advocacy/pdf/state-emergency-declarations-licensures-requirementscovid-19.pdf).
2. Medical insurance and medical assistance service center. The COVID-19 emergency declaration blanket for healthcare providers is exempt. December 1, 2020 (https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf).
3. The 2013 TELE-MED Act, HR 3077, Satoshi 113. (2013-2014) (https://www.congress.gov/bill/113th-congress/house-bill/3077).
4. The supporters of Norman J. Telemedicine have made new efforts for doctor licensing work across state boundaries. New York: Federal Fund, January 31, 2012 (https://www.commonwealthfund.org/publications/newsletter-article/telemedicine-supporters-launch-new-effort-doctor-licensing-across).
5. The Federation of National Medical Councils. U.S. Medical Regulatory Trends and Actions, 2018. December 3, 2018 (https://www.fsmb.org/siteassets/advocacy/publications/us-medical-regulatory-trends-actions.pdf).
Post time: Mar-01-2021