Interstate Medical Licensure and Emergency Response

Last month, the Federation of State Medical Boards (FSMB), a nonprofit organization representing the state commissions that regulate the practice of medicine, announced the release of model legislation that, if adopted by states, would significantly streamline the licensing process for physicians seeking to practice in multiple jurisdictions. Under the terms of the model legislation released by FSMB, a physician licensed in a participating state and meeting other eligibility criteria could obtain an expedited license in any other member state, thereby facilitating multi-state practice. Adoption of the model legislation by state legislatures not only promises to help expand the provision of medical services to rural and understaffed areas, but could also produce the added benefit of enhancing the ready availability of medical care in times of public emergency. Drafted under the auspices of the FSMB with participation by a team of state medical board representatives and experts from the Council of State Governments, the proposed legislation would create an Interstate Medical Licensure Compact designed to achieve maximal support among the states by leaving traditional licensure mechanisms in place while introducing streamlined processes. The compact operates by requiring physicians applying for expedited licensure in another jurisdiction to designate a “state of principal license” and seek a letter of qualification from that state’s medical board. It also establishes a new Interstate Medical Licensure Compact Commission to serve as a clearinghouse for the application process, acting as a conduit between state boards for purposes of verifying eligibility and assessing applicable fees. An expedited license received through the compact would, in those states adopting the model legislation, constitute a full and separate medical license, subject to relevant state dues and requirements. Unlike the Nurse Licensure Compact—which makes a nursing license in one of the 24 member states automatically “good” wherever the compact has been enacted—the proposed Interstate Medical Licensure Compact would not create a multistate license. Moreover, unlike previous FSMB efforts in the 1990s, the newly proposed compact for physicians would not authorize a special-purpose license applicable only to cross-border care. Rather, the major reform of the proposed compact would be to eliminate the need for physicians contemplating multistate practice to apply to each medical board individually, making it more realistic for doctors to hold multiple licenses and reach additional patient populations. Advocates of the proposed compact emphasize its potential benefits in promoting telemedicine as well as alleviating physician shortages in rural and underserved communities. In this sense, the compact marks the latest effort to reduce legal and regulatory barriers to expanding access to care. The ability of electronic health services and other technologies to transcend geographical boundaries has magnified the tension between jurisdictional licensure and patient choice. The American Bar Association’s section on health law has deemed multiple licensure requirements for tele-health practice to be “duplicative, expensive and burdensome.” The Health Resources and Services Administration, which oversees a federal grant program to reduce barriers to telemedicine, regards licensure portability “as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services.” Another possible advantage of the proposed compact has garnered less attention but is no less vital: the legislation could help emergency planners and public health officials improve disaster preparedness and response. Currently, licensure portability in the event of public health emergencies is addressed through a patchwork of disparate approaches, with the potential for significant gaps. For example, the Emergency Management Assistance Compact (EMAC) enables states to share disaster relief personnel and provides a mechanism for recognizing out-of-state professional licenses. However, EMAC is focused on government resources and is not automatically applicable to private-sector physicians. Moreover, the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA) authorizes licensure reciprocity during a declared emergency for private-sector volunteers, but to date it has been adopted by only 14 states, the District of Columbia, and the U.S. Virgin Islands. (It was also recently introduced in the Pennsylvania legislature.) In order to avail themselves of UEVHPA’s protections in applicable jurisdictions, volunteer health practitioners must register with approved programs, such as the Emergency System for Advance Registration of Volunteer Health Professionals or the Medical Reserve Corps. An earlier initiative known as the Model State Emergency Health Powers Act (MSEHPA) empowered state public health authorities to waive licensing requirements for out-of-state healthcare providers and prescribe their duties in response to a declared public health emergency. As of 2011, 40 states and the District of Columbia have incorporated some MSEHPA provisions into law, but only 17 states and D.C. have adopted the relevant licensure language. At the federal level, the secretary of Health and Human Services possesses some authority to waive licensure requirements for healthcare providers during a public health emergency. However, this prerogative is severely circumscribed by state primacy in the licensing arena under the constitutional principles of federalism. As such, the waiver provision solely covers participation in Medicare, Medicaid, and the Children’s Health Insurance Program. Moreover, such waiver authority is only triggered in unique circumstances, and even then it is limited in temporal and geographic scope. Although the newly proposed Interstate Medical Licensure Compact was not primarily developed as an emergency preparedness tool, it could nonetheless yield salutary effects in enabling eligible physicians to practice across state lines in response to both natural and man-made disasters. As with all such laudable interstate efforts, the key to overall success is achieving the widest possible adoption by the states. By keeping the traditional regulatory authority of state medical boards intact, the newly proposed compact may prove more successful than past efforts in obtaining widespread buy-in among state capitals. It poses no ostensible revenue threat to state agencies and facilitates an expedited process rather than a new form of licensure. It does, by necessity, leverage the physician’s home state license as the basis for granting new ones, which may cause some states to balk over concerns about patient safety or professional competition. State participation is strictly voluntary, but advocates of the proposed compact hope that its terms will prove both sufficiently flexible and politically palatable. The proposal released by FSMB will now proceed to state legislatures for consideration. Whether enough states ultimately enact the compact to make it a truly nationwide system will be a test of the adaptability of time-honored licensure mechanisms to meet contemporary challenges