Medical licensure: State lines pose daunting barriers

Knoxville, Tenn., family physician Chris Sawyer, MD, has traveled the world providing volunteer medical care for patients in countries such as Haiti, Venezuela and Chile. But volunteering to treat needy patients in the United States isn’t as easy.

Dr. Sawyer often finds himself hamstrung by laws that require physicians to be licensed by individual state medical boards.

Chris Sawyer, MD

“America is kind of funny in some ways,” he said. “To be in family practice, I have to take a national board exam every seven years, but I can’t go 50 miles from here to practice in Kentucky. I can travel all over the world, but I can’t go to Kentucky.”

Debate about medical licensing has gone on for years. Some physicians complain that the process is burdensome, redundant and costly. Doctors typically must complete complex licensing applications and submit credentialing documentation in each state. Getting a license can take several months to a year.

That makes it difficult for physicians to practice in multiple states if they want to volunteer to help victims of disasters or if they work for a growing number of health systems extending across state lines. The expansion of telemedicine also has fueled the debate for physicians seeking to use technology to bridge geographic barriers to care.

In response, several medical boards have taken steps to expedite their medical licensing processes to make it easier for physicians seeking licenses in multiple states. The Federation of State Medical Boards has received federal grant money to support its efforts to increase medical license portability.

The goal is to alleviate the burden for physicians without compromising patient safety, said Lisa Robin, FSMB chief advocacy officer.

“We support the state-based system, but also the need to accommodate an evolving delivery system where the borders are not only interstate, but global,” she said.

Standardizing the licensure process

Stan Brock, founder of Remote Area Medical Photo courtesy of RAM

Streamlining the medical licensure process to reduce barriers to multistate practice has been a priority of the FSMB for many years, Robin said. In 1995, for example, the federation developed model telemedicine legislation that has been adopted in 10 states.

More recently, the federation created the Uniform Application for Physician State Licensure, which is being used by 17 medical boards. The online application allows physicians seeking licenses in more than one state to input their information, make updates and submit the data to multiple boards rather than filling out separate applications for each state. An estimated 20,000 applications have been processed through the system since it was launched in 2009, Robin said.

The Federation Credentials Verification Service also is used widely to verify and store physicians’ professional credentials. That means doctors don’t have to send individual medical school transcripts or other documents to each state, Robin said.

The Idaho State Board of Medicine has had an expedited licensure process in place for about five years, said the board’s executive director, Nancy Kerr, RN. To qualify for expedited approval, physicians must be board certified, licensed in good standing in another state, have no significant malpractice or disciplinary history, and submit to a criminal background check. Those licenses can be processed in two to three weeks compared with an average of 45 days for nonexpedited licenses, Kerr said.

The result is that physicians can practice in the state more quickly. Like many states, Idaho has a shortage of physicians, particularly in some of its more remote, rural areas, Kerr said. Several other states have implemented an expedited licensing process, including Indiana, Iowa, North Carolina, Oregon, Texas and Wyoming, she said.

The Medical Board of California on Aug. 29 announced a new regulation that allows out-of-state physicians to volunteer short-term at organized events to treat uninsured or underinsured patients. The rule is intended to help alleviate shortages of volunteer physicians there, the board said.

In the Midwest, boards in nine states have partnered in a pilot project aimed at standardizing their medical licensing requirements to make it easier for physicians seeking to practice in more than one of the states, said Angie Hellenbrand, spokeswoman for the Wisconsin Dept. of Safety and Professional Services, which is leading the effort. The project consists of Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, South Dakota and Wisconsin.

The goal is to expand access to health care and services, Hellenbrand said. The project is still too new to gauge how it will work, but there are potential benefits to streamlining some aspects of states’ licensure procedures, said Mark Grapentine, senior vice president of government relations at the Wisconsin Medical Society.

“We have many members who must be licensed in bordering states,” he said. “Having a way to utilize one state’s review of the most basic application information verification just seems to make good sense.”

The American Medical Association supports standardization of licensure requirements, greater reciprocity among states and reduced licensing burdens on physicians. Doctors practicing telemedicine should be required to have full unrestricted state medical licenses, but with states providing allowances for them to see patients in person when needed or in emergent situations, according to AMA policies.

Barriers to disaster care

After Hurricane Katrina hit the Gulf Coast in 2005, Louisiana’s Legislature passed bills that allow physicians from other states to write prescriptions and orders for tests and treatments for Louisiana residents. The need arose as residents scattered to surrounding states after the storm but still needed to travel to their homes during cleanup and reconstruction, said Keith DeSonier, MD, an otolaryngology surgeon in Lake Charles, La. He is also a member of the board of governors of the Louisiana State Medical Society.

The Legislature also enacted a law allowing licensed military physicians stationed in the state to receive expedited Louisiana medical licenses. In addition, the Louisiana State Board of Medical Examiners has issued waivers for physicians from other states who have provided volunteer care in emergencies, Dr. DeSonier said.

“When it really happens, those first 72 hours after a catastrophe you need help fast,” he said.

Although some state efforts have helped, those initiatives are not enough, said Stan Brock, founder of Remote Area Medical, which provides free medical, dental and vision care to medically underserved populations. Brock said he has been campaigning for 25 years to make it easier for physicians to practice across state lines. Stringent state licensing laws have repeatedly blocked his group from providing free care throughout the U.S., he said.

“It is the greatest impediment to what we do as one of the largest providers of free medical care in America,” Brock said.

Dr. Sawyer, who is RAM’s medical director, said it shouldn’t be difficult for physicians to volunteer their time and skills, especially if it is with a well-established organization that vets its volunteers.

“We see people that nobody wants to see,” he said. “Why can’t I move freely around the country? I know there have got to be controls, but it seems like in situations like this, allowances can be made. It seems like an antiquated system.”

Brock said a solution needs to come from the federal government. “To get the rest of the states to do what has been done in just three or four states is just going to take so long that in my view it has to be a federal mandate,” he said.

Seeing patients via telemedicine

Telemedicine advocates have been working for years to make it easier for doctors to practice across state lines. But some medical boards have tightened their rules to make it more difficult for the estimated 20% of physicians who hold multiple state licenses, said Jonathan Linkous, CEO of the American Telemedicine Assn.

“We did a state-by-state analysis, and we estimate it costs about $300 million a year to do extra licenses,” he said. “That’s growing because physicians are increasingly holding multiple medical licenses. It’s an access problem. We have huge shortages of specialists that are growing.”

There has been some action on the federal level. Congress is considering HR 6107, the Veterans E-Health and Telemedicine Support Act. The measure would allow health professionals with the Dept. of Veterans Affairs to provide telemedicine services regardless of where they are located. The bill was referred to the House Veterans’ Affairs health subcommittee on July 27.

Medical license portability speeds up the licensing process, reduces costs and extends coverage to the medically underserved, said Robin, of the FSMB. But the robust system of regulation needs to be protected, she added.

“You want to ensure patient safety, but you do want to accommodate how services are being delivered,” she said.