Events

AMA Advocacy Insights webinar series: Emerging state models of physician licensure flexibility for telehealth

Webinar (series)

Telehealth licensure: Emerging state models of physician licensure flexibility for telehealth

Sep 19, 2023

Virtual

Moderator

Jesse M. Ehrenfeld, MD, MPH, president, American Medical Association

Speakers

Clark Barrineau, assistant vice president of government affairs, Medical Society of Virginia
Marschall Smith, executive director, Interstate Medical Licensure Compact
Sarvam P. TerKonda, MD, immediate past chair, Federation of State Medical Boards
Jared Augenstein, managing director, Manatt Health Strategies
Kimberly Horvath, senior attorney, American Medical Association

Meeting documents

Advocacy Insights: Telehealth licensure webinar slides (PDF)

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Transcript

Dr. Ehrenfeld: Thank you for joining us today for another AMA Advocacy Insights webinar. I'm Jesse Ehrenfeld, president of the American Medical Association, and I'm so delighted to serve as your host today. Our Advocacy Insight webinars, they're really designed to keep physicians informed about important issues that are affecting them and their patients. Today we're going to talk about legislative, regulatory and other advocacy efforts to support telehealth, in particular, issues around state licensure. We're going to do that with a panel of experts who are going to help us understand the current landscape of state licensure for telehealth and what's ahead.

Now, as we all learned during the pandemic, telehealth is an essential part of medical practice today. It can be a lifeline for patients, particularly those with limited mobility, those in rural economically or socially marginalized communities, and those who are managing a chronic illness. That's why even though the pandemic is behind us, the AMA continues to champion telehealth expansion as a part of our Recovery Plan for America's Physicians that we launched just last year.

One of the primary factors fueling telehealth expansion during COVID-19, was the easing of the many restrictions that had previously applied to virtual care. If you think back, prior to March of 2020, Medicare only reimbursed a limited number of telehealth services, and it did so only for patients who resided in rural areas and who had traveled to a medical facility to receive them. The AMA, we led the fight to lift those and other limitations so that patients nationwide could access telehealth services and get them in their own homes. A subsequent survey showed that 85% of responding physicians now embrace telehealth services.

When the COVID-19 public health emergency ended in May, ensuring that new policies enabling telehealth expansion would remain in place became an AMA priority. Our advocacy helped secure passage of federal legislation that's extended these pandemic-related telehealth flexibilities through 2024, and we are enthusiastic supporters of the CONNECT for Health Act of 2023. This is a bipartisan proposal, now pending in Congress, that would further expand Medicare coverage of telehealth services, while making pandemic-related flexibilities permanent.

And because the role of telehealth in the U.S. health care delivery is likely to gain even more prominence going forward, we are working at the AMA to ensure that physicians have all the tools, the resources and the support that they need to more seamlessly integrate telehealth into their workflows. And we're working to make sure that patients have access to those physicians. Now, we'll talk about that and a lot more today with our panel of experts. I want to make sure we have enough time to discuss these important issues and answer your questions. So let's go ahead and dive in.

I am so delighted to introduce an incredible panel of today's leading experts, and I'll ask them to join me now on screen. First we've got Clark Barrineau, who is an assistant vice president of government affairs at the Medical Society of Virginia, where he directs their advocacy efforts as chief lobbyist. Clark is a leading public affairs professional with a proven track record of results in government relations, social media advertising, regulatory affairs, crisis communications and organizational strategy. Welcome, Clark.

Next is Marschall Smith, executive director of the Interstate Medical Licensure Compact, which provides an expedited process for physicians to become licensed in multiple states. With more than 20 years of government management experience, Marschall brings a wealth of insight, medical health licensing laws and regulations. The Compact has been a leader in helping physicians obtain licensure in multiple states, and he's going to share some insights from their work with us today. Welcome, Marschall.

Next, I've got Dr. Sarvam TerKonda, a plastic surgeon at the Mayo Clinic and the immediate past chair of the Federation of State Medical Boards. His medical expertise includes published research on virtual care and telemedicine, including an article, "Payment and coverage parity for virtual care and in-person care. How do we get there?" Welcome, Sarvam.

We also have Jared Augenstein, managing director at Manatt Health Strategies, where he works with health care providers on strategy, digital health, telehealth and delivery system transformation. Jared has a lot of experience helping large health systems, academic medical centers and children's hospitals with strategic planning, transformation and population health infrastructure development. Welcome, Jared.

And finally, we've got Kimberly Horvath, a senior attorney at the AMA, where she provides legal oversight for our legislative and advocacy goals at the state level. Kimberly has over 15 years of experience in health care advocacy, and is a valued leader in helping us advance the mission of our organization. Welcome, Kim. I'm now going to turn things over to Kim and Jared, who will be presenting some materials before we move into the panel discussion.

Augenstein: Great. Thanks, Dr. Ehrenfeld. It's great to be with the AMA and this esteemed panel today. We're looking forward to the discussion. So are the slides available? I don't see them. There we go. Great. Thank you. We can go to the next slide.

