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As cross-state telemedicine waivers expire, virtual care advocates focus on long-term policy changes

As cross-state telemedicine waivers expire, virtual care advocates focus on long-term policy changes

Telehealth advocates are looking to capitalize on virtual care’s positive momentum after two years of COVID-19, hoping to shape a friendlier physician licensing landscape as states increasingly reformulate policies mediating cross-state care.

But there’s a complication: No one solution to the U.S.’ patchy physician licensing infrastructure has universal buy-in from the telehealth industry.

Some groups push for greater state adoption of compacts like the Interstate Medical Licensure Compact, which makes it easier for doctors to obtain licenses in bulk from the 38 participating states. Others lobby for reciprocal licensure arrangements between the states.

Telehealth stakeholders are also split on the role that the federal government should take.

The licensing of medicine is a state determination, though some are hopeful Washington could step in and open the doors to cross-state practice, which the nation was able to temporarily sample due to more generous licensure policies during COVID-19 that states are now rolling back.

Virtual care advocates say opening up cross-state care is integral to patient access moving forward. However, it’s unclear how much effect expanding cross-state telehealth access would have.

Though telemedicine across state lines increased significantly amid pandemic waivers, it still made up a small portion of overall Medicare telehealth usage, a recent study in Health Affairs found.

Out-of-state visits represented 5% of all virtual visits in 2020 and 0.8% of all outpatient visits. That’s compared with 8% of all virtual visits and 0.1% of all visits between 2017 and 2019, the University of Michigan researchers found.

Despite the small incidence, rural patients were more likely to use virtual care between states, suggesting its usefulness for expanding access to patients with geographic barriers to care. And, though most states saw fewer than 1% of overall visits virtually across state lines, utilization varied widely across the U.S., leading researchers to suggest decisions that future telehealth access is best left up to the states.

“In a short period of time the conversation has changed,” said Kyle Zebley, VP of public policy for the American Telehealth Association and executive director of ATA Action, a unit of the ATA focused on lobbying state and federal government to permanently enact temporary COVID-19 telehealth flexibilities. “There’s a lot of data that we can go back to and point to and say this worked.”

States: the starting line

The fact that medical licenses are granted and managed by state medical boards is a “complicating factor, to say the least, for the delivery of care across state lines,” Zebley said. “Prior to the pandemic, this was unquestionably a hindrance.”

Telehealth licensure prior to the COVID-19 pandemic was largely based on three models: being licensed in and caring for patients in a state; being a member of a licensure compact that allowed for care between states; or specific and prescriptive temporary licenses for telehealth. However, cross-state practice was uncommon, according to Latoya Thomas, senior director for policy and government affairs at virtual care company Included Health.

During COVID-19, states — needing doctors to help overwhelmed hospitals and facing a rising demand for telemedicine — enacted temporary allowances for clinicians who were properly licensed by another state to deliver services.

During the height of the public health emergency, all 50 states and Washington, D.C. used emergency authority to waive at least some aspects of their state licensure requirements.

But as the public health response to COVID-19 winds down, more and more states are ending their waivers or allowing them to expire, resulting in millions of patients losing that expanded access to telehealth.

As of mid-April, 15 states still had licensure flexibilities in place, down from 24 in early March, according to a tracker maintained by telehealth lobbying group the Alliance for Connected Care.

In many of the remaining states, cross-state licensure flexibilities are set to expire this summer, or are tied to the duration of the federal public health emergency.

The loss of those waivers will impact care for patients who began seeing out-of-state providers during the pandemic, telehealth advocates say.

“I certainly see this being a precursor to some sort of stagnation for patients,” Thomas said.