July 14, 2020

Line Dempsey: Welcome to our podcast, Regulation Matters: a CLEAR conversation. I’m your host, Line Dempsey. I am currently the chief compliance officer with Riccobene and Associates Family Dentistry here in North Carolina. I am on the CLEAR Board of Directors as well as the current chair of the National Certified Investigator Training Committee with CLEAR.

As many of you probably already know, the Council on Licensure Enforcement and Regulation, or CLEAR, is an association of individuals, agencies and organizations that comprise the international community of professional and occupational regulation. Our podcast is a chance for you to hear about the latest and greatest that's going on in our community, and today I'm joined with Marschall Smith. He's the Executive Director of the Interstate Medical Licensure Compact Commission, or the IMLCC. We're very glad to have you with us today, Marshall. Thanks for joining us.

Marschall Smith: You're welcome, and thank you for this opportunity to talk about the Compact.

Line: Absolutely. And also thank you to our listeners for joining us for another episode. So Marschall, what we'd like to talk about today is where to the idea of creating a physician compact state start, how is it formed, and what does it do? We've got lots of questions, but I guess let's start with the question of just what is the IMLCC?

Marschall: Right, so the Interstate Medical Licensure Compact Commission is an organization that's formed by states that join the Compact, and that action by the state and their governor then makes the compact. The compact then joins that state's governmental process. The formal identification or legal definition of what the compact is that it is a governmental instrumentality with rule-making authority. So we're not a non-profit, we're not our for-profit, we're not a state government, we are kind of one of those entities that performs a governmental function that states must agree to participate in, in order to be a part of the Compact and use its benefits.

So the other part too, is the idea of compacts is a very old concept in the United States, and it's something that happens all the time. There are all kinds of compacts out there, that some of them you may not even be aware of that occur and that you take a part in. For example, one of the most common ones is if you take a trip to another state and you go to the rental car counter, you're allowed to rent a car and drive in that state, making sure that you comply with those states' requirements to operate the motor vehicle, but you don't have to get a license in that state to operate a motor vehicle. There's a compact that the states will recognize other states' drivers license. So that's kind of where the idea of using this old concept and this old principle of allowing multiple states to benefit from a compact that will allow their physicians and citizens of their states to benefit.

So the concept behind the physician compact came about through discussions with the Federation of State Medical Boards at a meeting with their House of Delegates. The discussion started in 2013, and basically the discussion was about whether states could come up with the common set of principles that would allow them to accept the actions of another state to license a physician, and if those actions were sufficient, then they would then issue a license to the physician in their state. And so that's kind of kind of where the concept came from. There were a lot of discussions, legislation was introduced, and in April 2015, the Compact became a legal organization.

We're a bit different than other health profession compacts. There's a nursing compact that allows nurses to practice in multiple states. There's an EMT, there's an audiologist, there are a whole bunch of these compacts for healthcare providers that are coming about across the country. What makes the physician compact a little bit different is that most other compacts are generally categorized as an authority to practice, so if you're licensed in one state, you then have the authority practice in the other state without getting a license in that state. The physician compact is set up so that a physician who is licensed in one of the Compact states, then obtains licenses in those other states. And that's where what we've done is really a very Federalist concept of creating a nationwide benefit but leaving the control in the hands of the states, as they control and regulate the practice of medicine but they've created an alternative licensing process. So the concept was approved by the required states to make the compact a legal organization in April 2015. Between April 2015 and April 2017, the structure behind the organization was put together, and we actually received our first application and processed our first license.

Line: And that was in 2017 when you guys started processing applications?

Marschall: That's correct.

Line: Gotcha, so who governs and controls this compact?

Marschall: Yeah, so the compact is established by the passage of a bill in a state and signed into law by the Governor, so that the Compact statute becomes a part of that state's statute. And then each state then appoints two commissioners. And the commissioners then (which is obviously our title is the Compact Commission) the commissioners are the governing body, and each state, as I said, has two representatives from their state. The decisions made by the compact have to be approved by the commissioners.

Rule-making can only be done with the majority vote of the commissioners. So they have a lot of authority, they establish policy, they hire an executive director to run the day-to-day operations. The commission is responsible for ensuring that its laws and rules are complied with and followed, and they establish the direction of the organization. There is also an executive committee that has been established with elected officers. There's the Chair and a Vice Chair and a Treasurer, the executive director serves as secretary, and then the chairs of all of our standing committees form the executive committee. The executive committee acts on behalf of the Commission when it's not in session, and the only power that's not granted to the Executive Committee is the power to do rule-making and issue rules.

Line: So it seems like it would make sense that obviously a compact, if you've got multiple states involved, that this would obviously speed up the licensing processes since it's still happening within that particular state's licensing agency. I guess, what other things does the Compact do to help in that process?

Marschall: Right, so what the compact's basic operations and where we're allowed to do an expedited process... The best example that we use to explain what we do is that if you go to the airport and you want to board a plane, you have to go through a screening process where you have to put all of your stuff on a belt, it goes through an x-ray machine, you go through a scanner that makes sure that you're able to prep the travel and be allowed to board the plane. But there are two ways to get there--you can do the regular way where you're not a known traveler and you go through the process and you get to the x-ray machine, or you can go through one of the known traveler processes, the TSA Pre or any of the other commercial options to do that.

