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Location Shouldn't Matter in Telemedicine

— Let's keep allowing telehealth to flourish and let the bureaucrats sort out the licensing issues

MedpageToday
A senior woman at home listens to her female physician during a telehealth visit via laptop

At the peak of the COVID-19 pandemic, many of us pivoted to providing a great deal of care over video visits -- telehealth encounters over Zoom and other platforms -- where patients could stay safely in their homes and still receive healthcare.

This served an incredible public health purpose, protecting patients from coming in for their routine care while still being able to give them ongoing healthcare through contact with their doctors. We could get updates on chronic conditions, make new diagnoses, and get patients the medications they needed. We relaxed many of our policies, allowing people to have more refills over longer periods of time, and we were less stringent about requiring lab testing for ongoing monitoring when it was able to be safely deferred. We didn't want to make our patients come in on public transportation and expose themselves to unnecessary risks unless they absolutely had to.

Not a Good Time to Reverse Course

We learned an incredible amount about providing care in this novel manner, and have started down a path to making telemedicine an important part of the future of healthcare. Now that the pandemic seems to be easing, does this seem like the time to go back?

While it's true that inequities related to video visit access have continued -- for example, with patients who have limited access to broadband, or no smart devices, or limited tech literacy -- for many patients it has provided a necessary and vital link that has kept them healthy in so many ways. Similarly, much has been missed, and care opportunities have fallen by the wayside, that a better system could potentially have helped minimize. Preventive measures were put off, vaccines were delayed, elective surgeries were postponed -- leading to potentially worse outcomes -- and even cancer surgeries had to be put off at certain points in the pandemic, often with devastating sequelae.

But for the most part, our patients seem to really love video visits, and many providers have taken to it and feel that it has become an important part of their practices, now and potentially even more in the future. Now many states are starting to look at whether they want to continue to allow providers to practice across state lines, and some are reversing the easing of rules instituted during the pandemic-driven public health emergency.

For instance, my patients who lived in New York, but had taken refuge in their second home in Pennsylvania, or had moved in with relatives in New Jersey, were able, under these specific exemptions, to receive healthcare from me, a licensed New York State provider. Over the past few weeks and months, many insurance companies have announced that they're planning to roll back coverage of these across-state-line episodes of care, and they've insisted that we be the police who monitor this system to make sure our patients are where they say they are, and reside only in the state where we are licensed.

What Does State Licensure Really Mean?

At the root of all this, what exactly does it mean to be licensed to practice in New York State, and is this in some way different from being licensed in Connecticut? Is medicine so different in one state versus another?

I remember after medical school in New York, heading to California for residency, everyone told me I would "see a different world of medicine; they do things very differently there." But overall, it was mostly style, not substance, that was different. The diagnostic criteria for diseases remain the same, the standards of care we all strive to provide are the same, the dose of acetaminophen is the same whether you're east or west of the Mississippi River.

The vagaries of licensure in each state are worth looking at again, and maybe it's time that they change things, that they move into the 21st century, that they realize that our patients are now more mobile, and that it matters that we are able, that we remain able to take care of them, no matter where they are.

It has always been the case that if one of our patients, who lives in New York City, was traveling or on vacation either in Utah or New Mexico or South Dakota, and they got a urinary tract infection, it was okay -- it was always okay -- for them to call us, we would diagnose them, and send an antibiotic to a local pharmacy, potentially saving them a trip to an emergency room, and ensuring that their vacation or business trip got back on track. Why can't we extend this to the fact that our patients may be spending more and more time out of state, and less and less time residing strictly in their apartments in New York City or its environs?

Location is Usually Not Relevant

To ensure that we comply with the rules, the computer system looks to compare their current address to make sure it is within New York State, and then when they start their video visits they are required to certify that they are currently residing in and located in New York state, and then we need to put templated material in our notes that says that we are where we say we are, and they are where they say they are. It's bad enough that we have templated macros that say that the patient agrees to undergo a video visit and accepts the limitation that come with getting healthcare over a video link, that they are alone in their apartment or that they are speaking freely without duress and that I'm in my office in New York City.

Shouldn't we just be blinded to where they are, since for the most part it doesn't matter, unless they're in Lyme, Connecticut, with complaint of a tick bite, or in the San Joaquin Valley with fever and a cough? I would hope that as we continue to build these systems, and recognize the value of video visits and other telehealth opportunities, that the bureaucracies that manage licensing of physicians would recognize that the time has come to change things, and make the changes from their end.

Sure, medical licensure matters, and keeping tabs on doctors has some inherent value. But whatever tracking they need to do, they can certainly figure out how to do so across state lines. These systems should be smart enough for that. And the legal issues related to malpractice, insurance, certification, and all the rest should be able to be standardized and simplified, because that's the best thing for our patients, that's the best thing for the next time a public health emergency arises, and that's the best thing for the lives of all of us out here practicing medicine on the front lines.

No matter where we, or our patients, truly are.