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Extending medicine's reach

DermWorld takes a look at the Interstate Medical Licensure Compact.


By Andrea Niermeier, Contributing Writer, January 1, 2023

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In 1925, inventor and publisher Hugo Gernsback wrote in Science and Invention magazine of a “teledactyl,” a device that would allow doctors to not only see their patients through a screen but also touch them from miles away with robotic arms. While Gernsback’s device was fantastical at the time, nearly 100 years later with the regular use of telemedicine, virtual access to health care is not as far-fetched as it once seemed.

While some physicians were using telehealth prior to the COVID-19 pandemic, the demand for these services accelerated in 2020. When the Public Health Emergency (PHE) began, CMS temporarily waived the requirement that physicians needed to be licensed in a patient’s state. This waiver is still in effect until the end of the PHE — although state laws vary and physicians should check their state rules. Once the PHE ends, physicians will need to obtain licensure in every state in which they have patients.

For some specialties, telehealth has become a vital tool for physicians, and the Interstate Medical Licensure Compact (IMLC) has been one vehicle helping to deliver this type of care over the last five years.

Defining the IMLC

The IMLC is an agreement between state boards of allopathic and osteopathic medicine that allows board-certified physicians in one of the member states to obtain expedited licensure in other member states. Physicians can complete just one application, allowing them to receive multiple licenses faster with fewer steps. After completing the process, physicians receive separate licenses from each state in which they intend to practice. With the evolving health care landscape, the IMLC will likely continue to grow, offering physicians the flexibility to respond to the health care needs of patients and communities.

In 2013, with advancing technology and an increased interest in telemedicine, the idea of state licensure reform was a hot topic for Congress, insurance companies, and state medical boards. Members of Congress were discussing a national license, and the Federation of State Medical Boards (FSMB) took note. Lisa Robin, chief advocacy officer at the FSMB, commented that member boards came together to discuss license portability and potential licensure schemes. “A member board submitted a resolution, asking us to look at the feasibility of using a compact for physician licensure. That was voted on and approved by our house of delegates, and we moved forward with supporting those efforts. That was the genesis of the IMLC.”

Specifically, the FSMB looked to find those factors that — when verified by a primary source on one board — would be accepted by all other boards in the compact to issue a state license. According to Marschall Smith, executive director at the IMLC Commission (IMLCC), “The FSMB felt that if they could come up with factors or attributes that every state could agree to, that they would be able to accomplish the goal without the need for a national license.” Given both the authority of physicians under the state medical practice acts and the impact on people’s lives, the FSMB believed that an expedited process to issue a full, unrestricted license would be more appropriate. Most importantly, the FSMB wanted to ensure patient safety — maintaining the level of accessibility to physician information and the complaint process afforded to the public by individual states. In 2014, the FSMB — along with several state medical board executives, administrators, and attorneys — drafted a model compact.

The idea of a preserved state sovereignty in the compact was well received by medical state boards as well as medical associations, including the Academy. The Academy issued a statement recognizing the importance of the IMLC and supporting the FSMB’s “efforts in reforming state licensure in a way that preserves the authority of state medical boards while also promoting patient safety, high-quality care, and increased patient access.” In February 2015, Wyoming was the first state to join the Compact, followed by multiple other states. The IMLC became operational in April 2017, and a Wisconsin doctor became the first to use it to apply for licensure in Colorado.

Getting licensed through the IMLC

To qualify for licensure through the Compact, physicians must meet nine requirements, with highlights below. For a complete list of requirements, visit the IMLC website.

  • Practice in a participating state in the IMLC. Access the full list of participating states.

  • Be board certified in a specialty by an ABMS or AOA BOS board.

  • Hold a full, unrestricted medical license in the state of principal license (SPL).

  • Have primary residence or employer location in the SPL OR have at least 25% of your medical practice in SPL OR use SPL as address for federal income tax purposes.

  • Have a history clear of criminal activity or disciplinary actions against your license.

In addition, physicians must pay a non-refundable $700 fee during the application process. Once accepted, additional licensing fees are required for each state in which licensing is desired.

Patient access

Northern Wisconsin and the upper peninsula of Michigan are a few places where the Compact has already increased patient access to care. In many rural and underserved hospitals in these areas, physicians are often far from traditional physician centers; for example, physicians licensed in Wisconsin could be two to three hours from Madison or Milwaukee, making those rural positions hard to fill. However, the Compact has physicians reconsidering those spots. A physician living and licensed in the Minneapolis area is only 45 minutes to an hour from northern Wisconsin and the Upper Peninsula. By using the Compact to become licensed in Wisconsin, the physician can now easily extend their practice into these rural and often underserved areas. Hospitals who were having trouble finding physicians to stay open are now extending hours and offering additional services through telemedicine, Smith noted.

When the COVID-19 pandemic hit in February 2020, 31 member organizations had signed the Compact, including 29 states, Guam, and Washington, D.C. Lisa Albany, JD, director of state policy at the Academy noted, “When COVID first hit, immediately we wanted to make sure that our physicians could continue to practice safely and treat their patients. We were concerned about the implications of a disease progressing, and patients not having access to their medications.” The Academy provided a teledermatology toolkit to help physicians, including a list of teledermatology standards related to responsible telemedicine platform technology and telehealth reimbursement.

“It was very fortuitous that the Compact was in place when COVID hit because we provided a lot of elasticity to states so that they could quickly get physicians licensed and meet patient needs.”

