The COVID-19 public health emergency made clear that the issues of telehealth and state medical licenses are interconnected. But, while there is movement to make the temporary waivers of out-of-date telehealth restrictions permanent, the flexibilities that allowed physicians to practice in states where they are not licensed have mostly gone away.
These flexibilities were instituted during the early days of the pandemic in part to address the “huge mismatch” in physician supply and demand in states where COVID-19 was spiking and in those that had still not experienced a COVID surge, according to Jared Augenstein, managing director of Manatt Health Strategies.
Augenstein spoke during an AMA webinar examining emerging models of flexible state medical licenses that facilitate the delivery of telehealth services for patients located in states other than those where their physician typically practices.
Supporting telehealth is an essential component of the AMA Recovery Plan for America’s Physicians.
Telehealth is critical to the future of health care, which is why the AMA continues to lead the charge to aggressively expand telehealth policy, research and resources to ensure physician practice sustainability and fair payment.
During the webinar, Augenstein highlighted these four emerging models that streamline the licensing process and make it easier for physicians to practice in multiple states—either in person or virtually.
The Interstate Medical Licensure Compact (IMLC). The compact expedites the process by which a physician with an active license in good standing can get a license in multiple states. Since its launch in April 2017, more than 15,000 physicians have secured more than 63,000 licenses through the IMLC.
Licensure by endorsement or reciprocity. This model provides an expedited pathway to obtain a full license in the endorsing state or state with a reciprocity agreement based on a set of qualifying criteria. A reciprocity agreement between Virginia, Maryland and the District of Columbia was highlighted in the webinar.
Special purpose telehealth registries or licenses. This model allows physicians in other states to provide telehealth services to in-state residents.
Exceptions to in-state licensure requirements. These exceptions allow physicians in other states to deliver services via telehealth—and, in some cases, in person—under certain circumstances such as emergencies, providing ongoing care with an established patient temporarily residing in another state, or to consult with another physician.
“States are not just limited to one of these models,” said Kimberly Horvath, senior attorney with the AMA Advocacy Resource Center, adding that the AMA supports a state-based licensure system in which physicians are licensed in the state where their patients are receiving their care.
She predicted that reciprocity agreements will become more popular among states that share borders and noted that the process is aimed at lowering administrative burdens among both physicians and medical boards.
Horvath cited Florida as a state with a special purpose telehealth registry, and she explained that physicians in the registry are only allowed to provide telehealth services and that they must have someone acting as their registered agent in the state and must carry liability insurance for care provided to patients in Florida via telehealth.
This model of care is typically provided to deliver ongoing care for students attending college in another state or for “snowbirds” who live in warm-weather states during the winter.
Hawaii and Missouri recently joined the IMLC, bringing its membership up to 39 states, the District of Columbia and the territory of Guam. While New Jersey, Pennsylvania and Rhode Island are compact members the implementation of its licensing processes are still in progress.
In 2022, 17% of all new medical licenses in the U.S. were generated by the compact and 31% of all new licenses issued in compact-member jurisdictions came through the compact, said Marschall Smith, executive director of the Interstate Medical Licensure Compact Commission.
Smith cited research that shows “the single most important activity a state can take to increase the number of licensed physicians in their state is to join the compact.”
A major concern for Smith is that states may determine that telehealth should be subject to a separate type of license because “it’s a special kind of medicine.”
“It’s not,” he said. “It’s a modality by which physicians can provide treatment to patients.”
Sarvam P. TerKonda, MD, the immediate past chair of the Federation of State Medical Boards, agreed.
“The standard of care is the standard of care—it’s not dependent on the modality,” Dr. TerKonda said. “To protect patients, we have to ensure that the practitioner who uses telemedicine meets the same standard of care and professional ethics as a practitioner using traditional in-person encounters.”
Prior to the COVID-19 pandemic, telehealth use was governed by out-of-date regulations that were developed before widespread use of cell phones. Also, Medicare only covered a limited number of virtual health services and only for patients in rural areas who had to travel to a health care facility to receive them.
A recent survey showed that 85% of physicians now embrace telehealth services, said AMA President Jesse M. Ehrenfeld, MD, MPH, who noted that the AMA is an enthusiastic supporter of the CONNECT for Health Act of 2023, a bipartisan proposal that would further expand Medicare coverage of telehealth services while making pandemic-related flexibilities permanent.
“As we all learned during the pandemic, telehealth is an essential part of medical practice today,” said Dr. Ehrenfeld, a senior associate dean, tenured professor of anesthesiology and director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin.
“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,” he added.
Details on telehealth, state licensing, AMA policy, and recommended telehealth legislative language can be found in an AMA issue brief (PDF) on the emerging state licensing models.