Fantastic. So as Dr. Ehrenfeld mentioned, Kim and I are going to provide a bit of an overview of the state of play in telehealth licensure. Kim's going to provide a deep dive on specific state approaches, and then we're going to get into a panel discussion for most of the time today. Next slide.

OK. So I thought I would start by just providing a little bit of historical context on how we got where we are today related to state licensure, and in particular, state licensure in the context of the world in which we're living in where an increasing number of services are being delivered via telehealth. I think it's important to note that going all the way back to 1791, the Bill of Rights granted states the right to regulate health. Now, since that time, there's been a huge variability that's emerged in terms of the size, structure and authority of medical boards. Some are independent, other medical boards are integrated into larger state agencies like state departments of health, and most medical boards combine representation from physicians and also members of the public.

Now, fast forwarding a couple hundred years to 2020, the COVID-19 pandemic. To meet the increased demand for care, and in many cases, supply and demand imbalances that existed across the country, you'll remember, during the first few waves of COVID, there might be significant spikes in certain parts of the country where there were laws than other parts of the country. So for a while, we were really trying to manage this huge mismatch in supply and demand across the country.

And in light of that, many states, all states, in fact, provided some sort of flexibility related to licensure. In many states, licensure requirements—components of licensure requirement were waived. In many states, there were broad reciprocity waivers that were implemented, which essentially permitted physicians and other health care professionals with an active license in good standing in one state or territory to provide care in another state without going through the process of obtaining an in-state license. There were also some states in which telehealth-specific exemptions were implemented, which allowed out-of-state providers to deliver care in state via telehealth without an in-state license.

Now, many of these flexibilities were tied to state declarations of emergency. And so now fast forward to three and a half years later, about to be fall of 2023, nearly all states have lifted the temporary flexibilities that were implemented during the height of the pandemic. There's only a small handful of states that still have flexibilities tied to their state declarations of emergency. But states are now in a position of trying to explore, what policies that we implemented should we keep, should we revert to the pre-COVID norm, and how do we make sense of telehealth licensure and telehealth licensure and registration in the context of an evolving health care system?

And there's been some guidance that's emerging from national organizations, such as the AMA, FSMB, which I'm sure we'll hear about, and also the Uniform Laws Commission related to potential models for cross-state licensure, state-by-state licensure, and also the provision of telehealth across state lines. Go to the next slide, please.

So I'm going to provide a high-level overview of four different models that are emerging related to licensure for cross-state practice and telehealth services, and then Kim's going to go and provide state by state examples for each of these. And then I'm sure in the Q&A we're going to get into an even more granular level of detail in terms of what many of these models look like in practice.

So the first of these models is interstate compacts, and as Dr. Ehrenfeld noted, we're going to discuss today the IMLC, which is the Interstate Medical Licensure Compact. I will note that there are other compacts for other licensed health professionals, nurses, psychologists, audiologists, speech language pathologists and others. And the IMLC, in particular, creates an expedited licensure pathway for physicians to deliver either in-person or telehealth services in more than one state. More than half of states are signatories to the IMLC. At this point, I think more than 35 states. And that's one of the first pathway that is emerging.

The second is licensure by endorsement or reciprocity. This provides an expedited pathway for physicians to obtain a full license in one state based on a set of qualifying criteria in that state and offers an expedited pathway to full licensure. The third pathway here, special purpose telehealth registries or licenses. These are in addition to or in lieu of a full license.

These are special licenses or registrations that enable a physician or other licensed professional, depends on the state, who's fully licensed in one state to obtain a special license to deliver telehealth services to in-state residents often with some restrictions in place. These licenses or registrations are often less expensive or faster to obtain. And so that's the theory behind the emergence of these types of models and a handful of states offer these licenses or registrations, and Kim will provide some examples in a moment.

And then finally, exceptions to in-state licensure requirements. So within the context of a full license, there are certain states that are allowing physicians who are licensed in one state to deliver services via telehealth, and in more limited cases, in person to patients in that state without being licensed in that state under certain circumstances, such as in a case of emergency or follow-up care.

And, again, there are a range of different exceptions that are being explored and implemented in different states, and we'll discuss some of those as well. So that hopefully gives a lay of the land in terms of history and what some of the emerging models are. I'm going to hand it over to Kim, who's going to go one level deeper on each of these four models and provide some more specific examples. Kim.

Dr. Ehrenfeld: Thanks, Jared.

Horvath: Great. Thanks so much, Jared. Great overview. Next slide, please. As Jared said, I'm just going to dive in a little bit more. I'm not going to talk too much—I'm not going to talk about the Interstate Medical Licensure Compact because we have Marschall here who's going to provide a lot more information there. So I'm going to start with licensure by endorsement. This is not a new approach, so I just want to make sure that that's clear. And it's not limited to cross-state licensure for telehealth, but it can be used for that purpose. And, in fact, there are lots of states that have had licensure by endorsement in place even before the public health emergency.