In a sense, what the Compact is, is a complementary licensing process, very much like the known traveler process. So it's a known physician process that allows the application process to be expedited. So in order to qualify to use the compact process, a physician has to be licensed and have practiced in a member state. So we've got a known physician who has an established history with a state that's a part of the compact. That means that that state has already vetted that physician's license application. They've pulled the primary source documents regarding their medical school, the medical education, that they've passed a qualifying the exam, and that they've met the static criteria established for a physician to get licensed. In all of the states, there are nine criteria that a physician has to meet in order to be able to use the compact process. That state where they're already licensed, we call it the state of principal license or an SPL, has already had that information and then acts as the key that unlocks the licensure process in other states. So a physician fills out an application indicating that they wanna be a part of the compact, the state of principal license receives that application, they verify all of the information on that application, they then also do a criminal background check, they do a check against the physician disciplinary database that's out there, they check the DEA resources to make sure they're no actions. So the physician is verified and vetted and ensured that they meet our qualifications. Then the state of principle license issues what's called a letter of qualification. The letter of qualification is an indicator to all of the other member states that the physician's application has been vetted, that it has been verified to be true and correct, and that the physician does not have any actions against their license, and they have a clean criminal background check. Once that is done, the physician then goes back into their application, they select anywhere from one to 30 other states that they want to get their licenses from, and that single application has then allowed them to get licensed in the multiple states. Those other states, once they received the letter of qualification and the application, then issue a license to the physician without doing all of their normal or regular traditional licensing reviews.

Line: So obviously, since you guys have started taking applications back in 2017, I'm sure you've had some opportunities to, I guess, see what has worked and what hasn't work. Can you give us some examples of maybe some lessons that you've learned through this and maybe some of your achievements?

Marschall: Yeah, thank you. So one of the things that we believe we hit on a very important need for the physician community. As I said, we started in 2017. That first year of our operations, we received about 1,500 applications and there were about 2,250 licenses that were issued using those applications. Our next year of operations, it almost doubled. We processed 2,700 applications, and there were almost 4,000 licenses issued during that second year. This is our third year that we just completed, and in our third year, we did 4,400 applications, and there were almost 4,600 licenses issued. So there have been a total of 10,000, almost 11,000 licenses that have been obtained by physicians using our compact process.

One of the other parts that we're quite proud of is that the physicians that we issue our licenses to, those 10,000 licenses that have been issued, there haven't been any disciplinary actions taken against these physicians. So it's a high bar standard to get in, and then most physicians maintain that high bar standard and have been able to practice.

One of the other accomplishments that we've been able to do is we have a process in place that would allow us, in case of a physician who does start to run into problems or issues with their practice of medicine, we have a mechanism that allows the states to participate in a joint investigation or a joint process that would allow those states to share confidential information and conduct an investigation with the other states--something that currently does not happen now, as each state is kind of siloed and is not allowed to share or provide information about their confidential investigation. So we've created our process that protects patients by allowing multiple states to participate in the joint investigation if that physician is licensed in those states.

Some of the other things, we've put together a web-based process, and that really has helped us, especially during this COVID situation where, although we were not established to address those issues and giving licenses for states that needed physicians because of the COVID crisis, our natural process the way that it was established allowed us to step in and to make that opportunity happen. We saw an increase in our volume. We were doing about 350-375 applications a month. When the COVID situation happened, we saw an increase in our application volume, and we've been processing about 450 (or about 100 more) applications a month and would be able to provide a rapid method for physicians to obtain licensees in multiple states. So we were able to step up and use our current process to help that, and being web-based, I think certainly benefited from that ability because there was no requirement for face-to-face or contact to occur during that time.

Some of the other things that we've been successful in doing is we've created a mechanism that complements the states' licensing process. Most of our states report to us that they see an increase in physician licensing by about 5 to 10%. So it's certainly a significant part of a state's licensing process, but isn't the majority of the licensing of physicians. They still are using the traditional method to get licenses.

The other part that we're quite proud of is that we very much maintained the ability of our member states to be able to control the practice of medicine in their state. It's one of those things that's actually in our Constitution that it's a right, the regulation of health and healthcare is a power that's delegated to the states, and our states do very well at establishing how the citizens of their state should receive healthcare and how that health care should be delivered to them. And so our methodology lets the physician get the license and then turns the power over to the state to ensure that the physician is providing the healthcare they need for those states.

