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Practical solutions needed for licensure

November 20, 2015

A variety of groups have been dedicated to licensure reform for telehealth in the United States. Two new telehealth bills were recently introduced to Congress: TELE-MED Act (H.R. 3018 and S. 1778). These bills call for “one state license” for practitioners to be allowed to legally work throughout the United States to deliver Medicare and VA services.

The ultimate goal with such licensure would be to operate much like driver’s licenses, where licensure in one state would allow the driver to operate a vehicle in all 50 states. If our licensing boards evolve to such a point, it will be no sooner than five or 10 years. Meanwhile, we are stuck with the antiquated systems we have today.

In states where there is no specific mention of behavioral telehealth, the practice is not restricted. That is, licensed professionals are legally able to practice using telephones, email, text messaging or video, as they deem to be in the best interest of their clients/patients. Reimbursement is an entirely different matter, however. Many insurers will not pay for services delivered in one or more of these modalities.

Another issue is that some states do have laws related to telemental health, but use terms that are not standardized. For example, they may make reference to “telepractice,” “e-therapy,” “online counseling,” “distance counseling,” “behavioral telehealth,” “ web therapy,” etc.

Resources

Fueled by the Health Resources and Services Administration (HRSA) licensure portability grants, frontrunners on the professional association front include regulatory leaders at the Association of State and Provincial Psychology Boards (ASPPB), who have been active for almost a decade to develop a new policy for psychology boards to consider. Called the Psychology Interjurisdictional Compact (PsyPact), their proposed model is an updated and serious step in the right direction toward full portability, much like the American Nursing Association’s Nursing Licensure Compact, which has unfortunately been stalled for over a decade.

The Federation of State Medical Boards (FSMB) has also received a HRSA portability grant. Their Medical Licensing Compact model is different from ASPPB’s and involves reciprocity rather than full portability. That is, a licensee in a reciprocity state does not have their licensure apply in other states. Rather, their paperwork is shared by their regulatory board to that of other states for the purpose of getting licensed more easily and quickly in the counterpart state.

Other groups working toward portability include the American Counseling Association, which has been working on an initiative called 20/20: A Vision for Counseling, which includes a provision for licensure portability. The American Association of State and Counseling Boards (AASCB) and the National Board for Certified Counselors have also been working on licensure portability issues.

 More importantly, licensing law is not modality-specific. That is, licensing law is not dependent on whether or not a practitioner serves a client/patient in person or via a technology, (i.e., telephone, email, video, text messaging or any other communication channel). Licensing is relevant to the service being provided (counseling, medication management) and not the delivery mechanism. Until licensure reform is more prevalent, it may be useful for organizations to know that a number of states allow limited consultation by practitioners not fully licensed in that state.

For example, some states permit a practitioner in an adjoining state to provide such consultation in-person, but only so many times per year. Other states allow consultation by practitioners living within a number of miles from the state’s border, as when a city is in a tri-state area and residents cross town to see the professional, but that professional is literally in the state adjoining that of the patient/client. Practitioners utilizing these exceptions are not permitted full-fledged practice in the state, and could not, without becoming fully licensed, set up a physical office in the state and see patients there on a regular basis. They may pass a temporary license or obtain “registration,” which can allow them to work in the state for 30 visits, or perhaps 60, depending on the state.

State fines

It may also be of interest to know that some states levy fines for practicing in their state without license. For example, Vermont, Arkansas and Utah psychology licensing boards can levy a $5,000 fine per infraction and/or can impose a one- to five-year jail term.

A model that may serve as a limited, yet viable alternative for cross-border services is known as the “consultancy” model in traditional telehealth. Such a model evolved as the most practical solution to licensure barriers, in that a licensed clinician in one state can legitimately call another licensed clinician in another state (or country) to help with any particular patient in real time. In such a scenario, the patient is in the location of the referring clinician, who is licensed locally. The consulting professional can be anywhere on the planet, and yet, interview the patient to render an opinion about how the local practitioner can best proceed. Such a consultancy model has a long history of success in telehealth across disciplines.

As it stands today, most laws and regulations define the site of care delivery where the client/patient is located as the “originating site.” Professionals need to be familiar with the individual state requirements of the originating site. This issue is important in states such as Florida, where law requires that practitioners be licensed in that state, even when visiting from out of state for a month or two in the winter. 

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