Regulation and Legislation
In 2019 Congress asked for information to develop comprehensive telehealth legislation.26 Congress asked for public input regarding telemedicine expansion in rural areas, improving outcomes, increasing access to telemedicine, and reducing healthcare costs with telemedicine. More recently, The Center for Connected Health Policy released a newly updated telehealth billing guide to help providers correctly bill for telemedicine and virtually delivered services. This guide addresses the more recent changes in fee-for-service Medicare billing and uses the Center for Medicare and Medicaid Services rules as a resource.27
Another more recent change to the telemedicine landscape is the Emergency Broadband Benefit Program.28 On February 25, 2021, the Federal Communications Commission adopted this federally funded program that aims not only to increase internet access but also affordability in underserved communities. The program should open in late April 2021.
In a policy report for the Cato Institute, Shirley V. Svorny stated that requiring a medical license in each state to practice telemedicine is a significant barrier to care.29 She contends that Congress could eliminate this problem by changing the encounter location to where the provider is located instead of where the patient is located. The provider would then only have to meet 1 state’s licensing laws. Another solution was for individual states to open their market to providers in other states, states to join in reciprocal agreements, or for the federal government to start a new agency to issue national telemedicine licenses. She warned that physician groups would not support these proposals and could present a significant barrier to telemedicine.
Svorny contends that the Interstate Medical Licensure Compact (IMLC) for physicians will not solve the current problem. Although the compact would streamline obtaining multiple state licenses, it does not establish a single license. Currently, 28 states participate in the IMLC.30 The Federation of State Medical Board (FSMB) processed 11,000 medical licenses through the IMLC as of August 2020.31 The IMLC established that 1 license was valid in all states within the compact.32
Currently, 34 states recognize a nursing compact, and 6 states and United States territories are pending recognition. The Nurse Practitioners Organization is trying to establish a compact. Implementation of the compact can begin when 7 states enact compact legislation. Thus far, only North Dakota and Delaware have enacted a compact for NPs.
In 2017, the American Academy of PAs (AAPA) announced the Uniform Application for PA Licensure launch.33 Currently, 6 PA boards are participating in the Federation of State Medical Board (FSMB) Uniform Application program: Maine Board of Licensure in Medicine, Maine Board of Osteopathic Licensure, Montana Board of Medical Examiners, Oklahoma Board of Medical Licensure and Supervision, Washington Medical Commission, and Washington Board of Osteopathic Medicine and Surgery.34
In July of 2019, Congress awarded a grant to the FSMB to investigate an intrastate compact to increase PA license portability.35 The investigation was in the initial stages when the COVID-19 pandemic hit the United States. However, the FSMB continues to work with the AAPA to support this policy’s development.
Washington State, North Dakota, and Kansas passed legislation regarding PAs and telemedicine.36-38 Washington State adopted new guidelines for telemedicine, including changing the definition of “practitioner” to include PAs. In North Dakota, the medical board approved a new rule that stated there was no requirement for the physician and PA to colocate. In Kansas, H.B. 2028 required public and private insurers to reimburse telemedicine services if those services are reimbursable with traditional face-to-face office visits. The Kansas Academy of Physician Assistants was successful in adding PAs to the language as covered providers. AAPA supports changing telemedicine laws to name PAs as telemedicine providers.37
Utilization, Burnout, and Adaption
In an article regarding the use of telemedicine in rural locations, Stephen H. Hanson, PA-C,39 described telemedicine’s benefits in reaching underserved areas and the PA’s role in this healthcare delivery model. Discussion included the need for HIPPA compliant smartphone features and applications to aid in treating patients. Hanson believes that incorporating telemedicine in underserved rural regions would bring specialists to patients and facilitate better population outcomes.
According to a 2019 survey, only 1 in 5 physicians used telemedicine.40 Surveyed physicians said that telemedicine improves patient access to care, efficient use of time, and helps reduce healthcare costs. However, respondents also expressed uncertainty about reimbursement, CMS restrictions, and leadership support deterring telemedicine use. The survey showed a correlation between the interest in telemedicine use and high rates of physician burnout.
In a 2019 article, Powell et al41 discussed the importance of balancing work and family (or private life) to avoid burnout. Suggested strategies included “allocating resources, changing resources and barriers, sequencing goals, and revising goals.” The research showed that self-care is imperative with the increased stress and workload related to the COVID-19 pandemic. Incorporating telemedicine into medical practices allows a beneficial change in the interaction between provider and patient to alleviate provider stress and monotony.