Basically, these models offer, as Jared said, a streamlined process for physicians licensed in another state to obtain licensure in a state if they meet certain requirements. And Virginia is a good example of a state that has a licensure by endorsement process. Physicians who meet certain requirements as laid out here can apply for licensure in Virginia based on their existing state license in another state.

And before I move forward, let me just make an important point. And that is that states are not limited to one of these models that we're talking about here. And, in fact, states like Virginia have several of these models in place. Many states are members of the Interstate Medical Licensure Compact but also may have some exceptions to licensure. They may have a reciprocity agreement. So, again, you're not limited and states are not limited to one of these models.

Now, picking back up the models. So licensure by reciprocity is another thing that I think that we're actually going to see more and more of especially as states really start to dive into and really get a handle on who their patients are seeing. Are they seeing physicians? And I think what we're seeing is that they're—actually, when they're receiving telehealth services, it's often from a physician just across the border of their state. So I think we're going to see a lot more reciprocity with states that share borders like we have for Virginia, Maryland and DC. I imagine that we'll start to be seeing that.

But basically, this approach, it doesn't necessarily allow a physician to automatically receive a license in that state. So the process, for example, that Virginia, DC and Maryland came up with is that it is a very much more expedited streamlined process for a physician who is licensed in one of these jurisdictions to be licensed in one of the other jurisdictions. It is aimed at minimizing the administrative burden for both the physician, but also, frankly, the state medical board. And then working together, the three of these states can do that. And like I said, I imagine we'll see this in some other states.

Jared mentioned the special purpose telehealth registry or license. There are about a half a dozen states that currently have a special telehealth registry or license in their state, Florida being one of the first states to enact this type of model and actually did so before COVID. While requirements will vary by state, of course, typically, they have some of the same requirements that Florida does.

And that is the physician who is looking to have a special telehealth license in Florida, ... is limited to telehealth, that physician cannot have an in-state physical address. They cannot provide in-state services. They must also have a registered agent in the state and also needs to have liability coverage for telehealth services provided in the state. Again, I think that we'll continue to see states adopt this type of model. As Jared mentioned, the Uniform Laws Commission has a model registry process as well.

And finally, many states have an exception to licensure specifically for providing telehealth in certain circumstances. Here's a summary of some of the exceptions found in Arizona, but many other states have these in place as well. And, again, even before the pandemic, states have had in place exceptions to licensure in response to an emergency, or if a physician is consulting with a physician in another state who has an existing patient-physician relationship with the patient whom the physician is consulting on. So in those instances, physicians don't need to have a license to practice in those states.

But I think we're starting to see an uptick in interest in states looking at some other very narrow exceptions to licensure, and this is actually something that the AMA supports when we're talking about continuity of care. So, for example, where a physician is providing ongoing or follow-up care to a patient that happens to be in another state temporarily or for a limited period of time, we're talking about college students, we're talking about snowbirds who may be elderly who maybe live in Arizona or Florida for part of the year.

But those are the types of populations that this can really have a positive impact on. And, again, in those instances where that physician is providing follow-up care or ongoing care for that patient, they would not need to be licensed in the state via this exception. About a half a dozen states have this exception in place right now. And, again, I think it is something that we will continue to see, it's something that the AMA supports and it's something that we actually have model legislation on as well. Next slide, please.

And that's a good segue to the AMA perspective here, and we have lots of policy on telehealth. This policy and what you see here is really limited to our policy focused on licensure. Important to just note at the outset that we continue to support a state-based licensure system, policies that physicians and other health care professionals must be licensed in the state where the patient is receiving care, when they are receiving the services, right? And that is also because we believe that physicians and other health care professionals have to abide by state licensure laws, but also the Medical Practice Act and all other laws in the state where the patient is located.

The AMA has long supported the Interstate Medical Licensure Compact. As I mentioned, we support exceptions, some of those limited exceptions that I mentioned earlier. And, of course, we encourage states to facilitate telehealth for continuity of care to preserve that critical patient-physician relationship that I mentioned.

And, again, just a common sense exception, again, we have that in our model bill as well. There is an issue brief that we have that is available on our website. I can go ahead and put a link in the chat here so you can have access to it that outlines a lot of what Jared and I just talked about so if you want to have something to look at after the webinar. And with that, Dr. Ehrenfeld, I will pass it back to you to get started with the panel.

Dr. Ehrenfeld: Awesome. Jared, Kim, thank you so much for setting the stage for us. So let me go through some questions that I've got for our panel. And we're already starting to see some questions roll in. We got a bunch of questions through registration, so we'll get to as many as we can before the hour is up. So let me start with Dr. TerKonda.

Part of the rationale for state-based licensure is to ensure patient protections. That is, a patient has a clear pathway and a mechanism to report an issue to the state medical board for consideration and action. What role do you see the state medical boards playing in the regulation of cross-state telehealth practice, and how can state medical boards ensure patient safety and provider accountability?

