Many states are making it difficult for people to have virtual visits with doctors in other states, partly reversing the explosion in telehealth that occurred during the coronavirus pandemic and calling into question the durability of one of the major technological shifts from the past two years.
The rollback in telehealth access has been happening gradually and quietly over the past few months as pandemic-era emergency health orders have lapsed in one state after another, reimposing some of the old rules about when doctors can practice in multiple states.
At Johns Hopkins Medicine, some patients and their families now have to switch doctors or drive hours to different states when previously video calls from their homes would have been allowed under the looser regulations, said Dr. Brian Hasselfeld, the health system’s medical director for digital health and telemedicine.
The major barrier is licensing: a requirement rooted in the 19th century that a doctor must have a license from the state where a patient is located, even if the doctor is licensed elsewhere.
“Most states now are back to the pre-pandemic licensure rules, where you must be licensed in our state if you’re going 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 the licensing boards in U.S. states and territories.
Now, only 12 states still have their pandemic-era waivers, according to the federation. California, New Jersey and some of the other remaining states are scheduled to let their emergency waivers expire soon, the federation said. Nineteen more states have some long-term rules for interstate telemedicine, although they vary.
There’s a lot riding on the regulations for patients and doctors, as well as a wave of tech startups that has risen in the past two years hoping to capitalize on the convenience of remote visits.
And there’s renewed urgency among some patients and physicians to make telemedicine work across state lines because of the national debate around abortion and the likelihood that the Supreme Court will overturn the constitutional right to an abortion set out in the 1973 Roe v. Wade decision. A number of states have passed abortion-related carve-outs to their telemedicine regulations, often requiring doctors and patients to be in the same room for discussions about abortion.
Linda Branagan, the director of telehealth programs at the University of California, San Francisco, said the rapid changes in state laws and regulations are “operationally untenable,” especially when patients are often in such vulnerable positions.
“We have asked patients to come on site who we normally would see by video,” she said. “They’re either financially fragile or clinically fragile or both.”
Before the pandemic, about 2% of UCSF’s outpatient appointments happened over Zoom-style calls, and officials considered that a success, Branagan said. The share soon jumped to 60% of appointments during the height of social distancing, and it has since dropped to 25%, she said, as patients and providers seek a balance and try to comply with state regulations.
The reappearance of such barriers for physicians doesn’t affect in-state video visits or some calls with other medical professionals or nurses, but it’s still a common issue, especially for certain medical specialties or for in-demand doctors who are used to seeing patients from around the country.
“The true value in telehealth lies in being able to see your doctor, not any doctor,” said Dr. Thomas Kim, the chief behavioral health officer for Prism Health North Texas. He said he’s not worried about telehealth falling away, but he said providers need to think of it as a skill, not a service in and of itself.
Nearly 1 in 10 of the telehealth visits at Johns Hopkins are with patients who live in states where the system doesn’t have operations, Hasselfeld said. He said it’s now routine for the staff members who scheduled appointments to double-check where patients will physically be for video calls, which didn’t matter two years ago.
“It’s been really difficult to try to explain that providers can see patients only in specific areas,” Hasselfeld said.
Separate from the issue of medical licensing is who pays for telehealth visits — and whether providers get paid as much as they do for in-person visits. Since March 2020, Medicare has waived many restrictions on remote visits, but the waivers are temporary, and they are scheduled to end after the federal Covid-19 emergency order expires unless Congress intervenes.
Doctors, nurses and other medical professionals have historically been licensed at the state level, not by the federal government, and state medical boards have often tried to block out-of-state physicians from seeing patients in their jurisdictions.
“A lot of it is inertia from the way medicine has been practiced in this country for years and decades, really,” said David Peloquin, a partner at the law firm Ropes & Gray in Boston who represents academic hospital systems.
The cross-state practice of medicine wasn’t an issue before the widespread adoption of the internet made virtual visits possible, Peloquin said, and demand really picked up a decade ago as doctors involved in clinical trials sought geographic flexibility. Then the pandemic accelerated the demand.
But there are proponents of keeping something like a state-by-state patchwork, including state medical boards that run the licensing systems. They cite potential abuses, such as unlawful prescription drug sales or the possible difficulties of a medical board’s investigating a physician in another state.
“We want to achieve greater portability, but also we don’t want a system that compromises patient safety,” said Lisa Robin, the chief advocacy officer of the Federation of State Medical Boards.
In April, the federation put forward a new model policy for states to potentially adopt that would support patients traveling out of state or participating in remote clinical trials. The model policy stopped short, however, of full reciprocity between states.
The changes two years ago were meant to be emergency measures at a time of localized spikes in Covid-19 in states such as New York.
“They thought that there’d be a serious Covid rise in cases in one state and the state next door, for example, could have professionals who could help,” said Krista Drobac, the executive director of the Alliance for Connected Care, a lobbying coalition of large employers and hospital systems, such as Stanford, that favor deregulation.
But it turned out there were lots of reasons someone might want to see a doctor based in another state. It may be because patients have moved or have limited choices in their area, especially in certain fields, such as mental health. They may want to see specialists at highly ranked hospitals or participate in clinical trials based elsewhere.
Or patients may simply be on vacation or traveling out of state and want to speak with their regular doctors — a situation in which medical licensing boards have often frowned on interstate phone or video call appointments.
“Practically, 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 care policy and medicine at Harvard Medical School.
Last year, he wrote about a cancer patient who lives in New York who suddenly had to begin driving three-plus hours to Massachusetts after a state waiver lapsed and Boston-based cancer doctors could no longer practice medicine with patients over the state line.
“We can’t get every single one of our docs licensed in New York,” he said.
There are numerous proposals to lower licensing barriers, including moving to a driver’s license-type system, but none has moved forward. And an interstate compact launched in 2017 has attracted relatively few participants.
Mehrotra, who researches telemedicine, said the experience of the pandemic revealed clear patterns in who uses remote visits and why. There was a large uptake in urban areas, he said, because they have better internet access and had less need for telemedicine before the pandemic. And some fields, such as ophthalmology, didn’t translate as well to video chats as others, such as psychiatry.
“You see a lot of telemedicine for anxiety. You don’t see as much for cataracts,” he said.