Efforts to sign up more states for “multistate compacts” that allow out-of-state physicians and other health professionals to practice in another state are continuing into 2024, experts say.
For physicians, the ability to practice in multiple states has been simplified through the Interstate Medical Licensure Compact (IMLC), a project coordinated in part by the Federation of State Medical Boards. A total of 39 states as well as Guam and the District of Columbia currently participate in the compact, which “is an agreement among participating U.S. states and territories to work together to significantly streamline the licensing process for physicians who want to practice in multiple states,” according to the IMLC Commission website. “It offers a voluntary, expedited pathway to licensure for physicians who qualify.”
Spurred on by Telemedicine
The idea for the compact arose in 2013 when a group of state medical boards realized that more physicians would be practicing in multiple states as a result of the increasing use of telemedicine, according to the commission. Lawyers then drafted a model compact for state legislatures to adopt, and the compact officially went into operation in April 2017. The idea has the support of the American Medical Association, whose policy endorses streamlining the cross-state licensure process for doctors doing telemedicine and reducing the cost for physicians, including through the compact.
Under the process, eligible physicians who are licensed to practice in a state that participates in the compact — and who do at least 25% of their business in that state — can complete a single application to qualify to practice in multiple states. They will receive a separate license from each state in which they want to practice, “but because the application for licensure in these states is routed through the compact, the overall process of gaining a license is significantly streamlined,” the commission noted.
“We are able to get the physician licensed, on average, in between 7 and 10 days, where the process normally takes anywhere from 3 to 9 months to get a license the traditional way,” Marschall Smith, executive director of the IMLC Commission in Littleton, Colorado, said in a phone interview. “And what we do is safe, it’s secure. It’s a ‘high bar’ standard.”
In 2022, more than 17% of all licenses issued to physicians were issued through the compact process, according to the commission’s fiscal year 2023 annual report. In fiscal year 2023, the compact processed more than 19,000 applications, and nearly 31,000 licenses were issued through the compact’s process.
Of the 11 states that aren’t members of the compact, four state legislatures introduced bills to do so in 2023, Smith said: New York, Massachusetts, North Carolina, and Florida. Those bills will all carry over into this year’s legislative session, he added.
Also, of the four territories to which the compact could expand — Puerto Rico, the U.S. Virgin Islands, and the Northern and Southern Mariana islands — “our understanding is that there is active interest in the Virgin Islands and Puerto Rico,” Smith said. He noted that the commission is not permitted to lobby for the compact, “so we don’t actively lobby to get our bills introduced, but we work with groups in states that are interested in having the compact legislation passed in their state”; those groups often include medical and hospital associations, patient groups, and state medical boards.
The COVID-19 pandemic really forced the federation to re-think the cross-state licensure issue, according to Lisa Robin, chief advocacy officer at the Federation of State Medical Boards in Washington, D.C., who spoke during a phone interview at which a public relations person was present. During the height of the pandemic, “we saw that telemedicine visits increased something like more than 2,000%,” she said. “I think that that has evened out … But after that, we realized that we needed to revisit” the federation’s policy on licensure related to the use of telemedicine, based on that increase in utilization.
The federation established a work group to look at the issue and whether exceptions needed to be made. For telemedicine, the practice of medicine is considered to occur where the patient is located, “and physicians either need to be licensed or somehow authorized to practice where the patient is located,” said Robin. “But there’s some exceptions in this policy that we recommend, such as for consultations and any sort of follow-up care for established patients for clinical trials,” as well as for continuity-of-care purposes.
One example of that last exception would be for college students who “had to leave their providers in their university town and go home [during COVID], but were still wanting to access their providers by telemedicine,” she said.
Another Type of Compact
Physicians aren’t the only health professionals who have a multistate compact. Nurses and emergency service personnel also have compacts, for example, but theirs — known as a “privileged practice” compact — operates a little differently, Smith explained. In that arrangement, “if you are licensed in a state that is part of the compact, you have the privilege to practice in any other [compact] state without obtaining a license to practice there.” Physician assistants are also in the process of forming a privilege compact, but they need a minimum of seven states to sign on; so far, three have done so, according to the PA Licensure Compact website.
Privilege compacts can have downsides, according to Patricia “Polly” Pittman, PhD, professor of health equity at George Washington University’s Milken Institute School of Public Health in Washington, D.C. “From a worker perspective, there are concerns about health systems outsourcing via telehealth to states with lower wages ([in a] ‘race to the bottom’), especially in nursing,” Pittman said in an email to MedPage Today. “And states worry about the loss of workforce data that is critical to understanding their shortage areas, as more and more clinicians are licensed outside the state,” and therefore aren’t included in surveys that are given in conjunction with the re-licensure process.
“In my view, these [issues] aren’t deal breakers, but they should be discussed and, when possible, addressed,” she added.
A Variation on Privilege to Practice
A third kind of licensure compact is a variation on a privilege model, explained Jeff Rosa, managing director of post-licensure services at the Federation of State Boards of Physical Therapy in Alexandria, Virginia. In this model — used by physical therapists as well as occupational therapists, speech therapists, and audiologists — “if I am a licensed PT [physical therapist] or licensed PTA [physical therapy assistant] in a compact state, I have the ability to purchase a compact privilege in any of the other active compact states,” he explained. “So I can’t just show up in a compact state and start practicing. I actually have to purchase through the compact commission the legal authority to practice in the other states.”
It functions similarly to licensure by a state board, “but instead of going through the traditional license process, you’re going through the compact commission, and in 10 minutes, as long as you’re eligible for the privilege, you’ll immediately get your compact privileging and start practicing in the remote compact state,” Rosa said. Fees generally average $40 to $50, but can go as high as $260 depending on location.
The PTs chose this route for several reasons; first, it avoided the loss of state licensure revenue that occurs in privilege compacts where this type of purchase isn’t required. In addition, “the PT board wanted to know who actually is authorized to practice in their state,” he said. Under this model, “the state knows everyone who has a legal authorization to provide physical therapy in their state, versus a [privilege] model where I can just show up without notifying the state board that I am practicing in the state.”
Currently, 30 states are members of the PT compact; another seven states have passed the legislation but haven’t met all the requirements to join, Rosa said. In addition, there are compact bills active in Alaska and Hawaii that are holdovers from the last legislative session, “so we’re hoping that when the legislatures start meeting later this month, one or both of those bills will pass.”