Currently Viewing:
The American Journal of Managed Care January 2020
Using Applied Machine Learning to Predict Healthcare Utilization Based on Socioeconomic Determinants of Care
Soy Chen, MS; Danielle Bergman, BSN, RN; Kelly Miller, DNP, MPH, APRN, FNP-BC; Allison Kavanagh, MS; John Frownfelter, MD, MSIS; and John Showalter, MD
Currently Reading
Eliminating Barriers to Virtual Care: Implementing Portable Medical Licensure
Pooja Chandrashekar, AB; and Sachin H. Jain, MD, MBA
The Health IT Special Issue: Enduring Barriers to Adoption and Innovative Predictive Methods
Ilana Graetz, PhD
What Accounts for the High Cost of Care? It’s the People: A Q&A With Eric Topol, MD
Interview by Allison Inserro
Does Machine Learning Improve Prediction of VA Primary Care Reliance?
Edwin S. Wong, PhD; Linnaea Schuttner, MD, MS; and Ashok Reddy, MD, MSc
Health Information Technology for Ambulatory Care in Health Systems
Yunfeng Shi, PhD; Alejandro Amill-Rosario, MPH; Robert S. Rudin, PhD; Shira H. Fischer, MD, PhD; Paul Shekelle, MD; Dennis Scanlon, PhD; and Cheryl L. Damberg, PhD
The Challenges of Consumerism for Primary Care Physicians
Timothy Hoff, PhD
Advancing the Learning Health System by Incorporating Social Determinants
Deepak Palakshappa, MD, MSHP; David P. Miller Jr, MD, MS; and Gary E. Rosenthal, MD
Predicting Hospitalizations From Electronic Health Record Data
Kyle Morawski, MD, MPH; Yoni Dvorkis, MPH; and Craig B. Monsen, MD, MS
Opt-In Consent Policies: Potential Barriers to Hospital Health Information Exchange
Nate C. Apathy, BS; and A. Jay Holmgren, MHI
e-Consult Implementation Success: Lessons From 5 County-Based Delivery Systems
Margae Knox, MPH; Elizabeth J. Murphy, MD, DPhil; Timi Leslie, BS; Rachel Wick, MPH; and Delphine S. Tuot, MDCM, MAS

Eliminating Barriers to Virtual Care: Implementing Portable Medical Licensure

Pooja Chandrashekar, AB; and Sachin H. Jain, MD, MBA
In this commentary, the authors argue for moving away from state-based medical licensure and describe policy, technological, and administrative changes necessary for implementing portable medical licensure.
ABSTRACT

Telemedicine offers a promising solution to the growing physician shortage, but state-based medical licensing poses a significant barrier to the widespread adoption of telemedicine services. We thus recommend a mutual recognition scheme whereby states honor each other’s medical licenses. Successfully implementing mutual recognition requires policy, technological, and administrative changes, including a federal mandate for states to participate in mutual recognition, consistent standards for using and regulating telemedicine, a mechanism to enable interstate data sharing, financial support for states, and a “state of principal license” requirement for physicians. Reforming the United States’ outdated system of state-based medical licensure can help meet patient demand for virtual care services and improve access to care in rural and medically underserved areas.

Am J Manag Care. 2020;26(1):20-22. https://doi.org/10.37765/ajmc.2020.41223
Takeaway Points
  • The United States’ antiquated system of state-based medical licensure creates unnecessary hurdles that reduce the potential of telemedicine to address the growing physician shortage and improve access to care in rural and medically underserved areas.
  • Mutual recognition, a scheme whereby states honor each other’s medical licenses, is a comprehensive potential solution to enhance license portability and eliminate barriers to virtual care.
  • Implementing mutual recognition necessitates policy, technological, and administrative reforms to protect patient safety, prioritize the financial well-being of states, and streamline physician reimbursement.
By 2030, the United States could see a shortage of nearly 120,000 physicians.1 Telemedicine can alleviate the impacts of this shortage by helping physicians make use of unused time and see additional patients, allowing patients to access a larger pool of physicians and connecting specialists to hospitals in rural and medically underserved areas.2 Although telemedicine is growing in use and acceptance, state licensing laws create false geographic barriers and pose a significant challenge to widespread adoption.

