Crossing State Lines: The Enigma of Telehealth

Do you really need to be in the same state as your medical provider?

When I was on vacation with my sister and brother-in-law in Kansas for my brother’s birthday, my brother-in-law was sharing that he was unable to get his sleep apnea test results. The pulmonologist had performed the test the week prior, and Don, my brother-in-law,  couldn’t access the results on his provider portal. The doctor wanted to discuss them in a virtual visit, and Don explained that New Hampshire law mandates that virtual visits be done within the confines of the state.

I was skeptical because the public health emergency (PHE) is still in place, but Don is a pediatrician and knows what he is talking about. He said that when he does a virtual visit, he must confirm that the patient is in New Hampshire, too.

At the beginning of the pandemic, the Centers for Medicare & Medicaid Services (CMS) and states waived the requirement that providers be licensed in the state where the patient was located, and the telehealth was being provided. Telemedicine use was widely expanded to protect patients from being exposed to COVID-19, but it was found to be very convenient. The PHE is still in effect, but many of the state’s public health emergency declarations have expired, and the requirement for in-state telemedicine has been reinstated.

In September of 2021, I had some toe surgery. My provider saw me in follow-up and decided to leave the stitches in for an additional week. Several days before I was due in for suture removal, my father contracted COVID-19, and I had to answer that pre-screening question, “Yes.” As a result, my provider’s office rendered my follow-up visit virtual. I was perplexed as to how she planned on removing my stitches virtually. I got hold of a kit and dug the embedded stitches out myself, but I wondered how a normal, non-emergency physician patient would have managed. Suture removal is NOT appropriate for telemedicine.

There are some types of visits which lend themselves to telemedicine. Let’s start with most medical care that does not require a hands-on physical examination – for instance, a check-in to see if the antibiotics are having their desired effect or if the new medication has caused any side effects. A visual diagnosis, like “Is this poison ivy?” could be fitting for telemedicine. My opinion is that psychiatric and psychological visits might be appropriate, but there certainly are folks who prefer to be seen in person for mental health care.

Virtual visits may culminate in the provider determining that an in-person visit is necessary. The provider may decide a physical examination is indicated or that a test, like an EKG or biopsy, needs to be performed. The patient always has the right to decline a virtual visit and opt for an in-person one. I prefer to shlep my father to see his physician in person because I think a physical examination is valuable, and I like him having some human interaction. If the patient seems sick enough on the screen, the provider can always recommend presenting in person or that they should go to an urgent care or emergency department.

There are scenarios where in-state visits are not convenient or potentially feasible. People who live near borders may have established care with a practitioner prior to moving to the next state over and may want to remain in their practice. Out-of-state college-aged kids may need their attention deficit medications renewed. Snowbirds get sick in Florida, too. Vacationers with complex medical histories may benefit from the expertise of the provider who knows them well.

I have been licensed in Illinois, Michigan, and Ohio. My husband held multiple licenses because the Cleveland Clinic offered remote radiology services. I don’t recall any substantive differences – it was more a matter of filling out reams of paperwork and paying a fee. I suppose that is the rub – the states probably don’t want to relinquish a money-making venture. It isn’t really about the medicine – barring minor geographical differences in potential organisms, diagnosing a pneumonia is done pretty much the same anywhere.

With the widespread provider shortage issue, it may be time to think out of the box and create a national licensure. It would allow for telemedicine across state lines and would allow providers to pick up stakes and move to another community expeditiously. Locums practitioners could chip in where needed.

Maybe state medical boards could collect a fee for monitoring quality. But to me, this isn’t a financial issue – it is an access and continuity of care issue. And don’t we all want the same thing?

Patients should be able to get competent medical care wherever and whenever they need it.

Programming note: Listen to Dr. Erica Remer Tuesdays when she cohosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.