State lawmakers temporarily scrapped hundreds of regulations early in the COVID-19 pandemic to help businesses and consumers deal with widespread shutdowns, giving patients greater access to telehealth and helping spur an explosion in use of virtual care.
A number of states allowed medical professionals licensed elsewhere to hold telehealth visits with residents of their state during the pandemic, and some already have or are looking to make the rollbacks permanent.
Exact numbers are difficult to track because some policies overlap and are organized differently in different states, but as of July 28, 17 states and the District of Columbia still had some type of telehealth waivers in place, according to the Federation of State Medical Boards.
Other states like New York, Minnesota, Florida and Alaska are among those that have pulled back emergency waivers.
Alaska is going back to its old ways after its governor's emergency order ended. Patients there can only visit telehealth providers licensed in the state now after about a year without that rule. The same goes for Florida after its emergency declaration expired on June 26.
Meanwhile, Arizona lawmakers passed sweeping legislation in May making the state's pandemic-related telehealth waivers permanent, including requiring insurers to cover audio-only visits and allowing out-of-state medical professionals to conduct telehealth visits with patients in the state.
Advocates for allowing providers to permanently deliver virtual care across state lines say it would help ease staffing shortages, help patients and doctors maintain existing relationships and benefit patients in isolated communities by making faraway specialists more accessible.
But as long as medical licensing is regulated at the state level, the broad access to services and providers that existed during the pandemic won’t continue for everyone.
Patients in rural areas are often far away from a doctor's office, and in states like Alaska where flexibilities expired, can be even further from providers practicing certain specialties, such as a pediatric intensivist or certain oncologists, said Mei Kwong, executive director for the Center for Connected Health Policy.
"Maybe there aren't enough of those cases in those particular states to make it worth a provider's while to go and move there, but there's still a need because they may still have people who need those services," Kwong said.
The patchwork of red tape could also pose a challenge for providers who have pivoted to delivering more virtual care over the past year.
Mia Finkelston, a family medicine physician in Maryland, made the switch to telehealth nearly a decade ago and has been practicing with Amwell ever since. She's currently licensed in 29 states, and said the process to get her licenses varied widely.
"It's not standard as far as fees, it's not standard as far as what documents you need to give them. It really is based on those state medical boards and what they decide is important to them," Finkelston said.
As more states' waivers expire and others' rules change, one option for providers who want to continue delivering care across state lines is through the Interstate Medical Licensure Compact, which currently includes 30 states, the District of Columbia and Guam.
Similar to the nurse licensure compact, it allows eligible physicians to practice in other compact states.
It’s worth noting, however, that the Interstate Medical Licensure Compact does not issue a compact license or a nationally recognized medical license for physicians, but rather streamlines the process for them to receive multiple licenses from individual state medical boards.
Physicians pay an initial $700 compact fee, then an additional cost for each license in any compact state they want to practice in. States must pass legislation to join the compacts.
"No two states are totally alike in their legal and regulatory framework for the practice of medicine, which of course, affects telehealth, which is just one aspect of the overall US healthcare system," Kyle Zebley, director of public policy at the American Telehealth Association, a coalition with a board that includes representatives from hospitals like HCA and payers like CVS, said.
"Therefore a way to be consistent with our federal system, consistent with the way that the practice of medicine has been done in this country for so long, we've come up with this great model of compact, which is a way to be consistent with all that while still allowing for care across state lines," Zebley said.
As lawmakers try to facilitate continued access to telemedicine for those who need it most, licensure reforms will be key, the authors of a February article in the New England Journal of Medicine argue.
"The growth of large national and regional health systems and the increased use of telemedicine have expanded the scope of health care markets beyond state borders," the authors said.
They agree that a federal medical licensing system is the loftiest reform option and strengthening existing compacts is the way to go, suggesting Congress pass legislation to encourage holdout states to join the Interstate Medical Compact.
Other options include encouraging states to practice reciprocity, where they automatically recognize an out-of-state license, as the Department of Veterans Affairs does with physicians in its system.