PA Program Adaption to Pandemic
Students in PA programs faced disruption of their education as the pandemic continued. They were concerned about how they would learn how to conduct a physical examination if not allowed to touch patients or even attend class. The PA program at Rutgers University incorporated e-learning and virtual peer reviews to continue teaching the physical examination classes and other courses.42 The students received feedback from other students or faculty members as they practiced physical examination techniques on friends or family members. This method has been successful and is now part of the curriculum. Many PA schools are using similar methods to ensure that PA students continued to thrive in challenging times.
Although telemedicine benefits are evident, barriers to full implementation and continuation of telemedicine still exist. The technology, internet infrastructure, permanent parity in insurance coverage, and provider/patient acceptance are just a few of the barriers.
Legislation enacted during the pandemic must be made permanent. Doing so assures that patients will continue to benefit from the telemedicine services they have come to trust.
PAs can help ease the access to care crisis through telemedicine. For PAs to continue to answer this need, developing a portable PA license is a priority. When states modernize their laws and regulations surrounding PA’s license portability, they will reap the benefit of increased access to skilled healthcare providers.
Melinda Moore Gottschalk, MPAS, PA-C, DMSc, DFAAPA, is adjunct faculty at the University of Mary Hardin Baylor PA Program in Belton, Texas.
Ms Gottschalk has disclosed that she is a medical science liaison for Upsher-Smith Laboratories, LLC.
1. American Academy of PAs. CMS expands medicare telemedicine coverage. March 18, 2020. Accessed March 10, 2021. https://www.aapa.org/news-central/2020/03/cms-expands-medicare-telemedicine-coverage/.
3. Centers for Medicare and Medicaid Services. Glossary. Accessed March 10, 2021. https://www.cms.gov/glossary
4. Center for Connected Health Policy. What is telehealth. Accessed March 10, 2021. https://www.cchpca.org/about/about-telehealth
5. Waller M, Stotler C. Telemedicine: A primer. Curr Allergy Asthma Rep. 2018;18: doi.org/10.1007/s11882-018-0808-4
6. American Academy of Family Physicians. Virtual e-visits. 2018. Accessed March 10, 2021. https://www.aafp.org/about/policies/all/virtual-evisits.html
7. Izard SG, Juanes JA, García Peñalvo FJ, Estella JMG, Ledesma MJS, Ruisoto P. Virtual reality as an educational and training tool for medicine. J Med Syst. 2018;42(3):50. doi:10.1007/s10916-018-0900-2
8. Bifulco P, Narducci F, Vertucci R, Ambruosi P, Cesarelli M, Romano M. Telemedicine supported by augmented reality: an interactive guide for untrained people in performing an ECG test. Biomed Eng Online. 2014;13:153. doi:10.1186/1475-925X-13-153
9. Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017;7(8):e016242. doi:10.1136/bmjopen-2017-016242
10. Pinar U, Anract J, Perrot O, et al. Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic. World J Urol. 2020 Sep 9:1-6. doi:10.1007/s00345-020-03432-4
11. Brown Cooper S. Opinion leaders’ perspective of the benefits and barriers in telemedicine: A grounded theory study of telehealth in the Midwest. Q Rev Distance Educ. 2015;16(1):25-53.
12. LʼEsperance ST, Perry DJ. Assessing advantages and barriers to telemedicine adoption in the practice setting: a MyCareTeam exemplar. J Am Assoc Nurse Pract. 2016;28(6):311-319. doi:10.1002/2327-6924.12280
13. Pew Research Center. Technology use among seniors. May 17, 2017. Accessed September 2, 2019. https://www.pewinternet.org/2017/05/17/technology-use-among-seniors/
14. Pew Research Center. Mobile Fact Sheet.June 12, 2019. Accessed March 10, 2021. https://www.pewresearch.org/internet/fact-sheet/mobile/
15. Vogels EA. Millennials stand out for their technology use, but older generations also embrace digital life. Pew Research Center; September 9, 2019. Accessed March 10, 2021. https://www.pewresearch.org/fact-tank/2019/09/09/us-generations-technology-use/
16. American Medical Association. COVID-19 CPT coding and guidance. Accessed March 18, 2021. https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-coding-and-guidance
17. Wicklund E. Doximity charts the top 15 medical specialties embracing telemedicine. July 18, 2019. Accessed March 10, 2021. https://mhealthintelligence.com/news/doximity-charts-the-top-15-medical-specialties-embracing-telemedicine
18. Center for Connected Health Policy. Telehealth private payer laws: impact and issues. August 2017. Accessed March 10, 2021. https://www.cchpca.org/sites/default/files/2018-09/CCHP_%20Milbank-Telehealth-Report-FINAL_0.pdf
19. Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. March 17, 2020. Accessed March 10, 2021. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
20. Telemedicine. Medicaid.gov. Accessed March 10, 2021. https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html
21. Centers for Medicare & Medicaid Services. CMS Criteria for Submitted Requests. Telemedicine criteria. Updated March 5, 2012. Accessed March 10, 2021. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Criteria
22. Centers for Medicare & Medicaid Services. Telehealth services. Medicare Learning Network. March 2020. Accessed March 10. 2021. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf
23. US Department of Justice, Drug Enforcement Administration. COVID-19 Information Page. Accessed March 10, 2021. https://www.deadiversion.usdoj.gov/coronavirus.html#TELE
24. Tricare. Telemedicine: Covered services. Updated 8/24/20. Accessed March 10, 2021. https://tricare.mil/CoveredServices/IsItCovered/Telemedicine
25. Health Net Federal Services. Telemedicine services. 2020. Accessed March 10, 2021. https://www.tricare-west.com/content/hnfs/home/tw/prov/benefits/benefits_a_to_z/telemedicine_services/telemedicine_details.html
26. Sullivan T. Congress issues RFI on comprehensive telehealth legislation. Policy & Medicine. Updated March 25, 2019. Accessed March 10, 2021. https://www.policymed.com/2019/03/congress-issues-rfi-on-comprehensive-telehealth-legislation.html
27. Center for Connected Health Policy. Billing for telehealth encounters. CCHP. March 2021. Accessed March 16, 2021. https://www.cchpca.org/sites/default/files/2021-03/2021BillingGuideFINAL.pdf
28. Federal Communications Commission. FCC adopts report and order for emergency broadband benefit program.February 26, 2021. Accessed March 16, 2021. https://www.fcc.gov/document/fcc-adopts-report-and-order-emergency-broadband-benefit-program-0
29. Svorny SV. Liberating telemedicine: options to eliminate the state-licensing roadblock. Policy Analysis. 2017;826:1-12.
30. CompHealth. Interstate Medical Licensure Compact States List [and Guide for 2021]. Interstate Medical Licensure Compact States List [and Guide for 2021]
31. Federation of State Medical Boards. 11,000th medical license issued through the interstate medical licensure compact process. Accessed August 13, 2020. https://www.fsmb.org/advocacy/news-releases/11000th-medical-license-issued-through-interstate-medical-licensure-compact-process/
32. APRN Compact. https://www.aprncompact.com/index.htm
33. AAPA. Oklahoma Medical Board Launches Streamlined Licensure Process for PAs. August 29, 2017. Accessed March 10, 2021. https://www.aapa.org/news-central/2017/08/oklahoma-medical-board-launches-streamlined-licensure-process-physician-assistants/
34. Federation of State Medical Boards. UA Participating Boards. 2019. Accessed March 10, 2021. https://www.fsmb.org/uniform-application/ua-participating-boards/
35. Federation of State Medical Boards. Federal grant awarded to expand interstate medical licensure compact; support license portability for PAs. August 27, 2019. Accessed March 10, 2021. https://www.fsmb.org/advocacy/news-releases/federal-grant-awarded-to-expand-interstate-medical-licensure-compact/
36. AAPA. PAs included in new telemedicine guidelines in Washington state. October 23, 2014. Accessed March 10, 2021. https://www.aapa.org/news-central/2014/10/pas-included-in-new-telemedicine-guidelines-in-washington-state/
37. AAPA. Kansas enacts PA-positive telemedicine law. Accessed March 10, 2021. https://www.aapa.org/news-central/2018/05/kansas-enacts-pa-positive-telemedicine-law/
38. AAPA. North Dakota telemedicine rules recognize critical PA role. August 27, 2018. https://www.aapa.org/news-central/2018/08/north-dakota-telemedicine-rule-recognizes-critical-pa-role/
39. Hanson SH. Technology can extend the physician assistant’s role in care. Physicians practice. Physicians Practice. January 4, 2013. Accessed March 10, 2021. https://www.physicianspractice.com/view/technology-can-extend-physician-assistants-role-patient-care
40. Landi H. 1 in 5 physicians use telehealth. Burnout may drive more adoption, survey says. Fierce Healthcare. April 15, 2019. Accessed March 11, 2021. https://www.fiercehealthcare.com/tech/22-physicians-use-telehealth-and-burnout-may-drive-more-adoption-survey
41. Powell GN, Greenhaus JH, Allen TD, Johnson RE. Advancing and expanding work-life theory from multiple perspectives. Acad Manage Rev. 2019;44(1):54-71. doi:10.5465/amr.2018.0310.
42. McCarron B. In adapting to the pandemic, the physician assistant program found better ways to learn. Rutgers Today. November 29, 2020.