Relocating doctors face licensing hassles

Headaches from licensure regulations and insurance credentialing are common for doctors who cross state lines. These barriers also may contribute to supply woes.

By Jay Greene, amednews staff. Feb. 4, 2002.

Radiologist David Pennes, MD, wants to move someplace warmer than Indiana. Board-certified and without a malpractice history, Dr. Pennes thought getting a license in another state would be a walk in the park.

So far, that little walk is something more akin to a marathon in the jungle. Instead of lions and tigers and bears, there are licenses and credentials and insurance.

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More than 55,000 allopathic and osteopathic physicians each year go through the medical licensing process -- 45% are seeking initial licenses and 55% are relocating to other states. Most vastly underestimate the hassles inherent in the process, staffing and relocation experts say.

But medical licensing is just the first step toward full practice in a new state. Gaining necessary managed care credentials for billing purposes, joining hospital medical staffs for admitting privileges and finding affordable professional liability insurance are other time-consuming tasks -- some of which discourage physicians from moving.

Half the 55,000 physicians a year going through medical licensing are moving to other states.

"Where I go will be determined to a certain extent by licensure requirements," Dr. Pennes said. "I am not going to take any tests that make me study stuff that's not pertinent to what I do now. I haven't relocated yet, but perusing the state licensure board Web sites told me what a god-awful hassle it's going to be."

The myriad array of rules, regulations and costs associated with moving may be adding to the growing physician shortage problem in certain states, say physician staffing and relocation experts.

"Medical licensing boards do a good job at balancing public safety and convenience for physicians, but they don't do a good job at processing applications. They are just slow," said Dustin Koger, vice president of operations with Staff Care, an Irving, Texas-based locum tenens firm. "On top of regulations that duplicate what other states require for licensure, many boards don't have the staff to do the job promptly because they are part of state governments and subject to budget cuts."

Low staff, slow speed

Some state licensing boards take as long as six months to a year to approve applications, said Melinda Hilterbrand, manager with U.S. Medical Licensing, a Pace, Fla.-based licensing and credentialing assistance firm. Primarily because of a lack of staff, notoriously slow states include New Jersey, California, Florida, Illinois, Texas, New Mexico, Massachusetts and Wisconsin, she said.

"Most time boards take about three months," Hilterbrand said. "Some take much longer, depending on how well their office is run, their staffing levels and how many applications they receive."

To help speed up the application process, the Federation of State Medical Boards is expected at its annual meeting in April to issue recommendations on improving licensure portability, said Dale Austin, the FSMB's interim chief executive.

"Physicians are moving more often," Austin said. "We are looking to expedite the process, not shortchange it. We recognize there are frustrations and time delays. We are trying to balance that and protect the public."

Once a physician garners a new license, most managed care payers are in no hurry to speed up the credentialing process because that only increases their costs, Hilterbrand said. Hospitals are quicker to act, mainly because administrators understand how important it is for doctors and their patients, she said.

"There has been lots of migration to different states and you hear lots of complaints," said Edward Salsberg, PhD, director of the Center for Workforce Studies at the State University of New York in Albany. "There are requirements in states that could be a barrier, and it may be a problem for underserved areas, but it is not a very high barrier if you really want to go there."

One of the more physician-friendly licensing states is Michigan, experts say. The Michigan Board of Medical Licensure requires letters of clearance from states where physicians currently hold licenses, a process that cuts the approval process to about two months, said Thomas Lindsey, director of the state's bureau of health services.

"We try to strike a good balance with our regulations," Lindsey said. "You can make it so tight on the screening end that you hold up a lot of good people from practicing here in order to catch a few bad doctors."

Besides the letter of clearance, Lindsey said the state verifies credentials through several document-collection services, including the AMA's Physician Masterfile and the FSMB's Credentials Verification Service. AMA and FSMB verify such primary credentials as medical school graduation, residency completion and adverse licensure actions.

"10-year rule"

Aside from slow processing, the biggest barrier to licensing in some states is the so-called "10-year rule," staffing experts say. It works like this: If a physician hasn't taken a national board exam within 10 years, some licensing boards require physicians to take a Special Purpose Examination to test their general medical knowledge.

Of the 15 states that require SPEX, Arizona will waive SPEX if the physician holds a valid board certificate recognized by the American Board of Medical Specialties, said Tom Adams, deputy director with the Arizona Board of Medical Examiners. In addition, California, Delaware and North Carolina will waive SPEX if certain residency training requirements are met, officials said.

"Sometimes a doctor will call and say, 'I have been practicing for 20 to 25 years in Florida or New York and I don't think I should have to take a test,' " Adams said. "Some will choose not to come here. But if you have a doctor who can't pass that test, do you really want them as your doctor anyway?"

But Tina Rasmussen, manager of licensing at CompHealth, a Salt Lake City-based staffing firm, said some veteran physicians don't want to take tests. "Some are not willing to pay the money or study for a general exam," she said.

Dr. Pennes is one. "There's something ironic about the fact that a mid-career physician, born, educated and trained in this country, board-certified in his specialty, having been in continuous practice in the mainstream of his specialty and with no malpractice history, can't become licensed in [some states] without taking yet another test. My attitude is, 'There are other states, I'm not taking any more tests,' " he said.

States that require the SPEX for those who haven't recently taken a national board test or are not board-certified are Alabama, California, Illinois, Louisiana, Maryland, Minnesota, Mississippi, Montana, North Carolina, Nevada, New York, Oregon, South Carolina and Texas, the FSMB said.

Other ways to check out doctors

"The exam rule makes it difficult to recruit, and some doctors who are not board-certified or who haven't taken their boards in a while will just avoid those states. It happens all the time," Koger said. "I think there are a lot more important things to check out than a general medical test."

Once primary credentials are verified, Koger said, state licensing boards could check malpractice cases filed against physicians, review possible criminal histories and make sure the physician is not a drug user. "This would protect public safety a lot more than requiring special tests," he said.

Last year, the Medical Board of California caught up on its application backlog by hiring additional staff and streamlining the approval process, officials said.

"We were working seven days a week to catch up," said Pat Park, an associate analyst in the board's licensing division. "Our board told us to look at eliminating redundancies. We are still working on it."

With more than 20 states this year facing budget deficits, physicians fear larger backlogs and delays.

"States are understaffed and overburdened and in some cases overregulated," Rasmussen said. "This is a big discouragement for doctors wanting to locate there."