In the United States, for licensing and reimbursement, state laws define the site of care of a physician–patient interaction as being at the location of the patient. This means that physicians may not offer telemedicine services to patients in other states without a license to practice in those states. Many physicians are deterred by the time and expense involved in gaining those additional licenses and because it is challenging to adhere to multiple state-specific regulations and policies.
This limits access to care. This is especially true in rural communities, for patients with rare diseases who would benefit from access to specialists in other states, and for patients with serious illnesses who are too poor or fragile to travel.
In the wake of COVID-19, 18 states have waived restrictions on the cross-state practice of telemedicine. These waivers apply to out-of-state physicians and other clinicians in good standing in their home states, but the waivers are to last only for the duration of the pandemic. Most of the remaining states have also adopted temporary waivers, but they require out-of-state physicians to register (eight states), apply for a temporary medical license or permit (17 states), or have an association with an in-state provider (five states). To accommodate those actions, the Centers for Medicare and Medicaid Services temporarily waived requirements that out-of-state practitioners be licensed in the state where they are providing services.
On June 19, Senators Marsha Blackburn (R–TN) and Ted Cruz (R–TX) introduced a bill that would allow licensed providers to use telehealth to treat patients in any state based on their home state license — ending 180 days after the end of the national emergency. In Missouri, Gov. Mike Parson justified his state’s decision to temporarily allow out-of-state physicians to offer care in Missouri on the basis that it is important to “provide as much access to care as possible for the sake of all Missourians.” The irony is that it is always important to provide as much cost-effective access to care as possible.
Moving telemedicine forward / The telemedicine lobby hopes to garner support for legislation that would make the current temporary COVID-19-related Medicare telemedicine waivers permanent. Its primary interest is in cementing the waivers that allow payment for services provided to patients in their home and to expand coverage to beneficiaries outside rural areas.
Taxpayers have invested heavily in telemedicine. The Federal Communications Commission Rural Health Care Program allocates a half-billion dollars annually to support telecommunications and broadband services. The Federal Office of Rural Health Policy funds telemedicine-related technical assistance programs and research grants. The Coronavirus Aid, Relief and Economic Security Act included $200 million to reimburse costs of connected care services put in place in response to the COVID-19 pandemic.
Policymaking and license portability / When it comes to medical licensing, disorganized and disinterested voters have been no match for the physician and hospital lobbies. State-level barriers to the cross-state practice of telemedicine reflect this imbalance. When telemedicine is precluded and patients’ only option is to travel to access care, local providers face less competition. Also, restrictions on interstate telemedicine give local providers increased leverage in negotiating payments with health insurers.
It is not uncommon for government actions to impede innovation and competition. Consider the regulations and restrictions placed on Uber and Lyft as a result of lobbying efforts by existing taxi companies.
Pushback against license portability also comes from state medical boards. The groups’ national association, the Federation of State Medical Boards, proposed a move to license portability, but its member boards opposed it. Medical boards generate revenues when physicians are forced to seek multiple licenses, but that is surely not a good enough reason to derail a significant increase in access to care. How odd that these taxpayer-funded state agencies oppose an efficient means of providing health care.
With COVID-19, the number of deaths is posted daily on multiple media outlets. This may make it harder for legislators to acquiesce to self-interested efforts to limit access to care. When media outlets reported on “fatal waits” at Veterans Administration hospitals in 2018, the VA chose to set aside state licensing laws, allowing any VA doctor to provide care in any state.
A prescription for Congress / Congress can promote interstate telemedicine by establishing the site of care of a physician–patient interaction as that of the physician rather than the patient. Physicians would be allowed to provide care based on their home-state license to any patient across the country via telemedicine. Many patients already drive or fly to another state to get care, so this would be just another form of these doctor–patient interstate relationships.
Congress took a somewhat similar action when it eliminated restrictions on interstate banking in 1994. The Riegle–Neal Interstate Banking and Branching Efficiency Act invalidated state laws that precluded interstate activity. The elimination of barriers led to gains in banking efficiency, employment growth, and economic growth. Similarly, increased competition resulting from access to distant telemedicine providers will improve the efficiency of the health care sector.
It is imperative that Congress act quickly to do this. Continued uncertainty will deter investments in telemedicine. Economists have made this point about uncertainty and investment in general. Twenty-nine senators signed a June 15 letter authored by Brian Schatz (D–HI) that points out that continued investment in telemedicine requires a clear statement that indicates the long-term potential.
The train has left the station / Consulting firm McKinsey and Co. expects telemedicine to be huge post-COVID-19. They offer a cautionary caveat that “actions taken by healthcare leaders today will determine if the full potential of telehealth is realized after the crisis has passed.” So true.
State licensing requirements are nearly identical. In the United States, oversight by hospitals, malpractice insurers, health insurers, and other (liable) providers offers ongoing protection for patients. Congressional action to define the site of care as that of the physician would result in access to care that existing state laws preclude.