In the United States, state medical boards regulate physician licensing, creating a patchwork of inconsistent state licensure laws. With few exceptions, physicians must acquire and maintain a license for each state in which they practice medicine. This antiquated system of state-based medical licensure, originally enacted in the 19th century to reduce medical malpractice and protect patient safety, has profound implications for the promise of telemedicine to increase access to care for vulnerable populations and mitigate the impacts of the national physician shortage.3 In this commentary, we argue for moving away from state-based medical licensure and describe policy, technological, and administrative changes necessary for moving toward portable medical licensure.

Physicians must be licensed in each state where current and future patients are located, so physicians practicing telemedicine across state borders may be responsible for obtaining and staying compliant with up to 51 different state practices of medicine at any given time. There are some exceptions—for example, 10 states issue special purpose licenses for physicians who wish to come to their state for a limited time, scope, and purpose, such as to demonstrate a new technique or to educate medical students.3 However, these exceptions are few and far between.

The multistate licensure process is long and expensive; some states require physicians to pay annual license renewal fees, complete additional coursework, submit required documentation, and participate in interviews. Even after physicians complete these requirements, state medical boards can take several months to process licensing applications.3 Along with imposing substantial direct costs on physicians, state-specific licensing reduces competition that could lower healthcare prices, limits opportunities for physicians to gain experience by seeing more patients, and exacerbates health disparities.4 The impact of restricting telemedicine falls hardest on poor patients, the uninsured, and those who rely on state Medicaid programs, many of whom lack access to reliable transportation and cannot travel across state lines to see specialists.5

Over the past decade, the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents 70 state medical and osteopathic boards, has advanced several proposals to enhance license portability and reduce regulatory barriers to telemedicine. These include the Uniform Application and the Federation Credentials Verification Service, which are both web-based applications that eliminate the need for physicians to reenter identifying information and credentials when applying for multiple licenses. Most recently, the FSMB instituted the Interstate Medical Licensure Compact, an agreement to expedite the medical licensure process among member states. Physicians in good standing can freely practice in member states as long as they possess a “full and unrestricted” license in their state of principal license (SPL). To date, only 24 states have joined the compact.4

These proposals are a step in the right direction but far from the solution. They simply streamline—not eliminate—the process of applying for multiple medical licenses. Additionally, they do not reduce the cost to doctors of maintaining multiple medical licenses, estimated at $300 million each year.6 As a more comprehensive solution, we recommend a mutual recognition scheme whereby states honor each other’s medical licenses. This model has been successfully adopted in Europe and Australia and by the Veterans Health Administration, US military, and US Public Health Service.3 Furthermore, because standards for medical education apply nationwide and physician training requirements are set by federal agencies such as HHS, mutual recognition is warranted.

Proponents of the status quo argue that mutual recognition compromises patient safety, reduces revenues from state licensing fees, and complicates physician reimbursement. To address these challenges, mutual recognition should be accompanied by (1) a federal mandate, (2) consistent standards for using and regulating telemedicine services, (3) increased data sharing among states, (4) financial support for states, and (5) a requirement for physicians to select an SPL.

Federal Mandate

To reduce barriers to interstate medical practice, some states have attempted unilateral action. For example, in 2016, the Florida House of Representatives passed a bill with a provision allowing physicians licensed in other states to offer telemedicine services in Florida. However, the Florida Senate eliminated the provision. To avoid similar situations, Congress can require states to participate in mutual recognition. In fact, legal research suggests that federal action to promote interstate telemedicine is justified based on the Commerce Clause of the US Constitution, which states that Congress has the power “to regulate commerce…among the several states.”4 Another benefit of instituting a federal mandate is a consistent set of definitions needed to support mutual recognition (eg, SPL).


 
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up