State after state, some patients are losing access to telemedicine for doctors

Many states are making it difficult for people to have virtual visits with doctors in other states, in part by reversing the explosion of telemedicine that occurred during the coronavirus pandemic and questioning the duration of one of the major technological shifts of the past two years.

The restoration of access to telemedicine has come about gradually and quietly over the past few months, as pandemic-era emergency health orders have expired in one state after another, re-enforcing some of the old rules about when doctors can exercise. in multiple states.

At Johns Hopkins Medicine, some patients and their families now have to change doctors or drive hours in different states when video calling from their homes would previously have been allowed under more flexible regulations, said Dr. Brian Hasselfeld, the system’s medical director. healthcare for digital healthcare and telemedicine.

The main obstacle is licensing – a requirement rooted in the 19th century that a physician must have a license from the state the patient is in, even if the physician is licensed elsewhere.

“Most states have now reverted to pre-pandemic licensing rules, where you must be licensed in our state if you intend to see patients in our state,” Hasselfeld said.

A year ago, 26 states still had pandemic-era waivers that allowed residents to have virtual visits with doctors who were based in other states, according to the Federation of State Medical Boards, which represents licensing councils in the states and territories. of the United States.

Now, only 12 states still have a renunciation of the pandemic era, according to the federation. California, New Jersey and some of the other remaining states are expected to expire their emergency exemptions soon, the federation said. Nineteen other states have some long-term rules for interstate telemedicine, though they vary.

There is a lot to be done on regulations for patients and doctors, as well as a wave of tech startups that have increased over the past couple of years hoping to take advantage of the convenience of remote visits.

And there is a renewed urgency among some patients and doctors to make telemedicine work across state borders due to the national debate on abortion and the likelihood of the Supreme Court overturning the constitutional right to abortion established in the Roe v. Wade of 1973. A number of states have passed abortion-related provisions to their telemedicine regulations, often requiring doctors and patients to be in the same room for abortion discussions.

Linda Branagan, director of telemedicine programs at the University of California, San Francisco, said rapid changes in state laws and regulations are “operationally unsustainable,” especially when patients are often in such vulnerable positions.

“We asked patients to come to the place that we would normally see on video,” he said. “They are either financially fragile or clinically fragile or both.”

Before the pandemic, about 2 percent of UCSF’s outpatient appointments were via Zoom-style calls, and officials considered it a success, Branagan said. The share soon rose to 60% of appointments during the height of social distancing and has since dropped to 25%, he said, as patients and providers seek a balance and try to comply with state regulations.

The reappearance of such barriers for doctors does not affect video visits within the state or some calls with other medical professionals or nurses, but it is still a common problem, especially for some medical specialties or for in-demand doctors who are used to see patients from all over the country.

“The real value of telemedicine is being able to see your doctor, not just any doctor,” said Dr. Thomas Kim, head of behavioral health at Prism Health North Texas. He said he’s not worried about the downfall of telemedicine, but said providers need to see it as a skill, not a service in and of itself.

“They are either financially fragile or clinically fragile, or both.”

Linda Branagan, director of telemedicine programs at the University of California, San Francisco

Nearly 1 in 10 of telemedicine visits to Johns Hopkins involve patients living in states where the system has no operations, Hasselfeld said. She said it’s now routine for staff members who have scheduled appointments to double-check where patients will physically be for video calls, which didn’t matter two years ago.

“It was really difficult trying to explain that providers can only see patients in specific areas,” said Hasselfeld.

Separate from the medical license issue is who pays for telemedicine visits and whether providers are paid as much as for in-person visits. Since March 2020, Medicare has waived many restrictions on remote visits, but the waivers are temporary and are expected to end after the Federal Emergency Ordinance Covid-19 expires, unless Congress takes action.

Historically, doctors, nurses, and other medical professionals have been licensed at the state level, not the federal government, and state medical boards have often tried to prevent out-of-state physicians from seeing patients in their own jurisdictions.

“A lot of it is inertia about how medicine has been practiced in this country for years and decades, actually,” said David Peloquin, a partner at Boston-based Ropes & Gray law firm representing academic hospital systems.

Interstate medical practice wasn’t a problem before widespread adoption of the internet made virtual visits possible, Peloquin said, and demand really grew a decade ago, when doctors involved in clinical trials were looking for geographic flexibility. Then the pandemic accelerated demand.

But there are advocates of maintaining something like a state-by-state mosaic, including state medical committees that manage licensing systems. They cite potential abuses, such as the illegal sale of prescription drugs or the possible difficulties of a medical board investigating a doctor in another state.

“We want to achieve greater portability, but we don’t want a system that compromises patient safety,” said Lisa Robin, chief advocacy officer of the Federation of State Medical Boards.

“We want to achieve greater portability, but we also don’t want a system that compromises patient safety.”

Lisa Robin, chief advocacy officer of the Federation of State Medical Boards.

In April, the federation unveiled a new policy model that states could potentially adopt to support patients traveling out of state or participating in remote clinical trials. Model politics stopped, however, before full reciprocity between states.

The changes two years ago were supposed to be emergency measures at a time of localized Covid-19 spikes in states like New York.

“They thought there would be a serious increase in Covid cases in one state and the state next door, for example, might have professionals who could help,” said Krista Drobac, executive director of Alliance for Connected Care, a lobby coalition of large employers and hospital systems, such as Stanford, that favor deregulation.

But it turned out that there were many reasons why someone might want to see a doctor based in another state. It could be because patients have relocated or have limited choices in their area, especially in some fields, such as mental health. They may want to see specialists in top-tier hospitals or participate in clinical trials based elsewhere.

Or patients may simply be on vacation or traveling out of state and want to speak to their regular doctors, a situation where medical licensing boards have often frowned upon interstate phone appointments or video calling.

“Basically, it’s just a pain in the butt to go to a doctor’s office if it’s far away,” said Dr. Ateev Mehrotra, a professor of health policy and medicine at Harvard Medical School.

Last year, he wrote about a cancer patient living in New York who suddenly had to start driving more than three hours to Massachusetts after a state waiver expired and Boston-based cancer doctors could no longer practice. medicine with patients across the state line.

“We can’t get all of our documents under license in New York,” he said.

There are numerous proposals to lower licensing barriers, including switching to a driver’s license system, but none have progressed. And an interstate pact launched in 2017 attracted relatively few participants.

Mehrotra, who researches telemedicine, said the pandemic experience revealed clear patterns about who uses remote visits and why. There has been a large spread in urban areas, she said, because they have better internet access and had less need for telemedicine before the pandemic. And some fields, like ophthalmology, haven’t translated into video chat as well as others, like psychiatry.

“You see a lot of telemedicine for anxiety. You don’t see much for cataracts, ”she said.