Consequences of Telemedicine Legislation

February 16, 2012
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You probably think this post will focus on the bill being drafted by Senator Tom Udall and his staff.  Even though I plan to address it, the first part today is about another bill from a New York congresswoman and the S.T.E.P. Act which is now law.

You probably think this post will focus on the bill being drafted by Senator Tom Udall and his staff.  Even though I plan to address it, the first part today is about another bill from a New York congresswoman and the S.T.E.P. Act which is now law.

 Representative Kathy Hochul (D-NY) has introduced the Veterans Telehealth and Telemedicine Improvement Act to help veterans get easier access to healthcare.  A Buffalo TV station’s Web site, Your News Now, has a video about it.

According to the report, the bill offers veterans in rural areas improved access to specialty care via telemedicine.  Representative Hochul says the bill will increase the number of patients enrolled in Telehealth programs and gives the VA the authority to waive the co-pays for veterans.  The aim of the legislation is to cut down on the veterans’ travel and lodging reimbursements that amount to more than $1.3 billion.  The bill apparently enjoys bipartisan support, so it will likely pass in some form.

What has escaped a lot of attention was a rider that Congress okayed last year and President Obama signed on New Year’s Eve: the S.T.E.P. Act, which was included in the final 2012 National Defense Authorization Act.  STEP stands for “Servicemembers’ Telemedicine and E-Health Portability.”  Representative Glenn Thompson (R-PA) introduced the bill which is now law.  The STEP Act allows the Department of Defense a state licensure exemption to use credentialed healthcare professionals across state lines without the need to obtain new state licenses.  Often, the DOD’s healthcare professionals were not located in the states where veterans in need of behavioral health treatment lived.  This law cuts through the red tape and permits telemental health visits.  By the end of next month, the DOD and VA are to provide a report on their plans to develop and expand programs that will provide improved access to specialists.

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The significance of these two acts is that Congress is finally aware of the benefits of telemedicine to both patients and physicians.  The hope is this interest in providing access to healthcare can extend to those of us in the civilian world.  The draft bill from Senator Udall’s office seeks to make this happen by a “tandem medical license.”  As explained by Fern Goodhart, the legislative assistant working on the bill’s language, a tandem license is the best way to accomplish what would be a national medical license – not just for telemedicine.

What the bill would do is set up a mechanism in which a physician would apply for a medical license in the state where he intends to have an office practice, but at the same time would apply for a national license.  The tandem license would allow the physician to practice medicine, either in person or via telemedicine, in any state that adopts the tandem license. The reason Udall decided on this approach is because “telemedicine is medicine.”

According to Goodhart, state medical boards would retain jurisdiction over licensing and disciplining physicians and receive better information on infractions and more quickly from a national database that would also contain primary source documents on physicians, claims information, malpractice allegations, and criminal background checks. She says the bill will contain incentives for states to participate in the tandem license program.  She didn’t explain what those incentives will be, but the suggestion is that states will receive some compensation for the loss of licensure fees when physicians holding multiple state licenses get the tandem licenses.  The real incentive is to be among the first of the states to join (see more below).

I don’t think a lot of people understand the scope of this legislation.  Let’s say every state adopts the tandem license.  A physician licensed in Keokuk, Iowa could begin seeing patients in Trenton, New Jersey either via telemedicine or by opening an office in that city without applying for a New Jersey medical license.  There would no longer be licensure barriers to medicine. This is a modification of what has been known as the nursing compact.  Nurses licensed in one member state of the compact can practice in any of the other member states without applying for a license.  In fact, the Udall bill would be broader than just physicians; it would apply to all licensed healthcare providers.

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The Federation of State Medical Boards opposes the Udall bill for a number of reasons, but primarily because of patient safety concerns. State medical boards are funded in one of two ways – directly from physician licensure fees or indirectly by legislative appropriations.  Those funded by licensure fees would feel pressure to raise their fees, if they could, to cover the expenses in both the licensing and investigations departments because licensure fees from non-state resident physicians would disappear.  In Arizona, approximately eight-thousand of the some 23,000 licensees hold an Arizona license but do not practice in the state.  Similarly, those boards which receive their funding from their legislatures might see a drop in their appropriations because of a drop in physician fees.

The tandem license would effectively be licensure fee control.  The first states to adopt the tandem license will be in the best position to raise their fees if they have legislative approval to do that. Why? Because they will set the tandem license fee for the other states who will join later.  No other state will charge more than the first states because they might lose money in diminishing applications.  Physicians could acquire tandem licenses in the less expensive states and still practice in the state with the higher fees, at least until they were due to renew their licenses.  Then the bill as written would require them to renew in the state where there primary practice or their headquarters are located.  Udall’s office hopes that this will eventually provide states with the necessary funding to function.

I have no legal training, but I wonder – can there be collusion among state medical boards to charge the same fee?  As an unintended consequence of tandem licenses, I think licensure fees will have to rise.  To what? $2,000? Perhaps $5,000.  What do you think the ability to practice medicine in any state should cost?