Dr. TerKonda: So thank you, Dr. Ehrenfeld, and thank you to the AMA for allowing me to participate. State medical boards have, really, the statutory duty to protect the public. But given the changes in the regulatory challenges and patient safety concerns, we're having to adapt the in-person provision of medical care to this newer model of telehealth care. The one thing that's important is that the standard of care does not change with the modality and should remain reasonably consistent across states. We realize that the standard of care can be regional.

In the regulation of cross-state telehealth practice, state medical boards should provide some guidance and achieve some reasonable consensus on some of the broader issues, such as number one, harmonizing regulations to facilitate telehealth across state lines while maintaining patient safety. We should also establish clear guidelines and requirements for health care providers who wish to practice telehealth across state lines. This includes ensuring that providers are appropriately licensed and credentialed to practice in the state where the patient is located, and verify the qualifications and the credentials of those providers.

In addition, state medical boards should ensure that providers offering telehealth services are aware of and compliant with state-specific laws and regulations governing telehealth practice. State medical boards also have the responsibility of establishing clear and accessible mechanisms for patients to file complaints regarding telehealth services. And this is all part of making that cross-state licensure efficient. When a complaint's received, state medical board should have the authority and resources to investigate the matter thoroughly, even if it's across state lines. This may involve reviewing medical records, conducting interviews, and collaborating with other state agency.

I think, importantly, in the long term, state medical boards have the responsibility of monitoring and evaluating cross-state practices. There should be periodic assessments of the telehealth practices and regulations so that we can adapt to the evolving health care landscape. As Kim and Jared mentioned, there are a variety of approaches to facilitate interstate license portability.

I think, Kim, you had mentioned that the IMLC and permanent licensure, there are currently 23 states and the District of Columbia that have permanent interstate telemedicine mechanisms in place in addition to the IMLC. Nine states plus the U.S. Virgin Islands use telemedicine or special licenses. Nine states also use registration or waiver systems. Three states and the District of Columbia use a regional reciprocity approach, or a memorandum of understanding. Utah, in fact, allows a pro bono interstate telemedicine license. And there are two states that allow for consultative services only.

Regarding ensuring patient safety and provider accountability, the relationship between the physician and the patients is based on a mutual understanding of shared responsibility. Defining when the relationship begins can be sometimes difficult, but the relationship is clearly established when the physician agrees to undertake the diagnosis and treatment of the patient, and the patient agrees to be treated.

To protect patients, we have to ensure that the practitioner uses telemedicine to meet the same standard of care and professional ethics as a practitioner using traditional in-person encounters. From a board perspective, we see the failure to follow standard of care or professional ethics that may subject a practitioner to a discipline by a medical board.

I think one of the things to ensure a patient is to have the appropriate patient informed consent for the use of telehealth. Appropriate consent should, at a baseline, include simplistically, the identification of the patient and patient location, identification of physician, their own credentials and the physician's state of practice. We also need to have an identification of the patient's primary care physician for continuity of care. I think those are just the simple things from an informed consent practice. We also have to have patient—ensure patient privacy and make sure that that patient is being seen for an established care. So I'll stop at that point, Jesse.

Dr. Ehrenfeld: Very, very helpful to hear that perspective from FSMB. Marschall, can you tell us about the current state of the IMLC? How is it being utilized? What kind of data do you have around the number of physicians that are participating and what's the pathway to get 50-state participation?

Smith: Yeah. So the Compact—thank you—let me start out by saying thank you. I appreciate the invitation to participate in this panel and discussion. So as of the end of our fiscal year, which ended on June 30, we have over 16,000 physicians that have utilized the Compact and the Compact process. Those 16,000 physicians have completed and received 48,000 letters of qualification. And as a result of those letters of qualification, over 75,000 licenses have been issued to physicians to practice medicine in the United States.

We just published—we just completed an extensive—and thank you to the FSMB for helping us with this. We just completed a study of looking at the new licenses issued in the United States in the calendar year 2022. And what we found was that 17% of all new licenses issued to physicians in 2022 came through the Compact process. That includes states that are part of the Compact and not part of the Compact, 17% or almost a fifth of all the licenses issued in the United States in 2022 to physicians came through the Compact process.

And looking just at our member boards, so the states that are participating in the Compact, there are 39 states, the territory of Guam and the District of Columbia, 31% of those on average, 31% of all the new licenses issued in those states came through the Compact. So with regards to that, the Compact—and I would like to state on the record and publicly that the compact, really, is agnostic with regards to all of these different approaches to getting physicians so that they can practice in their state.

It is, really—I think there's a misnomer that there's, in a sense, a competition between, should we do this or should we do this? And really, I think the smartest approach that I've seen and certainly is one that the Compact endorses is, why shouldn't states create opportunities or, in a sense, a tool belt for the physician to make the decision on how they can best provide the care to their patient? Whether that's obtaining a full and unrestricted license through the Compact process, the traditional process, doing reciprocity and all of those sorts of things. So not wanting to get into that debate, but I think that's certainly a part of that.