Telemedicine was one way that dermatologists and other physicians could use the Compact to provide patient care. “It was very fortuitous that the Compact was in place when COVID hit because we provided a lot of elasticity to states so that they could quickly get physicians licensed and meet patient needs,” Smith noted about the timing of the medical license reform efforts. According to the American Medical Association (AMA), use of the IMLC grew by 47% during the pandemic: the IMLCC reported 8,126 licenses issued through the Compact from March 2020 to March 2021. Numbers also saw a sharp increase the following year with 7,749 applications processed and 13,069 licenses issued between March 2021 and February 2022.

Such a swift and significant increase in demand during the PHE was a test for the newly developed program. However, the system did not suffer from any significant delays or breakdowns. Smith felt that the test was “a true indication that the concept works — both effectively and safely.”

Filling a void

While the pandemic highlighted the efficiency of the IMLC, it also changed the way that physicians used the compact. Before 2020, a higher percentage of physicians used it for localized practice, with about 40% of physicians applying for licenses in a nearby state and an average 1.6 licenses issued per application. However, after the pandemic began, locum tenens and telemedicine needs increased, jumping to 66% of applications. The average number of licenses per application also increased to an average of four, with 42% of physician applications requesting three or more licenses. Smith noted the impact of locum tenens and telehealth solutions created by the compact. “These numbers mean that physicians are filling spots that traditionally have gone open and vacant.”

Filling these open spots has happened with quick efficiency. States who issued the most licenses during the pandemic are Wisconsin (330), Arizona (324), Illinois (303), Colorado (299), and Nevada (283). “It really was one of those situations where we had a safe, effective way to get physicians licensed in place who were able to react to the emergency that was happening,” Smith added. He recalled a physician who was needed in a state’s remote hospital, and the IMLCC worked with the medical board to get the physician licensed in the state within five to seven days. Normally processing time under the Compact is 45-50 days, which in many situations is still half of the time it takes to get licensed in a state using the traditional licensing process. “Most importantly, no shortcuts are taken,” Smith emphasized, “All of the qualifications, documentation, education, training, and history requirements are met, yet the speed can still happen.”

The convenience factor

The compact has not only increased access to health care in rural and remote areas, it has also helped save patients the time, money, and hassle involved with traveling to a specialized physician. Hospital centers such as Johns Hopkins, Mayo Clinic, MD Anderson, and the Cleveland Clinic traditionally required patients to travel back and forth from these centers multiple times for evaluation, treatment, and post-treatment care, but are now using the compact process to license the specialized physician in the patient’s state. “For example, now these patients can be evaluated in their local center, and an MD Anderson physician can consult with that local physician,” Smith remarked. While the patient may still travel for treatment, the patient does not need to travel again to receive their post-treatment care. “All the while the patient is receiving the same high level of care,” Smith highlighted.

Going forward

Smith and the IMLCC only see the number of participating members in the compact growing. “We are currently speaking with legislative staff or interested groups in six states, and we are hoping for five to six groups to introduce language next year.” He added that once a bill is introduced, on average it takes two legislative sessions for the compact to pass, and nine to 12 months to make the process operational. However, technology has helped increase the efficiency of this process greatly. Member boards can now log into test documents and test data, taking a four-to-eight-week training session down to two and a half weeks.

In many cases, the power of the compact may just be beginning to be realized. Once all 50 states and four territories are part of the compact, Smith anticipates that applications could begin to level off. While the IMLCC does not actively track or monitor practice, in February 2019 they did a one-time study of 1,340 applications and found dermatology to be less than 1% of physicians with licenses issued through the compact by a member board. “There is still a large group out there that we haven’t reached. As we find ways to do what we do better, there are really so many untapped opportunities out there,” Smith said.

One of those opportunities could help physicians not only get licenses in multiple states but also maintain them. According to Smith, one of the biggest issues the IMLCC hears from physicians is the difficulty in having multiple licenses with different renewal periods and continuing education requirements. In response, the IMLCC is working to create a single source for physicians to be able to log in to view all their licenses and track and control that information.

“It really was one of those situations where we had a safe, effective way to get physicians licensed in place who were able to react to the emergency that was happening.”

As physicians realize the full potential of the compact, member boards are likely to continue to benefit from it as well. Currently, 5-25% of license applications to a compact state are through the compact process, lessening the lengthy process of verifying information with a primary source for those applications for member boards. This allows those states to use staff resources more efficiently. They can focus on applications with exceptionalities and put more resources where they are needed.

Albany agrees with Smith that the Compact will continue to see numbers grow as physicians see benefits realized and concerns alleviated. “While telehealth may not be appropriate for all patients or situations,” she points out, “it does expand access during a time when we are seeing a shortage of dermatologists around the country.” In fact, the Association of American Medical Colleges projects a shortage between 3,800 and 13,400 physicians in medical specialties such as dermatology by 2034. The opportunities for locum tenens and telehealth medicine created by the compact may be one way to help meet patient needs. Albany also sees the compact being very beneficial to those dermatologists who are required to obtain medical licenses from multiple states, such as dermatopathologists who work for national laboratories that require multistate licensure. The compact could make this process more manageable, helping to fill these positions.

The IMLCC, FSMB, and Academy all agree that the IMLC has had and will continue to have a positive impact on patient care. The way to make patient care safe and more accessible moving forward may be less about Gernsback’s vision of screens and robotic arms, and more about a commitment and cooperation between states to best serve the patients in them.