Doctors Without (State) Borders, Coast to Coast

If taken ill traveling in New York or Texas, or any other of the 50 states, odds are you would not question the basic competence of the medical professionals who treated you there.  But consult that same doctor over Skype from within Virginia and state licensing laws might get in the way.

A bill introduced to the 2019 General Assembly, pending now in both the House and the Senate, would eliminate that basic barrier by in effect allowing Virginians to use telemedicine on a national basis, removing the requirement for a Virginia license if the physician or other provider is in good standing where he or she works.

Proposed language opening a wider door for interstate telemedicine in Virginia

Senate Bill 1221 was introduced by Senator Ben Chafin and House Bill 1970 by Delegate Terry Kilgore.  Both Republicans represent deep southwest Virginia, known to have a shortage of medical services, a shortage that may be worsened by higher demand created under Virginia’s expanding Medicaid program.

Two conservative activist groups which opposed Medicaid expansion are promoting this idea, in part because of those supply and demand concerns.  “Frankly, Virginia needs doctors! Demand for healthcare consumption is increasing as Medicaid Expansion takes hold, but supply remains unchanged (at best),” wrote Caleb Taylor of the Virginia Institute for Public Policy.  Americans for Prosperity is the other group pushing the idea.

Current Virginia law permits a doctor from another state with an office less than fifty miles from the Virginia border to engage in telemedicine. That picks up some urban centers near under-served rural Virginia, as well as Washington, D.C. and its environs.   This bill would expand that nationwide, with Virginia relying on the other states to police their providers.

A 2017 bill made it somewhat easier to prescribe medications through telemedicine, within Virginia.

The right to consult a physician in another state, or to have them monitor your treatment, is only one element of the bill.  It goes to the heart of the matter by requiring that health insurance cover that patient monitoring service and calls for the Department of Medical Assistance Services (DMAS) to expand the opportunity for telemedicine within the Medicaid program.

It also makes an important tweak to the code by defining the location of a medical practice as where the doctor is located, not where the patient is located.

There is no mention in the legislation or the talking points Taylor shared of efforts already underway to accomplish this through an interstate licence compact, or a telemedicine compact seventeen states (not including Virginia) have joined already.  The multi-state license process may be a response intended to maintain tighter requirements than the proponents of this bill want to see.  As you can see here, none of the states is willing to part with its licensing fee.

These cross-border access issues always combine good arguments for state oversight with naked turf protection, preventing competition for economic benefit.  There is also a debate going on about access to interstate health insurance options.  But getting at the cost of these services is vital and the technology is making this harder to resist.

Objections to the idea are bound to surface when the bills come up for discussion, both in subcommittees of the two health committees.  There no shortage of lobbying muscle on the part of the Medical Society of Virginia and related practitioner associations, and the health insurance industry is bound to have opinions.

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13 responses to “Doctors Without (State) Borders, Coast to Coast

  1. I’m not sure who would be opposed to this other than those who would fear competition, oh, and those who say this would be more “regulation”… yup

    But there is a big problem with it because we continue to refuse to embrace the concept of a universal medical record (known as an EHR – electronic health record) that is accessible to authorized/approved providers – so they are all working off the same information – complete and up-to-date.

    Instead, we continue to allow each medical provider to maintain their own separate records and when someone goes to a new provider – the very first thing that happens is that patients are given a clipboard to record their “complete and accurate” medical history – as if they can recall from memory their medical history.

    So, I’m all for this but it’s a crippled and potentially dangerous concept without an electronic health record – and I’m sure the folks who are opposed skype will oppose EHRs also.

    Sometimes, perhaps more often that needed, we insist on stupid and ignorant excuses to better lives for people… for really no good reason other than others see it as a cost and nuisance to themselves.

    We should have a system where if you travel and have a health emergency that the doctors can get your full medical record – in minutes and that same capability allows the opposite – remote doctors looking at your medical record while examining you via Skype.

    There really is no good excuse for not doing this.

  2. The major problem that I see with this proposition is the same problem that exists with other aspects of the internet. If I am traveling in Texas or California and get sick and need to go to a doctor, there is a physical office with, presumably, copies of the licenses of the doctors available in those offices. Therefore, I have some confidence that the doctor has met at least the minimum qualifications established by the state. However, as recent events have shown us, we have no assurance that persons on the internet are who they say they are. We already have enough half-baked medical advice on the Internet without allowing allowing people of officially practice medicine there.

    Steve, I agree with you that there will be turf protection behind much of the opposition to this bill. I learned early on that professions will fiercely fight any incursion into their territories.

    Larry, you are right in your comments regarding EHR. However, I am not sure more wider use of EHR would eliminate each provider wanting to keep its own separate records. For example, if the Department of Corrections has to send a sick inmate to the hospital in Greensville, but that inmate has to then be transferred to VCU/MCV medical center, MCV will not accept/reply on the X-Rays or other tests conducted by Greensville, but will insist on doing its own. The reason MCV gives is that, from a liability perspective, it needs to have its own tests, rather than rely on tests conducted by another provider. There may be some truth in that position, but I suspect there is a pecuniary motive, as well.

  3. The FEP BLUE program, operated by Blue Cross – Blue Shield, offers federal employees, retirees and their families (when insured) access to telemedicine programs. https://www.fepblue.org/wellness-resources-and-tools/get-care/telehealth Telehealth is an independent contractor.

  4. re: medical records. It’s not only inmates. It’s folks on Medicaid that will go to different providers. There’s also any of us that travel and have a medical emergency and we end up in an ER we’ve never been to and they have no records of us.

    re: ” we have no assurance that persons on the internet are who they say they are. ”

    In the wide open internet that is certainly true but there is a world of difference when there are a plethora of protected sites for banking and just about everything else. They use encrypted communication, two-factor authentication and other verification and validation – like one-use PINs, etc…

    You can do your taxes on the internet, you can refill your prescriptions, you can see your insurance, Medicare and Social Security records.

    Every day, millions of people buy stuff from Amazon using their credit cards and having it delivered to their front door – where yes.. some folks will steal, but that’s really no different than break-ins, or car-theft or other types of crime. Nothing is entirely risk-free… nothing.

    The time has come to extend this to electronic health records and stop allowing providers to use excuses and use FUD ( fear, uncertainty and doubt) to scare people from adopting these modern capabilities.

    • Sharing one’s EHR with a doctor in another state when one is on vacation is a whole lot different from using a doctor in another state, while sitting here in Virginia, to diagnose and prescribe one’s ailments.

      I did not assume that sharing tests was a problem only with inmates. It was the one concrete example with which I was familiar.

      It is not the security of the sites that I am worried about, although that is a factor (I refuse to engage in on-line banking). The government has to allow doctors to advertise, so, my concern deals with unlicensed folks from wherever, getting on the Internet and soliciting patients with promises of quick cures and low fees.

  5. Eventually, insurers will require you to start with a telemedicine appointment. Will you have a choice in which e-doctor you see? Or will it be random? Who will hire and employ the e-doctors? Probably the insurance companies.
    The next logical step is to move the e-doctors offshore to India, Pakistan, or Kurdistan. They’ve already done it with radiologists and other specialties that don’t require a lot of patient doctor contact.
    The final step will be to make the e-doctor your PCP and if you need in person treatment, you will go to a PA or a Nurse Practitioner.
    The beginning of the end of the family doctor general practitioner?

  6. I think this is a great idea.

    On the legal side: Once upon a time, the practice of medicine was inherently local. Now, thanks to the Internet, it can transcend state lines. States do not have the power to restrict interstate commerce. Ergo, the General Assembly needs to stand aside.

    On the policy side: Rural Virginia has a desperate shortage of medical practitioners. If this makes health care more accessible for rural residents, then it is a worthwhile fix.

    On the health and safety side: Is it possible that quacks and frauds in other states might peddle their services in Virginia and provide sub-par care? Perhaps. But guess what, folks, Virginia has its shares of quacks and frauds as well. Maybe we should prohibit Virginia doctors from practicing in Virginia as well!

  7. re: ” The next logical step is to move the e-doctors offshore to India, Pakistan, or Kurdistan. They’ve already done it with radiologists and other specialties that don’t require a lot of patient-doctor contact.”

    Actually – more and more of the specialties that do personally interact …
    endocrinologists, gastroentolists, prosthodontists, etc.

    Which is all the more curious when we hear that Americans themselves cannot seem to find professional career jobs…

    Jim talks about the cultural superiority of “Asians”. I’d submit that it appears to be that Americans have CHOSEN to not pursue these jobs and have abdicated to others.

    on the first contact, “tele” – I would suggest another approach. First, a nurse practitioner or other “para” for the initial contact, the taking of vital signs and medical history, etc.. get all that stuff together then go get the Skype doctor.

    • I have always suspected that The American Medical Association, among others, has worked to keep admissions to medical schools extremely restricted. They did this to keep the number of doctors low and the salaries of doctors high. Like all attempts to manage a market this failed. Various types of physicians’ assistants now treat cases that were once reserved for MDs.

      • Gee.. I’m forever waiting for the market to “disrupt” the cable companies and Dominion and the cell phone companies.. and a few others… 😉

        but agree.. over time…. the market prevails and in the case of medical care – it cannot come a day sooner given how much we currently pay in this country.

        And I continue to think/believe that if true universal electronic medical records were mandated – then people WOULD have choices… and the market would start to work.

  8. The U.S. has doctors that are paid significantly more than other OECD countries and we also have fewer doctors per capita than almost all. Like DJ says, the primary reason for this is the influence on licensure by the AMA and other organizations (requirements, accreditation of schools, residency spots and funding). We also tend to have more limits on what alternative providers like nurse practitioners can do and higher (more expensive) requirements on how they are supervised by doctors. Although this doesn’t directly address this issue, I think it can be positive for controlling costs.

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