Caring Across State Lines

Licensure Compact Would Ease Interstate Care for Texas Physicians

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Law Feature — March 2015

Tex Med. 2015;111(3):45-48.

By Kara Nuzback

A bill up for consideration in the Texas Legislature would give Texas physicians a speedy way to become licensed in other states. The Interstate Medical Licensure Compact would expedite the process to obtain a license to practice medicine in any state that participates in the compact, making it easier for physicians to move from state to state or to practice telemedicine. 

R. Russell Thomas, DO, a family medicine physician at Rice Medical Center in Eagle Lake and a member of the Texas Medical Association Council on Socioeconomics, says underserved areas along the Texas border are in dire need of more physicians. In underserved communities, where the closest metropolitan hospital may be in another state, the compact would reduce the administrative burden on hospitals that offer telemedicine to patients across state lines, as well as the burden on physicians who opt to travel to see out-of-state patients in person.

Dr. Thomas says certain specialties, including psychiatry, are limited in many areas of Texas. He says telemedicine gives him the ability to arrange for his patients to speak with a top psychiatrist in any area of the country. Telemedicine services should be used to enhance care from local physicians, rather than to replace in-person services, he says.

Dr. Thomas says if the Texas Legislature approves the compact, it could help put Texas on the map as a destination for cancer care by allowing institutions like The University of Texas MD Anderson Cancer Center to support physicians treating patients beyond Texas borders. He says it could also attract the country's top medical talent to the state. 

"Texas is certainly in need of physicians, and that need continues to grow," he said. Anything that makes it more convenient or practical to practice medicine in the state "can only be a benefit for us," he added.

At least seven states must adopt the licensure compact for it to take effect, and the Texas Legislature is set to consider whether the Lone Star State will be among the first. Sen. Charles Schwertner, MD (R-Georgetown), prefiled Senate Bill 190 on Nov. 24. The bill aligns with model legislation written by the Federation of State Medical Boards (FSMB). If enacted into law, SB 190 would establish Texas as a member of the compact.  

Senator Schwertner says Texas is one of many states with a physician shortage, and a quicker licensure process is one way to encourage physicians to come to Texas. He says he sponsored SB 190 because it maintains the state's high standards for board certification.

The Texas Legislature cannot change the compact; each state must adopt or reject the agreement in its entirety. The compact would not replace the existing process to obtain a medical license out of state; it would only add an alternative, accelerated process.

The American Medical Association adopted policy on Nov. 10 in support of the compact. In a press release, President Steven J. Stack, MD, said 10 states have so far indicated support for the compact. "We encourage more states to sign on to the compact so that we can ensure standards of care are maintained, whether treatment is provided in person or via telemedicine," he said.

TMA has not yet adopted an official position on the compact, but many TMA members support an expedited licensure process. 

"With dramatic changes in health care, there is an opportunity to utilize technology to provide greater access to health care expertise and services both within the state and on an interstate basis," said Darren Whitehurst, TMA vice president for advocacy. "The compact gives mechanisms to help ensure accountability for out-of-state physicians and protections to Texas patients. However, since the compact gives no ability to make changes to the legislation, TMA wants to make sure these mechanisms are appropriate and that they actually improve care."

TMB Leader Favors Compact

Last May, the Texas Medical Board (TMB) discussed the compact and agreed to pursue participation. Minutes of the board's May 2, 2014, meeting are available online

TMB Executive Director Mari Robinson says the compact would allow a streamlined process for licensing. She says under the current structure, there is no legal reciprocity for licensure, which means physicians who want to be licensed in other states must prepare for an extensive, document-heavy process, "depending on which state you're applying in," she said. The process is even more extensive for international candidates, she adds.

If Texas joins the compact, a physician candidate would apply for a medical license in his or her state of residence through the normal channels, which include proof of medical school graduation, residency training, and a criminal background check, among other things, she says.

Ms. Robinson says under the proposed legislation, after a physician obtains a medical license in a member state, he or she can apply for eligibility for an expedited license in other member states. 

Only physicians with spotless medical records are eligible to expedite the process. Such physicians must be board certified with no history of discipline, no history with the Drug Enforcement Administration (DEA), and no criminal history.

If a physician qualifies, he or she needs only to obtain an eligibility certificate, then register for and pay the individual state license fee, Ms. Robinson says. "You would not have to go back through the entire application process," she said. 

Ms. Robinson says the compact would make it easier for Texas physicians to take jobs in other states; the transition would take days, rather than weeks or months under the current system. The process would also ease the burden on recruiters looking to draw more physicians into Texas, she says.

"It can be hard to bring people here from out of state," she said. "It will hopefully drive up the number of licensees we have." In turn, that means a wider array of physicians and better access to care in the state, she says.

The program would have no cost for state medical boards, and physicians would likely pay the current fee for each out-of-state license, Ms. Robinson says.

"We don't anticipate raising fees," she said. "We expect it to be self-funded."

Critics of the compact worry about complaint sharing among member states, but Ms. Robinson says the compact would not change the current procedure. If a physician is licensed in multiple states and is subject to a complaint, he or she is subject to potential investigation in every state in which he or she is licensed. While more physicians may obtain a license in multiple states if the compact takes effect, complaint sharing is already the standard, she says.

Ms. Robinson says it is unlikely for one state board to dismiss a complaint and another state board to later take action on it. In actuality, she says, the compact would make it possible for all state boards to adopt one action, rather than subjecting a physician to multiple investigations in each state.

Critics also point out Texas' high standards for medical licensure and argue that an unqualified physician could go to a member state with lower standards to obtain his or her initial medical license and then obtain a medical license in Texas more easily through the expedited process.

But, Ms. Robinson says, in drafting the compact, "this was absolutely considered. That's why we used the highest licensure standards among all the states." 

Eligibility requirements are higher than the requirements for a candidate's primary medical license. If a physician has any discipline record with the medical board or any history of criminal or DEA investigations, he or she must obtain an out-of-state license through the traditional method.

"This is not going to sneak in any wide swaths of people who otherwise wouldn't be qualified in our state," she said. "We already know not everyone is going to qualify." 

Physicians would not be required to participate in the compact if the legislature adopts it; they could instead go through the current process to obtain a medical license in each individual state. 

Ms. Robinson says if a future legislature repeals the state's participation in the compact, physicians who obtained licenses through the expedited process would likely lose those licenses.

SB 190 would establish an Interstate Medical Licensure Compact Commission to administer the compact. According to the bill, the commission may develop its own rules to address the impact on physicians' licenses if a member state withdraws from the compact.

The Rise of Telemedicine

Dr. Thomas served on TMB from 1993 to 2001. During that time, he served on a committee for FSMB that developed a white paper on uniform standards with the intention of creating reciprocity for licensing between states.

"It went up on the shelf, and I'm not sure it ever came down from the shelf," he said. "It [a multistate agreement for licensure] has been beat around and considered for the last 15 years that I'm aware of."

But with recent advances in telemedicine, there has been a renewed interest in licensing doctors in other states, he says. The practice is especially common among radiologists, who can provide excellent services from remote locations, including other countries, he notes.

"Most radiologists don't go to the hospital as much anymore," he said.

According to SB 190, the compact would adopt the prevailing standard that the practice of medicine occurs where the patient is located at the time of treatment. Dr. Thomas says a common question that arises from telemedicine is: Where is the treatment actually taking place? He agrees a physician should adhere to the standards of medical care in the state in which the patient resides.

For example, if an out-of-state physician provides telemedicine care that results in a negative outcome for a patient in Texas, that physician is not likely to face repercussions in his or her state of residence; the physician should be licensed in Texas and held to Texas' standards, he says.

In April 2014, FSMB declared that the location of the patient — not that of the physician — defines the location of treatment. Still, there is no universal policy for telemedicine in the United States; that makes it difficult to provide care to patients across state lines, says the American Telemedicine Association (ATA)..

According to ATA's "State Telemedicine Gaps Analysis," published in September 2014, "State-by-state approaches prevent people from receiving critical, often life-saving medical services that may be available to their neighbors living just across the state line. They also create economic trade barriers, restricting access to medical services and artificially protecting markets from competition."

According to the gaps analysis, only Washington, D.C., Maryland, New York, and Virginia allow licensure reciprocity from bordering states. 

Texas scored a "B" on ATA's scale of licensure portability and was one of only 10 states, along with Alabama, Louisiana, Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon, and Tennessee, extending a conditional or telemedicine license to out-of-state physicians. No state scored an "A" on the scale.

In 2011, ATA adopted policy noting that all states have similar requirements for physician candidates, including taking the U.S. Medical Licensing Examination, to qualify for licensure, and arguing that individual state requirements are outdated and harmful to the public. 

State licenses differ only on what ATA calls "procedural and tangential issues." 

Kara Nuzback can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email. Amy Lynn Sorrel, associate editor of Texas Medicine, contributed to this story. 

Legal articles in Texas Medicine are intended to help physicians understand the law by providing legal information on selected topics. These articles are published with the understanding that TMA is not engaged in providing legal advice. This is not a substitute for the advice of an attorney. When dealing with specific legal matters, readers should seek assistance from their attorneys.


Interstate Medical Licensure Compact Quick Facts  

  • The compact cannot be modified; each state must accept or reject it in its entirety.
  • The compact does not take effect until seven states have signed on.
  • Physicians must have no history of discipline and no criminal history to qualify.

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