Almost overnight, the COVID-19 pandemic transformed telemedicine from a cumbersome service offered by a small number of physicians to an indispensable part of medical care. But as hematology practices and hospitals shift back to normal operations, many of the regulatory flexibilities that made telemedicine practical are in flux, creating confusion and uncertainty.
“Telehealth is here and it’s here to stay,” said Colleen Morton, MBBCh, associate professor of medicine and section leader for classical hematology at Vanderbilt-Ingram Cancer Center in Tennessee. “It’s convenient and it’s important for health care equity. But what we need to do is change the rules that do not allow us to do cross-state telehealth, especially for established patients.”
ASH Clinical News spoke with Dr. Morton and other experts about the current state of telehealth and inter-state care and how telemedicine affects quality of care and equitable access to medicine. As hematology care evolves and new guidelines are put in place, a hybrid model of in-person medicine and telehealth is emerging.
Pandemic Era Flexibilities
The three main regulatory flexibilities that made telemedicine feasible in 2020 were implemented as part of the COVID-19 Public Health Emergency. As a result, the U.S. government allowed Medicare to pay physicians in-person rates for visits conducted via telemedicine, provided coverage for audio-only telemedicine visits, and waived geographic and site-of-service requirements so patients could obtain care from home.
In the Medicare Physician Fee Schedule for 2023, which was finalized in November 2022, the Centers for Medicare & Medicaid Services (CMS) extended payment parity for evaluation and management visits conducted via telemedicine through the end of 2023.1 Coverage of audio-only visits and waiving of geographic and site-of-service requirements were extended through the end of 2024 as part of an omnibus budget package enacted in December 2022 (H.R. 2617).2
So far, private insurers have followed Medicare’s lead in terms of coverage and payment parity, though the individual policies and end dates vary, according to Leslie Brady, senior policy advisor with the Artemis Policy Group in Washington, D.C., who has been tracking how these telemedicine policies affect hematologists.
“There’s a lot of confusion among patients, providers, and even in the policy world about what is ending when and what it is tied to, whether it’s the Public Health Emergency or an end date set by Congress or CMS,” Ms. Brady said.
While the American Society of Hematology (ASH) and other professional medical societies have praised the extension of telemedicine regulatory flexibilities, they are also asking Congress to make these changes permanent and put a stop to the uncertainty surrounding last-minute extensions.3 However, concerns around the cost of making these changes permanent – estimated at $25 billion over 10 years – and the potential for fraud and abuse have hampered legislative efforts so far, Ms. Brady said.4
Another obstacle to making telemedicine available to more patients is physicians’ ability to practice across state lines. Because medical licensure is regulated state by state, U.S. physicians must be licensed in the state where their patient receives care or practice in a state that has reciprocity. At the beginning of the COVID-19 pandemic, most state governors issued emergency orders to drop these requirements, but many of those orders have expired or are being phased out, leaving physicians to figure out how to navigate the changing rules.
Traveling for Telemedicine
Jean M. Connors, MD, a hematologist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute and a professor of medicine at Harvard Medical School in Boston, has seen firsthand how rules about the inter-state practice of medicine have affected her patients who live in neighboring states. In the early days of the pandemic, when there was widespread confusion about the rules surrounding the use of telemedicine for patients in other states, one of her patients in Rhode Island drove across the state line and conducted her telehealth visit from her minivan in a retail parking lot.
Though neighboring states offered flexibility around telemedicine for at least a year into the COVID pandemic, Dr. Connors is once again required to be licensed wherever her patients receive care, even if that is at their home. For Dr. Connors, who currently only holds a medical license in Massachusetts, that means patients must drive across the state border for telemedicine visits. Recently, a 97-year-old patient from New Hampshire drove two hours to conduct his telemedicine visit from his daughter’s house. Driving all the way to the hospital in Boston was physically difficult for him and he was concerned about the risk of getting COVID, respiratory syncytial virus, or influenza, she said.
“We really need to examine what this means,” Dr. Connors said. “How you define who your patient is and where you are practicing are going to be the biggest issues. When I follow up with a patient through telehealth from my office in Boston, I don’t view it as practicing across state lines. I am seeing a patient referred to me in Boston because the hematology expertise to treat this patient is lacking at the local level. Patients are coming to me whether they are physically in my office or virtually in my office by video or telephone. That’s a very different view from legislators.”
Dr. Morton, who is vice chair of the ASH Committee on Practice, has had similar experiences with her patients, some of whom have conducted telemedicine visits with her from parking lots just over the state line.
“Doing telehealth in your car just because you have to cross the state line is not optimal,” she said, noting that patients are discussing personal health information in a public place with an unstable internet connection and plenty of distractions.
Dr. Morton does not hold licenses in neighboring states, though some of her colleagues do. As an alternative to having patients from other states sit in parking lots, she sometimes has patients conduct their telemedicine visits from other Vanderbilt clinic sites that are close to the state border.
“That is the biggest problem that we need fixed. We need to allow telehealth across state lines because currently, unless I have a license in a particular state, I cannot do the telehealth visit,” she said. “At a minimum, it would be nice to be able to see our follow-up patients, regardless of what state they are in, for health care continuity.”
Dr. Connors is applying for other state licenses but said filling out the paperwork and tracking the various requirements is an onerous process.
Interstate Compact and Reciprocity
A minority of U.S. physicians have medical licenses in more than one state. In 2020, just over 15% of licensed physicians held two active medical licenses and about 7% held three or more licenses, according to the Federation of State Medical Boards (FSMB).5 One mechanism that could help physicians expedite their path to obtaining multi-state licensure is the Interstate Medical Licensure Compact, which launched in 2017.
The Compact has agreements with 37 states, the territory of Guam, and the District of Columbia to quickly verify physician qualifications and issue licenses. To use the Compact, a physician must hold a full, unrestricted medical license in a member state that can serve as the state of principal license (SPL). Most, but not all, of the Compact’s member states issue SPLs. Since the SPL already holds primary source information on the elements required for licensure, it can issue a letter of qualification to be used in obtaining other state licenses.
Through the Compact, physicians fill out a single online application (imlcc.org) and apply to multiple states for licensure. The fee to apply through the Compact is $700, in addition to application fees charged by each state. The process of establishing the SPL and going through pre-qualification, which involves verifying a fingerprint-based Federal Bureau of Investigation background check, takes approximately 30 to 45 days. After that, requested licenses are typically issued in seven to 10 days, according to Marschall S. Smith, executive director of the Interstate Medical Licensure Compact Commission (IMLCC). He likened the process to the Transportation Security Administration’s PreCheck for speeding up trips through airport security.
The Compact, which was launched before the COVID-19 pandemic, experienced a spike in applications post-pandemic and an increase in physicians seeking multiple licenses as telemedicine expanded. Almost 65% of physicians who go through the Compact process now do so to facilitate the use of telemedicine, Mr. Smith said.
Going forward, Mr. Smith said the IMLCC is seeking to expand the number of states in the Compact. Five additional states have passed legislation to join the Compact and should be operational by mid-2023. He said the IMLCC will continue trying to enlist the remaining 13 states, too.
Physicians who live or practice in a state that is not part of the Compact or does not issue SPLs, such as Massachusetts and New York, must apply to each state medical board and request their primary source documents through the FSMB, a process that costs $395 for an initial request and $99 for subsequent applications, plus the state fees, