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Many of the state policies and regulations that enabled greater flexibility about access to telehealth across state lines have been retracted as COVID-19 rules and mandates relax. The patchwork of varying policies regarding telemedicine has prompted a call for more streamlined pathways to interstate credentialing for physicians who see patients in other states.

Neurologists at Wake Forest Baptist Health in Winston-Salem, NC, never used to get this kind of call, but it's happening more and more these days. A patient from a town like Blacksburg, VA, nearly two-and-a-half-hour's drive away will travel just over the border into North Carolina, seek out a parking lot with good cell reception or Wi-Fi, and connect via the health system's electronic medical record patient portal to their Wake Forest stroke specialist or epileptologist.

Our catchment area includes southern Virginia and West Virginia, said vascular neurologist Amy K. Guzik, MD, an associate professor of neurology at Wake Forest. Many of our patients have mobility and transportation limitations and may require a care partner or other person to drive them to the clinic. When telehealth limitations were lifted during the height of the COVID-19 pandemic in 2020, that was really beneficial for these patients, especially for follow-up appointments, and we were hoping that would continue. Now we have to ask each patient what state they are in before we are able to see them.

States of emergency issued by state and local governments in 2020 have gradually been lifted over the past year, and with them, temporary waivers allowing doctors licensed in one state to provide care to patients in other states via telemedicine.

As of October 6, 2021, the Federation of State Medical Boards (FSMB) reported that 18 states still had such waivers in place, while 32 states plus the District of Columbia no longer have waivers. Virginia's waiver, for example, expired in June 2021, but West Virginia's is still in place.

The geographic boundaries are so arbitrary, said Dr. Guzik. If a patient is 10 miles in one direction, I can't see them, but if they're 10 miles in another direction, I can.

The patchwork of emergency orders has created confusion for providers and health systems around the country, said Lisa Robin, FSMB's chief advocacy officer.

A few states have made their waivers permanent, while others have allowed them to expire. A lot of bills are being introduced surrounding telehealth in state legislatures, with licensure and credentialing being a key piece, but also credentialing of facilities and broadband and infrastructure resources to support telehealth. We expect a busy state legislative session. (Federal waivers that allow Medicare billing for both video and audio-only telehealth services remain in place at press time.)

For some neurologists and their patients, the end of the licensure waivers in some states has not proven particularly burdensome.

Here at NYU, for example, our out-of-state patients are frequently in Florida, because a lot of people go from New York to Florida for the winter, said Neil A. Busis, MD, FAAN, clinical professor of neurology at the NYU Grossman School of Medicine, associate chair for technology and innovation in the department of neurology, and clinical director of the telehealth program.

Florida makes it extremely easy to get a pure telehealth license; the process literally takes like half an hour. We also have many patients from Connecticut, which has the relaxed requirements for telehealth in place until June 2023, and New Jersey, which has made it fairly easy to get a temporary telehealth-only license with policies that are in place through the middle of January 2022.

But in neurology deserts like the Mountain West comprising Wyoming, Utah, New Mexico, Nevada, Montana, Idaho, Colorado, and Arizona, and for patients with rare conditions for whom there are only a handful of centers of excellence across the country, the waivers had provided access to expert neurologic care that would otherwise have been all but inaccessible. This was true, particularly given that travel can be burdensome for people with conditions such as epilepsy, Parkinson's, and Alzheimer's disease; post-stroke patients; and children with rare neurologic conditions.

The Child Neurology Foundation has had a series of strategic discussions this year on the role of telehealth in child neurology, said Dr. Busis. Imagine that you're at home with a child who has frequent seizures and may be on a ventilator and require frequent suctioning. You have a lot of supportive equipment that has to be with you at all times. It can take hours to pack up a medically fragile child for a visit to a specialized center an hour or more away, and if you're halfway there and the child has a seizure, what do you do? In the cases of these children, and other people who may be on home ventilation or other significant supportive care, it's not just I can't miss work today, it's life-altering. It's a quality of care issue.

