Should licensed physicians be allowed to practice telemedicine across state borders? Lawmakers in Congress have been reluctant to move this forward. An exception is the recent VETS Act of 2017, versions of which just passed in both houses of Congress.
Department of Veterans Affairs’ health care professionals will be allowed to practice via telemedicine in any state, no matter where the clinician is licensed or the patient is located. Why not make this type of access available to everyone?
Lawmakers have introduced bills that included language to reduced barriers to interstate telemedicine, but ultimately pushback from state medical boards and physician groups have doomed these efforts. Reps. Devin Nunes, R-Tulare, and Sens. Mazie Hirono, D-Hawaii, and Joni Ernst, R-Iowa, tried to expand cross-state accessibility for Medicare recipients via the Telemedicine for Medicare Act of 2015. Sen. John McCain, R-Arizona, addressed the needs of TRICARE beneficiaries by including a similar provision in an early version of the 2016 National Defense Authorization Act. In both cases, the provision was stripped from the final legislation. Rep. Mike Thompson, D-St. Helena, included a provision in the Telehealth Promotion Act of 2012 that would have allowed physicians to practice across states on the basis of their home-state licensed and would have applied to all Americans: “For the purposes of [telehealth service] … providers of such services are considered to be furnishing such services at their location and not at the originating site.”
In each case, well-respected and politically powerful groups, including the American Medical Association, and representatives of state medical boards opposed the language. As always, when it comes to proposals that would inject competition into the market for physician services, physicians raise the patient safety flag. However, there is no evidence to support this claim.
So the existing laws stand. Physicians who want to provide services to residents in another state must be licensed in that state. Initial license fees (about $430 a state — double that if the physician uses a private company to assist in the process) and renewal fees (about $220 a year per state) limit the number of out-of-state licenses a physician is likely to acquire and maintain. Another complication to interstate practice under multiple state licenses is that state requirements for medical practice, including patient informed consent and continuing medical education, vary. So do rules regarding such things as fee-splitting and referrals. As health care lawyer Erika L. Adler put it, “Every state has its own rules for just about everything.”
Setting aside costly state licensing requirements would allow telemedicine practitioners to expand into each and every state. This would allow large-scale providers, who are potentially more efficient, to develop a presence across the country. This would encourage patients to choose telemedicine over more costly sources of care, including emergency rooms, urgent care facilities, and even doctors’ offices.
Interstate telemedicine also offers options for patients in small states without specialists, or for seriously ill patients who have a rare disease and are too ill or too poor to travel across state lines for care.
The irony of opposition by the largest physician organizations is that telemedicine offers the scores of overworked, unhappy physicians unprecedented flexibility. Telemedicine neatly solves the problem of physicians who, increasingly, are unwilling to be on call on evenings and weekends. Remote digital encounters improve patient access to care and save commutes for both the physicians and their patients. With remote medicine, physicians can see additional patients without expanding their offices (saving money on staff and facilities).
Via telemedicine, physicians may practice at the hours they choose, allowing for more personal time. The ability to practice remotely may keep some physicians active who would otherwise retire, putting a dent in the expected physician shortage. When necessary, or if they choose to, it would be legal for physicians to talk with patients when the patient is vacationing in another state. This would facilitate continuity of care for snowbirds who travel to Florida or Arizona for the winter months.
The fact that private insurance companies are expanding the use of telemedicine tells us that telemedicine saves money. Legislation that would allow physicians to practice across state borders — perhaps redefining the location of the practice of medicine to that of the physician — would make telemedicine even more attractive.
A greater awareness of the benefits of telemedicine is needed to counter special interest groups that benefit financially from the status quo. Physicians’ increasing appreciation of the value of telemedicine, both for themselves and their patients, could offer politicians the leverage needed to open state markets to out-of-state telemedicine providers. Such an opening would normalize and strengthen a burgeoning practice that stands to revolutionize the delivery of health care, potentially making it more accessible and more affordable. For anyone who can see their way through to put the needs of patients first, it makes all the sense in the world.