is juggling a lot these days. She’s a biology professor at upstate New York’s Ithaca College, where she balances teaching and research on messenger RNA (suddenly a topic of global interest). She is a mother of a vivacious 10-year-old who just finished fourth grade, and that means lots of driving back and forth to gymnastics and swimming practice. And she has lung cancer. In April, after years of clean scans, the cancer was back. She just had major surgery and is starting chemotherapy again. She has a lot of appointments with her local oncologist and her oncology team at the Dana-Farber Cancer Institute in Boston.
One silver lining of the pandemic for Ms. Inada was that she didn’t have to drive to Boston for her appointments. She began having video calls with her doctors and planned to conduct many of her postoperative and oncology appointments via telemedicine. But regulatory changes in the past month have thrown a wrench in those plans. Dana-Farber told Ms. Inada she’ll have to be physically located in Massachusetts for a visit. She doesn’t have to go all the way to the doctor’s office, a 5½-hour drive each way. She can drive 3½ hours, cross the border into Massachusetts, pull over, and have a telemedicine visit in the car.
So for her next appointment, the grandparents drove 11 hours to Ithaca to watch their granddaughter, and Ms. Inada and her husband drove to Boston. After she had some scans at the cancer hospital, she quickly had a telemedicine visit from the lobby. But she had to skip one of her postoperative appointments because you can only drive back and forth so many times.
This sudden, severe and senseless inconvenience results from one of the historical vestiges of U.S. healthcare. The practice of medicine is regulated by state medical boards, which can license doctors only to practice medicine in their state. Traditionally, medicine is “practiced” where the patient is located. If Ms. Inada is in New York during an appointment, then her physician must be licensed in New York even if he is somewhere else.
Early in the pandemic, most states relaxed the rules and allowed out-of-state providers to provide care to patients in their state. These temporary waivers allowed Ms. Inada to have telemedicine visits at home in New York with her doctors in Massachusetts. But as these temporary waivers began to lapse, Dana-Farber changed its policy. It’s too expensive and complicated for the cancer center to have all its physicians licensed in every state.
The problem is especially acute for patients like Ms. Inada who suffer from rare diseases that require specialists who aren’t available locally. For residents of metro areas that span several states, such as New York, Philadelphia and Washington, licensure rules are a barrier to using telemedicine even for routine appointments. In theory they might even ban phone or email consultation across state lines, but physicians and hospital lawyers are especially cautious about telemedicine visits because they’re “on the books”—billed to the patient or his insurance company.
Fortunately, a problem caused by such a technicality has lots of sensible solutions. One path is to make it easier for out-of-state physicians to practice telemedicine in the state, as Florida permits them to do with a few simple steps. Alternatively, states could join an existing compact that makes it logistically easier for physicians to get a license across state lines.
Ideally individual state medical boards would permanently implement automatic reciprocity—allowing any physician licensed in another state to provide care within their state. But state boards worry about their ability to discipline physicians in other states. They also have exhibited a tendency to act as a cartel, protecting physicians in their state from competition rather than serving the needs of patients.
Other solutions require federal intervention. Washington could use the spending power of Medicare to mandate that a physician licensed in any state can care for a Medicare beneficiary anywhere in the U.S. There is already a similar reciprocity setup for the Veterans Affairs system, and this would push the states to do it for all patients. Congress could also establish a federal licensure regime and pre-empt those of the states. But until there is action, many patients who are sick, nauseated or in pain will either have to drive long distances or consider forgoing care.
When Ms. Inada was first diagnosed more than a decade ago, she considered getting her cancer care in New York City, only a little closer than Boston to her home. Telemedicine didn’t figure into her decision. But if she were given the choice now, she might opt for New York providers, who could provide telemedicine visits while she is in Ithaca. That might please New York’s physicians and the state medical board that represents them, but it’s not good for American healthcare. Patients should have the freedom to select physicians based on their expertise and quality of care, not on accidents of geography.
Dr. Mehrotra is an associate professor of health policy at Harvard Medical School. Mr. Richman is a professor of law and business administration at Duke.
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