And then before I get to how we're going to get to all 50 states—which is what we will do. I've made that my enduring vow and it'll be marked on my tombstone. So we keep hearing there are two main pain points for physicians with regards to the Compact process and obtaining state-based licensure in that. The first is regarding the cost or the fees that are associated with that. And the Compact, really, has no influence or ability to influence our member boards and the fees that they charge.

However, I would note that most states look at the fees that they charge on an annual basis. And we've had five states that have reduced the cost of all licenses, physician licenses for all physicians, not just compact licenses. And I think the compacts and the input that we have had in providing those additional licenses for those states have had an impact on that. So I think that was one of the things that will continue to happen.

The Compact itself, we look at our fees every year. We have a model that we look at our revenues. We're trying to anticipate that going out into the future, and making sure that what we charge is appropriate. I'm aware that there is a study being done and hopefully will be published in October so we can actually talk about it. But this study, a university has been studying the Compact since 2017. And what they found is that states that have introduced the Compact have reduced the overall, not just the licensing fee aspect and the preparation aspect, but all aspects of a physician preparing to be able to have a practice in multiple states.

Meaning that sometimes there is a variable amount of knowing when you're going to get that license in that state, and being able to establish your practice, and open an office and hire staff, and all that stuff. The Compact provides a stability to that. There is very strong evidence with regards to how quickly physicians can get licenses. And that average for us is about seven to 10 days. So it is a known factor, and all that will be coming out.

The second pain point is with regards to keeping track of all these darn licenses that I've now got. And the Compact is making a major investment. We just have engaged a vendor, Mockingbird, to create what we're calling an enhanced physician portal. That enhanced physician portal, the goal behind it and we're intending for it to be rolled out about a year from now, will be, in a sense, an electronic physician wallet.

The physician in one place will be able to track all of their licenses that they currently have, that they've ever held and those licenses that they're currently using will be able to record and keep track of all the continuing education requirements, all the requirements for all of the different states, and it will be in one place, and it'll be electronic and be available for those physicians. So we're doing that.

Now, to the tricky question of getting all 50 states. Part of what we're finding, especially now that we're down to the last 11 states is really there isn't much—and this is an overly broad statement, but there really is not much opposition to the Compact and to joining a state. It's really more of—someone has to—the Compact, the way that it's designed, we can't advocate for the introduction of the bill. We can provide information and education and support the bill once it's introduced, but it's finding that advocate, especially in those larger states like California and Florida, and getting that advocacy moving forward.

Once it starts, it's generally found there, really, is no downside to patients by having the Compact in a state, and that, really, the fears that have prevented some states from joining the Compact, that it's going to take away physician jobs, it's going to have a negative impact on the hospitals and their ability to have local talent, that it's not really going to reach out to rural and underserved areas, all of those, really, are being found to be false. We've been in business and operating for six years, and the data is supporting those claims that those concerns and fears are not based in fact.

And so one of the things that we're doing is we're working on our advocacy. We're doing these studies, looking at the data, getting hard information so legislators can make their decision about that. We're surveying physicians to find out if the Compact is meeting their needs and if we're doing things appropriately. And I think the answer starts to become—it really does make sense for a state to join the Compact. It's one more tool for them to use or for physicians to be able to use to be able to practice in their state and address those issues.

One of the things that—and I've seen an advanced copy of this study, and I'll close with this comment. But one of the things that that study has found and they actually have the data to support it is that the single most important activity a state can take to increase the number of licensed physicians in their state is to join the Compact.

It's twice as effective as all of the other methodologies where you're forgiving student debt, where you're creating reciprocity, where you're creating special licenses or special processes, joining the Compact is two times more effective than all of those other things. And so, again, I don't think it makes sense for a state not to join Compact and do these other things, too, if they believe that's appropriate. And we support that activity.

So with that, I will be quiet. And thank you, again, for this opportunity to participate.

Dr. Ehrenfeld: Fantastic, Marschall. Thank you so much, and thank you for previewing that study. We'll look forward to that coming out soon hopefully. Let me turn to Clark. So, Clark, the National Capital Region has been at the vanguard of thinking around licensure policy. Can you walk us through how Virginia developed reciprocity to licensure with DC and Maryland, and why is that important to physicians?

Barrineau: Yeah, absolutely. So here in Virginia, we're, obviously, blessed with close proximity to several advanced states in the world of health care. So several years ago in 2018, Senator Barbara Favola of Northern Virginia—Northern Virginia, obviously, being, usually, at the forefront of these conversations having a lot of people go in and out of both DC and Maryland due to the employment with the federal government—asked the Board of Medicine here in the Commonwealth to look at reciprocity. And that was just what we call a Section 1 bill, but it just said, Board of Medicine, go figure this out, was essentially what the bill said. You don't need to go to law school to write that one.

