Licensure laws and other barriers to telemedicine and telehealth: an urgent need for reform

A few weeks ago, a man in his mid-60s with worsening pulmonary fibrosis sought the expertise of a specialist physician (GR) via a telemedicine visit. The patient took the visit in his car by the roadside. Although a telemedicine visit in a car is never ideal, it was particularly difficult because he was using supplemental oxygen at 6 L/min and his oxygen saturation was only 90%; every cough during the conversation led his oxygen saturation to drop even further. The patient was not in the car by his choice or because his pulmonologist recommended it—both would have preferred the telemedicine visit from the comfort of the patient's home. The visit occurred in the car parked just within the border of Washington, USA (figure ) to comply with state licensure.

Figure.

Map of northwestern states of the USA

To meet current licensure requirements for telemedicine, the patient travelled over 8 h (black arrow). The pulmonologist (GR) providing the telemedicine visit is in Seattle, Washington, USA (white star). The arrowhead of the black line indicates the patient's location at the time of telemedicine visit, over 5 h of additional travel would have been needed to reach Seattle (dotted grey line with the arrowhead). To ensure privacy, the patient's home is not at the point of the red star. The red star is placed in an arbitrary spot in the state of Idaho that corresponds to approximately the distance from Washington that the patient lives.

In the USA, and around the world, the onset of the COVID-19 pandemic triggered a sudden surge in the use of telehealth. This growth was facilitated by many temporary payment and regulatory changes made by governments and health plans to ensure that patients with acute and chronic illnesses receive the care they need.¹ Telehealth was particularly important for physicians treating rarer and complex diseases and whose patients often live hundreds of kilometres away or in other states. For diseases such as interstitial lung diseases or pulmonary fibrosis, input from a specialist can be crucial for management² but travel can be extremely taxing. It is not surprising that many patients and pulmonologists have turned to telemedicine.³

Historically in the USA, each state mandated that physicians must be licenced in the state where the patient is physically located at the time of encounter.⁴ Early in the pandemic, most states temporarily waived this requirement. Unfortunately, most of these waivers have now expired. This brings us back to our patient. The patient drove from where they live in Idaho to Clarkston, Washington (USA), which is just inside the border (figure). The patient was still more than 500km from Seattle, where the physician was located, but they now met the requirements of state law.

The negative consequences for patients of these reinstated restrictions to providing telemedicine across state borders are substantial, especially for patients confronting life and death decisions similar to our patient.⁵ This patient is not unique; many patients in the USA are now taking video appointments in their cars, on roadsides and in parking lots, travelling unnecessarily to the doctor's office, or simply skipping follow-up care. Our patient's trip required substantial planning, and the patient had to pack several tanks of oxygen to ensure that he had sufficient oxygen for the entire trip. Patients are now subject to accidents of geography. Two patients with the same lung disease who both live the same distance from their pulmonologist can have very different access to their physician. The patient who lives in the same state as the physician can have a telemedicine visit from the comfort of their home. The patient who lives in another state must travel or skip the appointment. The current situation also encourages patients to lie to their physician. To ensure they are compliant with state laws, physicians typically ask patients where they are at the time of the visit. For all practical purposes, the patient could be sitting in a car just outside the home and tell his physician that he was within the state border. Indeed, just the other week, a man in his mid-70s with pulmonary fibrosis considered this, as he thought it was pointless to drive approximately 4 km to be within the border of Washington just to sit in his car for a telemedicine encounter with GR.

Given that the current US licensure does not work for telemedicine, there is a clear need for reform. The medical conditions and management of patients are the same across state lines, and licenced physicians are all trained in accredited programmes in the USA. Ideally, a licenced physician could freely care for any patient in the nation. Many licensure reforms are being debated. One idea is that the federal government could create a single national licence that would allow a physician to care for any patient in person or via telemedicine. Unfortunately, this idea does not have substantial support. Reforms being considered by individual states include full licence reciprocity between states (rather than having physicians being licenced in each state), creating special telemedicine-only licences for physicians in another state, or creating exceptions for licensure when the patient and physician have previously had an in-person visit.⁴

The potential benefits of telemedicine visits, as well as home monitoring for the treatment of pulmonary disease, have been discussed elsewhere in this issue.6, 7 However, the benefits will not reach all patients unless challenges are addressed. We have focused on licensure, because of its sudden salience and need for reform, but we acknowledge that there are many other barriers. For example, there remains uncertainty on whether all telemedicine visits will be paid for in the future by government payers and private plans. With this uncertainty, pulmonologists and health systems might be reluctant to make investments in telehealth infrastructure. Relatedly, there is uncertainty on how telehealth should be paid and, specifically, whether physicians, providers, specialists such as pulmonologists, or subspecialists should receive reimbursement for each visit or capitated payments (eg, a monthly payment for a given patient).⁸ Another barrier is that the provider, physician, or specialist cannot provide high-quality care for all patients with just a video encounter on a computer or smartphone.⁹ Data such as oximetry for oxygen saturation, forced vital capacity and FEV1 by home spirometry, electrocardiograms, day-to-day physical activities such as ambulation (eg, steps per day or distance covered over a defined time), and auscultation from digital stethoscopes are often crucial for optimal diagnosis and management. It remains unclear whether the data collected by patients are similar to the measurements obtained by trained staff and supervised in a medical facility. It also remains uncertain how patients should access these digital tools, how society should pay for such home measurements and assessments by remote devices, and how these results should be incorporated into the electronic health record. Only when these, and other barriers to care, are addressed will all patients have access to the clinicians they need, regardless of their origin and location.

GR is a long-standing licenced physician in the state of Washington, USA, pulmonologist in clinical practice, and an expert in the field of interstitial lung diseases and pulmonary fibrosis; he reports research grants from the National Institute of Health (NIH); and is a consultant for Bristol Myers-Squibb, Bellerophan, Fibrogen, Gilead Sciences, Nitto, Novartis, Roche-Genentech, and Veracyte for studies outside of the submitted work. AM reports grants from NIH, Commonwealth Fund, and Arnold Foundation; personal fees from Black Opal Ventures, Commonwealth of Massachusetts, Pew Charitable Trusts, Sanofi-Pasteur, and HHS Assistant Secretary Planning evaluation outside of the submitted work.