by MELISSA McGINLEY
As predicted, telemedicine has emerged as a key health issue this 1997 legislative season. To date, 8 states have enacted laws providing for out-of-state physician licensure, reimbursement for telemedicine services and funding for telemedicine projects. Additionally, legislation pending in 17 states, as well as in Congress, would, if passed, ease some of the barriers hindering telemedicine, particularly reimbursement by Medicare.
Licensure continues to plague state lawmakers and telepractitioners, however. Licensure laws adopted by states thus far range from highly to mildly restrictive. The prevailing trend is to require nonresident physicians to obtain full licensure (Georgia, Mississippi, Nebraska) or a less restrictive special purpose license (Alabama, Arkansas). Exceptions are usually granted for infrequent telemedicine consultations or emergency services.
These new laws stand in contradistinction to federal initiatives, like the pending Comprehensive Telehealth Act of 1997, which would require the Secretary for Health and Human Services to report on efforts to ease state licensure barriers by early next year. If passed, this act will likely prompt the federal government to intervene in state licensure to increase professional mobility.
A development to watch is how states define, or in some cases, re-define telemedicine. California, a state with progressive telemedicine laws, has a measure pending to exclude medical information or data exchanged or transferred by telephone or fax from its existing definition of telemedicine. Similarly, Texas House Bill 2033, if passed, would strike medical services performed by use of telephone or fax from its definition of telemedicine.
Additionally, California has proposed a bill that could impact telepractice in that state and beyond. Senate Bill 1133 would encourage the development of California's encryption industry, to ensure data transmitted via the Internet remains secure. As concerns over privacy and confidentiality of telemedical transactions continue to grow, look for other states to introduce encryption measures in the near future.
The following summary represents current state and federal telemedicine activity:
Alabama. Provides for three-year special purpose licenses for nonresident physicians and osteopaths practicing within the state, which can be renewed by paying a licensure fee. Exceptions include informal, uncompensated and undocumented consultations. A more unique provision of the law requires the licensure candidate's home state to issue reciprocal licenses to Alabama physicians and osteopaths wishing to practice there.
Arizona. Clearly defines "telemedicine" as any audio, video or data communication of medical information occuring in the physical presence of the patient, even for consultation purposes only. Also requires patient consent for telemedicine services, excepting emergencies, consultations and interactions not directly involving the patient.
Arkansas. Provides for temporary licensure of nonresident physicians practicing within the state, to apply until final action is taken on their licensing applications. Exceptions are made for nonresident physicians who episodically consult with state physicians or medical schools, provide services otherwise unavailable in the state, or who are physically present when seeing the Arkansas patient. Arkansas also approved 3 measures appropriating funds for a statewide distance learning and telemedicine network.
Georgia. For a pioneer in statewide telemedicine, Georgia's new law is surprisingly restrictive. It requires full licensure for nonresident physicians practicing on Georgia patient, excepting occasional consultations, lectures or demonstrations for state medical schools. Nonresident physicians licensed by Georgia can be disciplined by the state medical board.
Mississippi. Requires full licensure for nonresidents practicing medicine across state lines, excepting telepractitioners whose services are requested by a Mississippi physician, when the physician requesting the service has a prior relationship with the patient.
Nebraska. An act nearly identical to Mississippi's requires full licensure for nonresidents practicing medicine or surgery across state lines, with an exception made for practitioners providing consultation services to licensed, Nebraska physicians or surgeons who regularly treat the patient.
Oklahoma. States that health care service plans, disability insurer programs or state Medicaid contracts issued, amended or renewed on or after January 1, 1998, shall not require person-to-person contact.
Connecticut. A nonresident physician is not required to obtain a Connecticut license if the physician is licensed in another state or country, limits his or her practice to telemedicine consultations with licensed Connecticut physicians, and doesn't preside over the care of Connecticut patients.
Florida. Requires full licensure of nonresident physicians unless they provide infrequent consultations only.
Hawaii. Provides for limited, temporary licenses of 3 months to licensed, nonresident physicians substituting for a Hawaii physician due to illness, vacation or training. Exceptions are made for military medical officers and nonresident physicians consulting with physicians licensed in Hawaii. Also pending is a measure to appropriate $550,000 over the next two years for distance learning.
Illinois. Requires full licensure of nonresident practitioners delivering care to Illinois residents, unless he or she is merely providing a second opinion.
Louisiana. Two measures are being considered to void any terminology in insurance policies prohibiting services via telemedicine, and to ensure telemedicine reimbursement by insurers apply to government programs.
Maryland. Requires nonresident physicians to obtain special purpose licenses to practice in Maryland, excepting irregular or infrequent consultations. Would require licensing candidates to have clean disciplinary records and hold full, unrestricted licenses in another state. Received an unfavorable report from the Senate Committee on Economic and Environmental Affairs.
Montana. Provides for 2 year telemedicine certificates to be issued to nonresident physicians practicing only telemedicine in Montana. Candidates for certification must be fully licensed in another state, have clean disciplinary records, no pending investigations, and malpractice insurance.
New Mexico. A measure to appropriate $406,000 for equipment costs and additional staff for its telemedicine program.
North Carolina. Requires nonresident physicians treating North Carolina patients to obtain full licensure, excepting consultations with licensed, North Carolina physicians and state medical schools. Physicians in neighboring states who regularly practice in North Carolina are also exempted. Allows patients to bring malpractice claims against nonresident physicians into state courts.
Ohio. Nonresident practitioners treating patients in Ohio must obtain a certificate to practice from the state medical board. Exceptions include a nonresident physician providing ongoing care to a patient originally residing in his/her state, and physicians licensed in a bordering state as long as the state grants reciprocal privileges.
Oregon. Requires full licensure for nonresident physicians practicing in Oregon, excepting emergencies and informal, uncompensated consultations. Candidates must have clean disciplinary records.
Rhode Island. Provides for licensure and discipline of any nonresident practitioner providing treatment to a Rhode Island patient, even by telephone. Exceptions apply to services initiated by a patient within Rhode Island from a nonresident physician, or to consultations.
Washington. A non-resident physician providing direct care through tele-electronic means to a Washington patient must be sponsored by a physician licensed by and residing in the state. Gives the medical quality assurance commission the power to establish rules for telemedicine providers and their sponsors. A second measure would appropriate $8,000 for telemedicine.
The Comprehensive Telehealth Act of 1997. Besides mandating reports on efforts to ease state licensure barriers, the act would require the Health Care Financing Administration to reimburse any Medicare eligible provider for telehealth services by July 1, 1998. The bill also provides for seed money to encourage health care providers and other community segments to jointly use telecommunications resources. The bill is currently in the Senate's Finance Committee. Its House companion, The Improved Access for Telehealth Act of 1997, has been referred to the House Committees on Commerce and Ways and Means.
Medicare Telemedicine and Medical Information Demonstration Act of 1997. Provides for a project to demonstrate the application of telemedicine and medical informatics to improve the delivery of health care services under the Medicare and other government health programs.
Rural Health Improvement Act of 1997. Section 601 would require the implementation of a method for making payments under part B of Medicare for Telemedicine Services.
Medicare Modernization and Patient Protection Act of 1997. Title VII of the bill amends the Communications Act of 1934 by adding requirements for Internet access for health care providers in rural areas. Also establishes a Congressional Commission on Telemedicine.
Managed Care Consumer Protection Act. Section 9918 directs the Secretary of Health and Human Services to consider telemedicine and other innovative means to provide follow-up care to newborns and their mothers.
This article is part two in a four-part series on telepractice legislation.
