The Telemedicine Landscape is Changing– Again

The broad access to such services that occurred at the beginning of the COVID-19 pandemic should not be rolled back.  Finding a way to extend the regulatory waivers that made this possible is in our patients’ best interest.

By John Halamka, M.D., president, Mayo Clinic Platform, and Paul Cerrato, senior research analyst and communications specialist, Mayo Clinic Platform.

Those of us who work in digital health were encouraged to see the changes in telemedicine policy and regulations that occurred during the COVID-19 pandemic. During the early days of the pandemic, the Centers for Medicare and Medicaid Services loosened its regulations on telemedicine services. Similarly state medical licensing boards around the country waived their rules governing online patient care provided by out-of-state practitioners. These policy shifts enabled countless patients to receive at-home care, reducing their risk of infection. The variations in national, state, and local policy are putting these waivers at risk.

On a positive note, CMS has been instructed by the current administration to extend the public health emergency declaration that expanded telemedicine coverage so that it goes beyond January 11, 2023. But most states have not followed the federal government’s lead on this issue. “As of November 1 [of 2022], such declarations were still in place in only 11 states, with most due to end within days, weeks, or a few months, according to the National Academy for State Health Policy. Only California, New Mexico, and West Virginia hadn’t set expiration dates for their emergency declarations.”

That’s not to suggest that the public has no need for the telemedicine services of out-of-state clinicians. According to one recent report, more than 430,000 Medicare patients used such services between January and June 2021. And these visits occurred after COVID vaccines had become available and the health care ecosystem had become more stable.

Why the change in direction among state medical boards?  Medicine is by nature a conservative profession that adheres to the principle: Above all else, do no harm. Many state licensing boards believe that allowing physicians to offer online care to patients outside their state would harm patients. But critics see things differently. In a 2021 perspective in the New England Journal of Medicine, experts from several top medical schools posited: “There are also long-standing concerns that state licensing boards are overly focused on protecting their members from competition rather than on serving the public’s interest. In 2014, the Federal Trade Commission successfully sued the North Carolina State Board of Dental Examiners, arguing that the Board’s arbitrary prohibitions on non-dentists providing teeth-whitening services violated antitrust laws. This Supreme Court case was later invoked in Texas to challenge licensure regulations that limited the use of telemedicine in the state.”

Several possible options exist that could resolve the state licensing roadblocks that currently prevent many patients from seeking the online care they want. One option would make it easier for a physician to apply for an out-of-state license. The Interstate Medical Licensure Compact, launched in 2017, has been pursuing this solution. Applicants pay a fee to join the group and a separate fee to obtain another license in states that have agreed to participate in the program. Another approach is to enable reciprocity, in which case a state would automatically recognize an out-of-state license. That mechanism is already in place in the VA system. Some reformers have also suggested that the current system of state licensing boards be replaced with a federal medical licensing system. All these options have their advantages and disadvantages.

During the 41^st Annual JP Morgan Healthcare Conference in San Francisco, Eric Larsen, president of the Advisory Board, pointed out the different philosophies that separate leaders in technology and medicine: “… there is an intrinsic divide between the Silicon Valley tech ethos, which is if we can improve the average, we’re in great shape, and the healthcare ethos, which is if a technology endangers even one patient, we must slow things to a crawl. This Hippocratic-oath-infused incrementalism is a good thing but has negative externalities. One of which is the industry misses out on innovation.” There must be a middle ground between these two perspectives, one that puts a patient’s needs first and enables them to still benefit from the expanded access to telemedicine services that has occurred in the last few years.