As a stroke specialist, Dr. Guzik said she has found that telehealth is particularly beneficial for transitions of care as patients are discharged from the hospital to home and are adjusting to a new set of limitations.

After they're home for a couple of weeks, we want to check in and see how they're doing, she said. Maybe they do need that physical therapist they didn't think they needed at discharge, or the occupational therapist to help them modify their home. But it's difficult when you've just gotten home to turn around and go back to the medical center with your caregiver, especially if you're in a different state.

One potential solution to the licensure challenge is the Interstate Medical Licensure Compact (IMLC), which offers a voluntary, expedited pathway to licensure for physicians who wish to practice in multiple states. First launched in 2017, the Compact now has 33 member states and two member jurisdictions; Ohio became the 33rd state in July 2021.

Eligible physicians can qualify to practice medicine in multiple states by completing just one application within the Compact, receiving separate licenses from each state in which they intend to practice, according to the IMLC's website. These licenses are still issued by the individual statesjust as they would be using the standard licensing processbut because the application for licensure in these states is routed through the Compact, the overall process of gaining a license is significantly streamlined. Physicians receive their licenses much faster and with fewer burdens.

The FSMB strongly supports the IMLC, said Robin. We had expected that the number of licenses issued would fall off as the pandemic began to wane, but it has not. More states are joining the Compact and going live. With Texas and Ohio having joined the Compact this year, that's a lot of additional eligible physicians. We are going to work hard to try to get additional states to join.

The FSMB is also working on a new telemedicine policy to replace the one originally issued in 2014. The draft is expected to be released by the end of 2021, and will be voted on at the Federation's 2022 Annual Meeting in April. We are hoping to come to consensus on a very much expanded policy that addresses questions about licensure, modalities, continuity of care, and many other areas, Robin said.

In a telehealth position statement published in Neurology in August, the AAN called for a number of steps to make telehealth more accessible and equitable for all patients. Licensing, prescribing, and related policies should be simplified, the authors noted. A desirable solution could include blanket reciprocity and an expedited licensing process that would require one unrestricted state license, a new background check for each state in which telemedicine is practiced, and reduced annual fees for limited practices. This would ensure protection of patients' rights to receive telehealth services as they require.

Telehealth should be here to stay, said Riley Bove, MD, associate professor of neurology at the UCSF Weill Institute for Neurosciences in San Francisco and a co-author of the AAN telehealth statement. It reduces the barriers to care, reduces patient costs for a visit, and decreases the burden of specialty visits for patients who are navigating multiple conditions. And during the pandemic, we have learned that this is broadly doable.

Before COVID-19, we had many colleagues who said that you can't provide good neurologic care via video. Through the past year and a half, however, we have become experts in examining patients via video and learned what is more and less beneficial, and what are the use cases where we need the patients to come in versus where we can spare them that trip and expense.

Lobbying for more streamlined pathways to interstate credentialing can be challenging, however. When I talk to our state legislators, they're mostly concerned about the patients in their own state and their constituents there, so they could say, Well, we want our own doctors in our own state to see the patients here, Dr. Guzik said.

Of course we do want the best, closest neurologist to see these patients, but there are situations with certain conditions or subspecialties or locations where it just makes more sense to see an expert in another state. Telehealth allows us to meet our patients where they are, let them live their lives and also get good medical care.

Certain cases are definitely not appropriate for telehealth, Dr. Bove acknowledged. And in others, it's just about patient preference. I have some patients who have said, Please, I just want to see you in person again. But there are others who never want to come back in person because they find telehealth so convenient. The reason most medical care happens in the clinic is not because that's where it's always best provided, but because it's most convenient for the clinician.

The patchwork of state policies and regulations regarding licensure, and variable payment reimbursements for telehealth reflects so much that is difficult about health care in America, Dr. Bove said. It underscores the major flaws in our health care system. And it needs to be changed.

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