And, of course, when it comes to reciprocity, it takes two to tango. So you can't just establish—my wife had to say yes to marrying me, a state has to say yes to doing licensure reciprocity. And so they reached out to all of the available states that applied. So North Carolina, Tennessee, DC, and Maryland. And Tennessee and North Carolina said, no, thank you. DC and Maryland said, well, let's wait and see.

So the conversation kept going and going and going, and then as many things in the world of telehealth, post-COVID, the floodgates really opened up DC and Maryland, either through a leadership change or just advocacy therein said, hey, let's do it. And then consequently over the past year, really two years ago, I suppose, they hashed out all the legal arrangements, and then that went live in the winter, the late winter of 2023. So currently, if you are a licensed physician in Virginia, Maryland or DC, we now have licensure reciprocity, meaning with hopefully just a few clicks of the button that your associated Board of Medicine state site, you can get a license in as little as 48 hours.

So we're still hoping for Tennessee and North Carolina to come on board. I asked our chairman of our Board of Medicine, have you heard from them in a while? And then he tells me some unkind words. But we're still trying to do that because we still have individuals in those regions where I think it would make a lot of sense to have that arrangement. But it's been a boon to members of the Commonwealth and physicians therein. And as a former resident of Alexandria, Virginia, who lived in DC and dated a girl in Maryland, I can tell you that reciprocity is much needed.

Dr. Ehrenfeld: Very, very helpful. Let me throw out two questions for anybody on the panel, and, folks, feel free to just jump in. Biggest opportunity for the industry and states when it comes to developing telehealth licensure regulations and the biggest risks, what do people think?

Dr. TerKonda: Well, Jesse, I can just start off just in a general way from a board perspective world. We're going to expand access to health care. I mean, that's one of the biggest reasons to bring telehealth to the forefront. It reduces those geographic barriers, allows for improved and specialized care, hopefully, and access to that and improves continuity of care.

I don't know if we can actually say we have reduced wait times because we still don't know if access has really improved incredibly through telehealth. Hopefully we can improve on chronic disease management and mental health services, which has been at the forefront of telehealth from the beginning. You can see that mental health services have increased dramatically over the past few years. So I'll let others speak to some of the opportunities for improving telehealth licensure portability.

Dr. Ehrenfeld: Jump in.

Smith: OK. So I would say, I think one of the biggest potential issues or hurdles with regards to telemedicine and its adaptation and providing medical services is that there is a danger or a fear—I think there's a danger with regards to the idea that it's different or it's a special kind of medicine. And in reality, it is not. It's a modality by which physicians can provide treatment to patients.

And I think the more we bring it back into that concept that you have to have a license to practice medicine, and as a professional, the physician is responsible for figuring out the best way to treat that patient. It may be telemedicine, it may be inpatient, but getting away from treating telemedicine as something special or something unique. While it is, and I understand where we've gotten to, but I think if we continue to take that too far, I think there's a—I would have a fear that we start creating special licenses for it, and then it becomes a different type of medicine.

Barrineau: And then I would just add, as a lobbyist, I think about threats all the time, and it's a very healthy way to live. I would just say the threat is the opportunity for money when it comes to telehealth and licensure. Here in Virginia, we're seeing a lot of corporate interests start to staff up and lobby up when it comes to the world of telehealth. And there is a scenario that I don't think is too crazy to think that those interests want to basically churn and burn telehealth services without state licensure.

So they want to pick whatever state is the cheapest state to do business in, warehouse a bunch of kiosks with a fast internet connection, hire some mid-level providers, and then churn and burn telehealth visits. You only need to Google the company Cerebral, which made the New York Times about a year ago, I think, which is in the telepsych space, but that is the worst case scenario of what we have, which is why, at least, here in Virginia, the state level boards and that protection, that patient protection that you talked about is our line in the sand on any telehealth piece of legislation and probably going forward always will be.

Dr. Ehrenfeld: Very helpful. So Sarvam and Clark, what are you hearing from physician? People who practice telehealth in addition to an in-person practice, telehealth-only people, what are your experiences with the licensure flexibilities that we had during the public health emergency that people really want to see carried forward?

Dr. TerKonda: So feedback from some of those physicians early on was a challenge. There were those that adopted telehealth fairly readily and quickly, and then those who were a little bit more traditional wanted to see their patients so they had a little slow adoption. But those who embraced telehealth actually have a very high, both patient and provider satisfaction, physician satisfaction, upwards over 90%. So as Clark's or I think Marschall, the standard of care is the standard of care, not dependent on the modality. And so those who embraced that thought process as they moved forward ensuring that when the patient was seen, that the standard of care was met for that patient did very, very well with embracing telehealth.