One of the things that we've also noticed is that, and we're working to figure out... We have anecdotal information; we don't have hard data, and we're now trying to get at that data, but the ability of physicians to use the Compact to get licensed in multiple states has helped the telemedicine process. So physicians can, if they've got the patient in a state that they're not currently licensed in and they need to get licensed there, and that state is a part of the Compact, they can use the compact process to get licensed quickly and then be able to treat those patients. We've seen, often times people are not living close, the closest population center to where they live is not necessarily in their state, but it's in a neighboring state, and the compact process has allowed those physicians in the closest population center to get licensed in those states, so they're able to serve rural and underserved areas because they're closer to their patients by being in a population center in the neighboring state than the population centers in that state. And we've also heard reports of rural and underserved communities and their hospitals being able to expand their hours and extend their ability to provide care to patients because they can use remote access physicians and create abilities that they couldn't find normally in their communities, just radiologists and those sorts of things.

And so I think there's a lot of benefits that have happened because of the compact-- things that we had planned on and very unintended consequences. And I think that's really a benefit to what we do. Every year, the compact does a data study, so we take a specific set of completed applications, and then we look at those applications to try to determine some trends and some ways that we can improve our processes. And we're quite proud of the fact that even though we've increased our volume very significantly over the years, we've kept our processing times about the same. So it takes a physician our average processing time from application being filled out to all licenses requested, it takes about 45 days. Thirty to 35 of those days are taken up by the physician working with their state of principal license to verify all of the information on the application, do the criminal background check and provide all of that information and data to the state so that they can issue that a letter of qualification. But on average, it takes about seven days once that letter qualification has been issued to get the licenses that the physician wants. And then that letter of qualification is good for 365 days, so if at another point the physician wants to add another state or multiple states to where they're licensed, they can very quickly access that letter of qualification and get the state, and that secondary or additional licensing process takes about seven days on average. So we're very proud of the fact that we've created a process that is expedited that allows physicians flexibility in obtaining multiple licenses in multiple states but is also safe and it's also secure, and it also ensures that patients are receiving excellent care because it's keeping a state's Medical Practice Act intact and allowing the state to do one of the things that it does very well, which is regulate the practice of medicine in their state.

Line: That definitely does sound very fast. Obviously, I think one of the next things that you guys I'm sure are looking at or working towards is getting expansion to all 50 states. But what is next on your agenda?

Marschall: Yeah, that is very important that the compact expand to all 50 states. I think we would see a benefit from that, and all of our territories. Currently, we have 31 member states-- there are 29 states, the District of Columbia, and the territory of Guam. And then there was active legislation in six states when the COVID pandemic hit that derailed them. Most of them intend to reintroduce the language in the 2021 legislative session. We're working with a couple of our territories; so the US has four territories and we would hopefully be able to add all four of those to the process too. But that's one of our next big steps is to keep expanding, keep providing this opportunity to states, keep showing them the benefits of joining the Compact.

The other thing that we're working on is coming up with... I think there's a saying or there's an understanding in the IT world of, whatever you have right now is only as good as right now, and you always need to be finding a newer and better and more effective way of using the technologies to creat an increased or a better process. And we're working on that too. Every year we put together, we have a technology committee, that technology committee looks at what we currently have, looks at the technologies that are available to us out there and starts moving. We have a plan and we implement improvements. In this next year, some of those improvements are... Right now, we have a siloed process, so one system gathers the payment, then it tells the next system that it's gathered the payment, and that next system gets the application and then it moves down the line. And we're working now on having a cloud-based system where everything's contained and the systems are working with a common database. And I think that's quite exciting and it's kind of putting new technology to our process so maybe we can be a little bit faster or provide a little bit better customer service to the applicants. So I think those are the two big things that we're working on and hoping to improve upon in the next year.

And the other part to it is the Commission is an open public organization, so all of our meetings are held via teleconferences. And anyone that's interested in finding out about the compact can participate or can attend those meetings. Our information is out on our web page; it's imlcc.org. Thanks.

Line: Absolutely. Well, great, I think this has been a great discussion and I certainly do want thank you, Marschall, for your time and being part of this podcast. As I said earlier, it's always wonderful having the opportunity to talk about these issues and also learn from each other as we move forward in today's new COVID world. So thanks again for joining us.

Marschall: Thank you very much for the opportunity. I very much enjoyed the time and like talking about the Compact. I think we're doing great work, and I appreciate this opportunity to talk some more and get more people involved and understanding what we're doing.

Line: Excellent! And we also wanna thank our listeners. We'll be back again with another episode of Regulation Matters: a CLEAR conversation very soon. Again, thank you to our frequent listeners. If you're new to this podcast, please subscribe to it. It's available on Podbean, iTunes, Apple Podcasts, Google Podcasts and Google Play, Stitcher, Spotify, or TuneIn. We've got a lot of different areas that we're available. If you've enjoyed this podcast episode, please leave a rating or comments in the app. Those reviews help us to improve our ranking and make it easier for new listeners to find us. So it is very helpful.

Finally, feel free to visit our website at www.clearhq.org for additional resources and a calendar of upcoming training programs and events. And finally, I'd like to say a special thanks to our CLEAR staff, specifically Stephanie Thompson, our content coordinator and editor for this program. Once again, I’m Line Dempsey, and I hope to be speaking to you again very soon.

The audio version of this podcast episode is available at https://podcast.clearhq.org/e/imlcc_mobility/

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