Interstate Medical Licensure: Major Reform of Licensing to Encourage Medical Practice in Multiple States
July 27, 2014
The Interstate Medical Licensure Compact is a streamlined process that would allow physicians to rapidly become licensed to practice medicine in multiple states.1,2 If the compact were to be approved by state legislators and incorporated into the laws of most, if not all, states, it could catalyze many substantial changes in medical practice. The potential benefits include easing the physician shortage in rural and other underserved areas and speeding the growth of telemedicine. Telemedicine, whether by telephone, e-mail, videoconference, or online, has increasing uses in medicine, ranging from radiology and pathology to mental health visits, the early diagnosis of stroke, and consultation with medical personnel in emergency departments and intensive care units. The compact could also facilitate specialist consultations for patients with complicated or rare illnesses.
An interstate compact is a legally binding agreement between states, as well a component of state law. The proposed licensure compact, developed by representatives of state medical boards under the auspices of the Federation of State Medical Boards, would allow eligible physicians to apply for expedited licensure in participating states (Box). Only some physicians, such as those with specialty certification or a time-unlimited specialty certification and a full and unrestricted medical license for at least 3 years, would be eligible. The physician would designate a member state as the state of principal license and, if found eligible by that state’s medical board, could apply for expedited licenses in other member states through a newly created interstate commission. The expedited license would be a new state license that would be the same license a physician would receive if applying to another state directly. It would not be a multistate license or a national license; the physician would select the states and pay the required fees to the states and the interstate commission.
- A full and unrestricted medical license in any state over at least the past 3 years.
- A full and unrestricted medical license issued by a medical board in a state that is a member of the compact.
- Designation of a member state as the state of principal license, defined as the state of primary residence; the state where at least 25% of the physician’s practice of medicine occurs; the location of the physician’s employer; or, if the other criteria do not apply, the state of residence for purposes of federal income tax.
- Successful completion of graduate medical education approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association.
- Specialty certification or a time-unlimited specialty certificate recognized by the American Board of Medical Specialties or the American Osteopathic Association’s Bureau of Osteopathic Specialists.
- Never convicted or subject to certain alternatives to conviction by a court for “a felony, gross misdemeanor, or crime of moral turpitude.”
- Never subject to discipline related to a medical license by a licensing agency, excluding actions related to nonpayment of license fees.
- Never had a controlled substance license or permit suspended or revoked by a state or the Drug Enforcement Administration.
- Not under active investigation by a law enforcement or medical licensing agency.
At present, if a physician wants to practice in more than 1 state, he or she typically applies directly to one of the 70 medical and osteopathic boards within the United States and its territories. A credentials verification service, established by the Federation of State Medical Boards in 1996 and now used for more than half of new license applications, and a uniform application, which is used by about 25 boards, can make the process of obtaining multiple licenses less arduous. A few states have reciprocity agreements; however, individual applications are still required. Some states also have special telemedicine licenses.
Many physicians have more than 1 active license, but it is unusual to have 3 or more. In 2012, there were 878 194 physicians with an active license to practice medicine in the United States (789 788 with medical degrees and 58 329 with osteopathic degrees); 78% of physicians held only 1 active license, 16% had active licenses in 2 jurisdictions, and 6% had active licenses in 3 or more jurisdictions.3 Of the approximately 51 000 physicians with 3 or more active licenses, 8825 (1% of all physicians) had 5 or more, 1764 (0.2%) had 10 or more, and 312 (0.3%) had 25 or more (Aaron Young, Federation of State Medical Boards, written communication, July 15, 2014). Although it is likely that many of the physicians with 5 or more state licenses are radiologists or pathologists who practice telemedicine, the characteristics of such physicians have not been specifically analyzed.
The impetus for the licensure compact came in part from areas of the country that are sparsely populated and heavily reliant on physicians who live elsewhere to provide medical care. For example, Wyoming, the least populous state, has fewer than 600 000 residents. Of 3200 physicians with active Wyoming medical licenses, only about 40% live in the state; 76% of the licensees have at least 2 state licenses, the opposite of the national situation (Kevin Bohnenblust, executive director, Wyoming Board of Medicine, written communication, July 16, 2014). Encouraging the growth of telemedicine as well as the ability of physicians from regional health systems to provide care in the state could have clear advantages.
Under the compact, the practice of medicine would occur where the patient was located when the visit took place, as is currently the case, not where the physician was located or where the physician received payment. Thus, the physician, regardless of whether the encounter was in person or not, would be under the jurisdiction of the patient’s state, as would any subsequent investigations, discipline, or presumably malpractice claims. The state boards participating in the compact would be required to share complaint and investigative information with each other.
The licensure compact is a fully developed policy proposal that builds on the existing system of state medical licensure and that limits eligibility to physicians who meet the criteria. The compact is not, however, the only approach to making medical practice more portable. For example, physicians employed by the Department of Defense and the Department of Veterans Affairs need only be licensed in their home state to treat military personnel and veterans, respectively, on federal property. The existing Nurse Licensure Compact, established in 2000 under the auspices of the National Council of State Boards of Nursing, allows nurses in 24 states to have 1 multistate license, with the ability to practice in their home state and the other participating states, without additional applications or fees.4 A nursing license in a compact state automatically becomes a multistate license, as long as it is in good standing.
Such examples can be used to advocate for other changes to medical licensing. These might include allowing physicians to practice in other states with their home state license, such as for Medicare beneficiaries and other patients in federal programs, as well as standardized state regulations for medical practice and telemedicine. Among the advantages could be improved access to care and a decrease in the duplication and fees associated with requiring physicians to obtain and renew multiple medical licenses. Among the disadvantages could be lower licensing standards than those in some states and diminished authority of state medical boards to provide oversight and protect patients.
Because the interstate licensure compact has yet to be finalized, the eligibility criteria and other specifics may change. For example, the draft compact does not include criteria related to the number of years in practice or to maintenance of certification. Another unresolved issue is the demand among physicians for additional state medical licenses. Although it is likely that an increasing proportion of medical care will be delivered through telemedicine, the rate of growth will be influenced by factors specific to telemedicine, including the technologies, patients’ needs, standards of care, and reimbursement policies.5,6
If the Interstate Medical Licensure Compact were to move forward, it would herald a major reform in medical licensing. But the actual influence on practice is likely to be gradual, and there would be no effects on physicians seeking additional state licenses until multiple states enacted the compact. The Federation of State Medical Boards hopes to finalize the compact in 2014, so that in 2015 state legislatures could consider bills that would incorporate the compact into state law. The licensing and other fees for physicians have yet to be set. Although the rationale for the compact is strong, a sufficient number of states will now have to enact it.
Corresponding Author: Robert Steinbrook, MD, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, I-456 SHM, PO Box 208008, New Haven, CT 06520 (firstname.lastname@example.org).
Published Online: July 28, 2014. doi:10.1001/jama.2014.9809.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
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