Telehealth rule flexibility could connect physicians, patients in different states

Changing state licensure rules for telehealth visits could connect physicians and patients who live in different states.

Meanwhile, residents of some states will be much more affected than others by restrictions on interstate telehealth, according to a new study.

Use of telehealth exploded during the COVID-19 pandemic and that couldn’t have happened without temporary rules that give physicians and patients flexibility to connect online, by telephone or across state lines, researchers said in a news release.

With those temporary rules expired or about to be, now is the time for policymakers to craft telehealth licensure rules that could benefit people who need healthcare.

“With patients and providers now much more used to telehealth than they were two years ago, and with interstate licensure waivers expired or expected to expire soon, the question of how to design longer-term licensure policies to facilitate interstate telehealth is urgent,” senior author Chad Ellimoottil, MD, MS, said in the news release. “Each state should prioritize this issue based on patterns of care among their residents.”

The study, “Interstate Telehealth Use By Medicare Beneficiaries Before And After COVID-19 Licensure Waivers, 2017-20,” was published in Health Affairs. Researchers from the University of Michigan’s Institute for Healthcare Policy and Innovation (IHPI) examined data from older adults covered by traditional Medicare before and during the first year of the COVID-19 pandemic.

“Prior to the pandemic, state licensure rules hindered telehealth,” study first author Juan Andino, MD, MBA, said in the news release. Before the pandemic, state licensure rules limited telehealth to patients who in the state where clinicians were licensed to practice medicine. Clinicians can seek licensure in multiple states but must meet each state’s requirements to achieve and maintain their license.

During the pandemic, all 50 states allowed out-of-state clinicians to perform telehealth visits with residents of their state and telehealth visits rose markedly by the end of 2020. Most of the interstate visits were between patients and clinicians who had established relationships, and the most common conditions treated were those that benefit from regular evaluation and management (E&M) visits, such as high blood pression, depression and anxiety, the news release said.

In some states, less than 1% of telehealth visits in 2020 were interstate. But there was great variation between states, with some locations such as Vermont, New Hampshire and Washington, D.C., seeing interstate visits making up 4% to 9% of all E&M visits conducted via telehealth. States whose residents were more likely to go out of state for in-person care also had higher interstate telehealth care.

Rural residents especially appeared to have taken advantage of interstate healthcare. Of all rural residents included in the study, 18% crossed state borders for in-person care or telehealth, compared to 13% of nonrural residents using interstate healthcare.

In 64% of interstate telehealth visits, the patient and provider were in neighboring states, such as patients in rural areas of Michigan who saw clinicians in Wisconsin or Indiana, according to the news release.

“For residents of the District of Columbia and states such as Vermont, West Virginia, Wyoming and New Hampshire, 15% or more of in-person and telehealth outpatient visits occur with a clinician in another state,” said Ellimoottil, who is an assistant professor of urology at Michigan Medicine and director of IHPI’s Telehealth Research Incubator lab. “For these areas, finding a permanent solution to the interstate licensure issue is essential. For states like California and Texas, interstate healthcare may be a lower priority because less than 2% of total outpatient care occurs across state lines.”