Curbside Consult with Dr. Jayne 9/12/22

I was glad that Mr. H mentioned Friday’s opinion piece by former VA Secretary David Shulkin MD. With a title like “State lines should no longer be barriers to health care,” I was hooked.

Going through medical school, I had a passing exposure to the idea that one would need a state-specific license when they went into practice. Mostly this exposure came by watching the anguish that your supervising residents went through as they tried to obtain licenses so that they could earn extra money by moonlighting at rural emergency departments or by covering nights or weekends on the medical center’s newly created hospitalist service. The medical center had a variety of services to support the application process, including access to fingerprinting courtesy of campus police and notary services from the medical school office of student affairs.

Once out in practice, that process becomes more difficult. Especially in a post-COVID world, the process may require making various appointments in person and during normal business hours, which isn’t terribly helpful if you’re a busy physician. Although some states are members of the Interstate Medical Licensure Compact which can expedite this process, a significant number of states have yet to opt in. This can mean going through the licensure process from scratch – providing various transcripts, reports of test scores, copies of certificates, and more.

One state where I applied demanded a copy of my high school transcript, which didn’t seem terribly relevant for someone with a medical degree and a couple of decades experience under her belt. I had a very interesting conversation with the registrar at my high school who eventually found it on microfilm. It looked like something that couldn’t possibly be a legitimate document, with each semester’s results being contained on an address label-like sticker that was applied to a single sheet of copier paper that had my name handwritten on the top. But it had the all-important embossed school seal, so I guess that made it official.

Still, and especially since this was a state that bordered my own, I thought it should be easier since the same standards of care that apply on one side of the line apply to the other. They are called “community standards of care,” not “state-specific standards of care.”

I had been practicing telehealth part time when COVID hit, and the relaxation in licensure requirements boosted my volumes. Almost overnight, I could see patients from 17 states, and as more states relaxed their rules, our wait times for on-demand telehealth visits decreased dramatically. As the pandemic eased, however, many states ended these programs, thereby limiting their residents to a smaller pool of clinicians.

One of the reasons that was cited by multiple states was the concern that easier access to telehealth would result in higher healthcare expenditures and the states didn’t want to be on the hook for that. States were also lobbied by their own state medical boards, in the context of the boards wanting to be able to ensure quality care and discipline physicians. Those boards also receive licensing fees from the physicians who want to practice in a given state, so I’m sure that was a factor.

We knew it would take time to see whether patients would return to in-person care or if they’d continue flocking to telehealth visits. Although many of us have witnessed changes in our volumes, the evidence was largely anecdotal. This week also brought us some research, as the journal NPJ Digital Medicine published a study looking at “The impact of expanded telehealth availability on primary care utilization.” The authors looked at 4 million primary care encounters from 939,000 unique patients from three health systems during the period between 2019 and 2021. They found little change in overall primary care utilization as telehealth services became more broadly used. They noted that “our results suggest the availability of telehealth is not resulting in additional primary care visits, rather, telehealth is serving as a substitute for certain in-person encounters resulting in no overall increase in primary care utilization. Further, it seems telehealth was mostly utilized for patients whose medical needs required multiple primary care visits during each year, suggesting that these telehealth encounters enabled follow-up for patients with chronic illness.”

They noted that additional studies are needed to determine the impact of expanded primary care access on other types of visits, such as urgent care or emergency visits. The authors also noted some limitations to the study, including the inability to determine if patients received additional primary care services from other facilities outside the study dataset. They also could not assess the quality of telehealth encounters compared to in-person visits.

I would also note that although the study looks at visit volume, it doesn’t take into account the differences in the costs of different types of visits. I’ve seen lots of institutional data that shows that telehealth urgent care visits are extremely cost effective, with one organization reporting a savings of nearly $150 for each patient encounter that was handled virtually versus at one of their brick-and-mortar urgent care clinics.

Now that states are cracking down on licensure, it makes it difficult for organizations to maintain the flexibility they need to care for patients. I can barely practice telehealth urgent care now because I’m not licensed in enough states. As an independent contractor, I’m not about to shell about big bucks, and a bigger amount of my time, to obtain additional licenses, so I’m effectively a wasted resource in the primary care / urgent care space.

David Shulkin calls for the states to adopt a model that stretches the boundaries of care, much like the Veterans Administration has done. Many organizations continue to lobby state legislatures to allow continued licensure flexibility, and some states have created lower-cost, telehealth-specific licenses that allow continued practice with more acceptable overhead. Shulkin uses motor vehicle driver licensure as an example, with operators being obligated to follow the laws of the state they’re in regardless of where their license was issued. In that kind of model, physicians would agree to abide by the laws of the patient’s state.

Such flexibility would not only help telehealth programs, but would also help in-person care. Organizations that require support from locum tenens physicians would have access to larger pools of physician candidates and would experience fewer delays in a physician arriving onsite. Ultimately patients would win, which should be the goal of 99% of what we do in healthcare. This would be administrative simplification at its finest.

Unfortunately, I know how state medical boards think, and I don’t see them running to jump on this particular bandwagon. Still, a girl can hope. Maybe some day I’ll be able to see more than two patients a day again.

What do you think about cross-state licensure? Will we see improvement in this decade? Leave a comment or email me.

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