Caring for out-of-state patients when telemedicine is restricted

By Jules Murtha | Fact-checked by Barbara Bekiesz
Published November 22, 2022

Key Takeaways

  • During the height of the COVID-19 pandemic, policymakers temporarily changed state laws to allow physicians without a license in a particular state to treat its residents via telemedicine.

  • Between January and June of 2021, among Medicare beneficiaries, 57.2% of out-of-state telemedicine visits were made by patients who lived in counties within 15 miles of a state border. Patients in rural communities were the most likely to receive telemedicine care out-of-state.

  • Experts say that the current trend toward reinstituting state-licensing restrictions borders on “cruel,” and undermines the continuity across state lines that is imperative to providing high-quality care—especially for critically or terminally ill patients who might not otherwise have access.

An article published in The New England Journal of Medicine (NEJM) recounted the story of J., an 8-year-old who fought cancer throughout his short life, receiving care from a team in Massachusetts, although he and his family did not live there.[]

Nevertheless, the team worked closely with J. and his family, in person as well as over the phone. The type of remote relationship they relied upon became much more common not long after, as the COVID-19 pandemic precipitated a “telemedicine revolution.”

The game-changing role of telemedicine

Like J., many patients have depended on remote care since the outbreak of COVID-19.

To some clinicians, the widespread use of telemedicine was one of the few positive outcomes of the pandemic.

According to the NEJM article, telemedicine allowed doctors to see patients’ faces during a time when everyone was masked, and healthcare professionals (HCPs) were all but swallowed by layers of PPE.

Telemedicine allowed much more emotional information to be obtained than even from an in-person visit for that reason, as clinicians could see facial expressions. It gave doctors the opportunity to peer into their patients’ lives and catch glimpses of their homes, pets, and other aspects of who they were apart from their illness—all without the risk of transmitting COVID-19.

Patients were able to seek medical care from their homes. Not only did this diminish health disparities by broadening access to care, but it also alleviated anxiety, making it easier for patients to ask questions and digest medical information, according to NEJM.

Telemedicine also enabled patients and hospitals to cut care and travel costs while reducing carbon emissions.

Legislators regulate telemedicine

Despite these benefits, state legislators are starting to roll back out-of-state telemedicine privileges, which could disrupt the provider-patient relationship.

The authors of the NEJM article, Shannon M. MacDonald, MD, and Julia Berv, PA-C—both key players on J.’s care team—spoke to the ill effects of these rollbacks.

"We now feel even more restricted than we did before the pandemic about communicating with such patients, as hospitals inform doctors and staff through new policies, lectures, and emails that doing so puts our licenses at risk."

McDonald SM, et al., NEJM

As more states rescind access to out-of-state care, the repercussions may affect patients who had the most to gain from telemedicine and have the most to lose from losing their care team in the fallout.

Who uses telemedicine the most?

Although patients across the US reaped the benefits of telemedicine, there are some populations who relied on it more than others.

A 2022 article published by JAMA Health Forum looked at out-of-state telemedicine visits from the first half of 2021.[]

Of more than 8 million Medicare beneficiaries who had a televisit during that time, 5% sought care at least once from an out-of-state healthcare professional (HCP) via telemedicine. Nearly 10% of patients who used telemedicine during this time did so for cancer care. Primary or mental health care made up 64.3% of televisits.

In terms of geographical patterns, patients who lived in counties situated within 15 miles of the state border composed 57.2% of all out-of-state telemedicine visits.

Additionally, patients living in rural communities were more likely to receive out-of-state telemedicine care than those who lived elsewhere (33.8% versus 21.0%).

These data point to the probability that patients in need of cancer care, mental health services, and primary care, as well as those who live near a state border or in a rural area, are most likely to be hit hard by state-licensing restrictions—and HCPs aren’t happy about it.

Related: COVID-19 stoked the adoption of electronic prescribing, yet issues remain

The consequences of legislative changes

As policymakers reinstate state-licensing restrictions, what are HCPs saying about it?

Nate Gladwell, RN, MHA, senior director of clinical operations for the Office of Network Development and Telehealth at University of Utah Health, didn't dance around what’s at stake.

“By making telehealth difficult to access, we’re making it harder for many patients to get adequate care for many diseases, and that’s just a travesty,” he said in an article published by AAMC.[]

Dr. MacDonald and Berv shared similar sentiments.

"We know that rolling back specialists’ telemedicine privileges will increase the financial burden on families and the health care system alike."

MacDonald SM, et al., NEJM

“It will also mean missing a rare opportunity to immediately expand access to care for life-threatening rare conditions for patients like J. throughout the United States,” they concluded.

What this means for you

COVID-19 changed many aspects of medical practice, including the use of out-of-state telemedicine. Through telemedicine, clinicians gained greater insights into patients’ lives, and patients could engage with the visit with less anxiety. Now that policymakers are reinforcing (or debating to reinforce) state licensing rules, HCPs are concerned about how a loss of broader access to telemedicine could disrupt continuity of care and have a negative impact on the doctor-patient relationship.

Read Next: Launching a telepsychiatry practice: 4 critical considerations

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