I think some of the flexibilities that patients—or the providers miss from the PHE or the emergency is the waiver of the state licensing requirements. We didn't have to worry about having licenses and having state boards maybe look at your ability to practice in that area. We also didn't have the issues surrounding reimbursement. I mean, we saw Medicare and Medicaid relax on their requirements for where telehealth could be practiced, and also endorse the payment methods for that. So I think that's where we see the flexibilities. If we can't improve on payment models for telehealth, I don't think we'll grow it any further.

Dr. Ehrenfeld: Thanks. Clark.

Barrineau: And then here in the Commonwealth, we're really having conversations about how all in to go with telehealth is what I'm hearing. Obviously, we had the expansion COVID and post-COVID. And then the question is, should I keep doing this much telehealth versus this much in-person? Should I go all in? And I think what you're seeing is an ongoing conversation, and I know the leadership at the AMA is talking about this, but what do patients want out of their providers? What do they expect?

I have two small children, and I'll tell you, pretty much every pediatrician I've ever come into contact with just gives out their cell phone number now and says, text me when you need me when things come up. And that's almost going to be the expectation, I think, but that is a immense burden on the physicians and provider community to basically be available at all hours of the day. So if that's something that we're gearing towards and patients have come to expect, is that something that's sustainable, and then what protections, both financially, personally can we build in to make that happen?

Dr. Ehrenfeld: Thanks. So let me ask one more question for Marschall, and then we'll get to the audience Q&A. Any future where there emerges a national compact structure that offers reciprocity as some newer licensed health care professional compacts offer.

Smith: I would say I think that is probably more of a good think tank topic. Yes. I think looking at, how do we—because the Compact itself and the way that it's established has a high bar bright light standard that if a physician meets this, they can participate, and if they don't, they can't.

And I think it does miss out on those physicians who are just graduating and who have an opportunity. And I think that, really, to me is the next opportunity, the next kind of compact. How do we Compact 2.0, or something like that of where—now that we know this process works and it's there, how do we start expanding it out and make that available to more? Did I get to the question?

Dr. Ehrenfeld: Yeah. No. That's great. Thanks for that, Marschall. So let me turn to our audience. So we're going to go through some questions that were submitted online now in the chat as well as in advance. Thanks for those that are rolling in. We've got a ton of questions. I know we're going to have time because we've only got about 15 minutes left. So let me throw one out to everybody. Any interest in solving this on a national or regional approach, or is it just going to be state by state? Is there any reason there can't be a United States medical license?

Barrineau: Congress.

Barrineau: I think the legislative possibilities of such a thing would be very, very difficult. But that's all.

Smith: And I think, also, for all of its controversy, the Dobbs decision really did reinforce the idea that the practice of medicine is a state-based activity. And so now we've got a Supreme Court decision that supports that concept, and I think it would be difficult to overcome that sort of a legal challenge to create a national license. But, again—and those are my opinions not the opinions of the Compact. But I think that's where we're—coming up with a national license, I think, is a dead topic in today's environment.

Dr. TerKonda: Jesse, if I may add there. Building on Marschall's thought processes, as these licenses are state-based, you have to realize the medical practice acts are state-based. And to try to align 50 states and their medical practice acts would be exceptionally difficult. So I think that's the biggest—that's one of the biggest hurdles in all of this.

Dr. Ehrenfeld: Let me stick with Marschall. So current certification by ABMS or AOABOS board is required for participation in the Compact. Because of some of the changes happening, requirements for yearly fees, MOC, many excellent physicians are letting their board certifications lapse. Are they still allowed to participate in the Compact based on their initial certification?

Smith: Yeah. The board certification requirement is for the initial letter of qualification. And once the physician has their initial letter of qualification, they can come back and get more, the board certification requirement drops off. And that was in recognition of maintenance of certification and all of those sorts of issues and concerns that were raised. And so it's required as an initial, but after that, it's not required for the physician. So they can get their letter of qualification and drop their certification the next day, and they can continue to use the Compact.

Dr. Ehrenfeld: Very helpful. This next one I think is for, probably, Sarvam. So are physicians allowed to have a telehealth visit with an out-of-state new patient?

Dr. TerKonda: So traditionally, we say that telehealth should be for established patients, and that's where we believe is best approached. For a new patient, that patient needs to be seen by a physician that has a license in that state if they're going to move forward with a new telehealth.

You can see a new patient, but you have to meet the standard of care. If you need to have a physical examination to make a diagnosis, obviously, telehealth prevents that. So you haven't met the standard of care for that patient. So remember, no matter if it's a new patient or an established patient, standard care is the standard of care, and that must be met in evaluating those patients.

Dr. Ehrenfeld: Very helpful. Kim, do you want to jump in on that one?

Horvath: Yeah. I think the only thing I would add—I think Dr. TerKonda answered it perfectly. I think the one thing I would add is just that exception for consultations, right? Where if a physician has a established relationship with a patient that's consulting with another physician who might be out of state, that would be an area where they wouldn't necessarily need a license in that state, but that's a very narrow consultation exception.

