Suspending State-based Licensure Requirements — An Unnecessary Barrier to Telemedicine — Must Outlive the Pandemic
Yash S. Huilgol
Robert M. Wachter, MD
While the national response to the COVID-19 pandemic has been disappointing and disjointed, one area the Trump administration got right was its support for telemedicine. In late March, the administration lifted the antiquated requirement that physicians licensed in one state cannot treat patients in another.
It is vital that this change be made permanent.
Even before SARS-CoV-2 struck, many patients living in rural areas or those with specialized problems but no nearby specialist found telemedicine to be a godsend. However, the COVID-19 pandemic quickly turned telemedicine from a “nice to have” into a “must have” for even more patients.
First, older patients with chronic diseases are at particularly high risk from coronavirus, so it was crucial that they stayed away from clinics that might be filled with infected patients. Second, given the high risk of viral spread, many clinicians were forced to work from home. In a world of only physical visits, such clinicians would be rendered useless — despite the massive need for their services. In response, every health system ramped up its telemedicine capacity. At UCSF Medical Center, where we work, televisits now account for about 60% of all outpatient visits, up from 2% three months ago.
Telemedicine allows physicians to provide high-quality care in an environment in which neither patients nor clinicians may want to, or be able to, go to a physical site of care. Recognizing that telemedicine is essential during this crisis, Congress passed a bill that allocated $500 million to support telemedicine services. The administration also removed the requirement — long an obstacle to telemedicine adoption — for state-by-state licensure via a Social Security Act 1135 waiver.
State-by-state licensure has distant roots. In the 1800s, states established systems of licensure to protect patients from untrained doctors. The logic of state-by-state licensure was sound at the time: why would a patient in Oklahoma ever need to be seen by a doctor licensed in Oregon? And, if a patient did need to see an out-of-state doctor (such as going to the Mayo Clinic for a second opinion), it would be the patient, not the doctor, who traveled.
The closest comparison to state medical licensure is the state bar exam for lawyers. Such a requirement seems reasonable since laws actually do vary state-to-state. However medical standards largely do not, which has meant that state licensure for doctors has long outlived its original purpose. Doctors already have a single national board certification for specialties (such as oncology or vascular surgery); there is no reason to suspect that a doctor who is competent to practice in Texas is not competent to do so in New Jersey.
Until recently, the requirement for state licensure was simply a time-consuming and bureaucratic annoyance, one that was relevant only when a physician moved to another state. But the requirement is now an outdated and unhelpful impediment to telemedicine adoption and spread. This became obvious as the coronavirus crisis grew, and physicians from less hard-hit states (including ours, California) sought to help out in more affected states like New York.
We were pleased that the federal government loosened the state licensure requirement (along with other reforms, including equalizing payments for televisits and in-person visits) during the COVID-19 pandemic. These changes have already generated tangible benefits for patients. For example, at the height of the surge, UCSF palliative care physicians were able to support patients and families in New York City via telemedicine, stepping in for their overtaxed colleagues.
When the crisis recedes, patients, clinicians, and healthcare systems will have seen the benefits of telemedicine. It is vital that the state licensure reforms be made permanent to allow telemedicine to continue to meet patients’ ongoing needs.
One proposal being considered is to expedite licensure for out-of-state physicians. The Federation of State Medical Boards has proposed the Interstate Medical Licensure Compact, which would allow board-certified physicians in 29 states to practice across state lines. This is a reasonable start.
But the Department of Health and Human Services should go further, by adopting a national licensing system. The federal government has already shown that this can be done: the Department of Veterans Affairs has eliminated state licensure requirements for its more than 10,000 doctors. Unsurprisingly, the VA has a flourishing telehealth program, allowing veterans to be treated without worrying about their doctor’s location.
We applaud the decision to suspend the requirement for state-based medical licensure for the duration of this pandemic. It’s high time to remove these antiquated restrictions for good.
Yash S. Huilgol is an MD/MS candidate, Joint Medical Program, UCSF School of Medicine and UC Berkeley School of Public Health. @yash_huilgol
Robert M. Wachter, MD is professor and chair of the Department of Medicine, UCSF. @bob_wachter
(Dr. Wachter is on the advisory board of Teladoc, a provider of telemedicine services.)