Dr. TerKonda: Yeah. And building on that, Kim, is those exceptions for licensure, physician-to-physician consultations, prospective patient screening for complex referrals to centers of excellence, episodic and follow-up care for established patients is the norm, and any type follow-up travel, surgical or medical, and clinical trials. We think, in those situations, that's an exception for licensure, and you don't necessarily have to have a license in that state where the patient's located.

Dr. Ehrenfeld: Got it. Very helpful. So there's a question regarding shield laws and state licensure compacts, and how they interact. Anybody want to tackle that one?

Smith: I will boldly go where most fear to tread. This is one of the most common concerns being raised, and we've had conversations and talks to provide a testimony to—Rick Masters and I have provided testimony to state legislatures about the shield laws, but also on the other side, there are concerns about those shield laws being overreaching and allowing physicians to go where—to use that protection to provide services that are not in accordance with the Practice Act of a state.

The Compact has been very, very consistent and insistent on the idea that we are found. And Section 1 of the Compact statute is each state has the complete and full right to regulate practice of medicine in their state, and they regulate that practice through the issuance of a license. That authority and that right of that state ends at their state border. And we continue to believe that is true. We believe that that's the best sort of federalism. We believe that's the intention of state-based health care regulation, and we continue to support that, and we continue to strongly say the Compact support shield laws.

Being a member state of the Compact provides additional statutory authority to protect those shield laws because of how the Compact language is established and works. It also works for those states that have chosen to restrict the health care options for physicians to provide to women. And we are not wading into the politics of it, we're not wading into the right or wrong of any of those decisions, but we are wading into the fact that it is each state's right to do that. And the Compact supports that, and supports those laws, and support shield laws, and it also supports those states that choose to have those restrictions in place.

Dr. Ehrenfeld: Marschall, how has the Interstate Medical Licensure Compact helped physicians?

Smith: I think the biggest thing that we have done is made it easier for the physicians to practice, and to expand their practice and ability to control those costs. We know that on average it costs $385 to apply for a single state license using the traditional method. $700 is what the Compact charges. And so a physician applying to two or more states, it's more economical to use us.

It's one place. It's one stop. It's one website. It's something we strive for. So I think it's something I'm very proud of and my staff and the board staff. We have allowed boards to focus on—we handle the squeaky clean applications. the board staff gets to focus on those that require their expertise and knowledge to make sure that the license being issued is to a physician who is safe.

Dr. Ehrenfeld: Thanks for that. A lot of questions coming online. One was from Daniel. Are there any states that require telehealth providers be physically in the same state as the patient at the time of the service assuming that provider is licensed in the state where the patient resides at the time of the visit? Thought maybe New Mexico had such a restriction? The follow-up question is, what happens if the physician is abroad?

Dr. TerKonda: So, Jesse, there are some international laws that would prevent you providing some telehealth services if the physician is abroad. I think they have to look into those international regulations there. On the other hand, providing telehealth to international patients also presents some issues. One that I repeatedly hear is about China. If you're providing telehealth service to a patient in China, even if it's a U.S. citizen, that medical record has to exist in China and not in the United States. So I think going internationally, you have to be very, very careful and make sure you meet all the regulatory issues that may arise there.

I mean, I think if you're practicing in a state, you have a state license in that state and you're providing telehealth services, I don't think there's any state board that would say you couldn't do that. I'm not familiar what's happening in New Mexico, but I'd be interested to know.

Dr. Ehrenfeld: Maybe Jared wants to weigh in.

Augenstein: Yeah. Not on New Mexico specifically, but just to add one more layer to this. Some states, this is not related to the ability to practice in the state. But from a payment perspective, some payers, commercial payers or Medicaid programs in particular will often require either a physical address in order to enroll in the Medicaid program or with a commercial payer. And so it could also be that what is being seen is more of a payment level issue than the actual ability to provide the service.

Dr. Ehrenfeld: Let me ask one last question, then I'm just going to make a closing comment or two. And the question is, should pathologists who read glass slides from patients out of state have a medical license in the state in which the patient resides? And I imagine you could extend that maybe to a radiologist who's reading a film from a patient in a different state.

Dr. TerKonda: That's an interesting question, Jesse. And I think if you're a practicing physician, you need to have a license where the patient's physically located. To have carve outs for specialties, I think it makes it much more difficult.

Barrineau: In Virginia the answer is, yes.

Dr. Ehrenfeld: Sounds like there's consensus for you as well. Awesome. So thank you to everybody who logged on. We had several hundred attendees today. Obviously, this has been recorded, so we'll post it online along with all of the materials, the slides that were shared. Really appreciate everybody on the panel for walking us through some solutions.

We've heard a lot today from our experts and through the questions, learned a ton about how we collectively can support telehealth, not just for physicians who provide the virtual care, but at the end of the day, it's all about our patients. Our patients who are relying on this modality. Thank you, all, so much for your time today, and I hope you can join us for our next AMA Advocacy Insights webinar. Bye-bye.

Dr. TerKonda: Thank you.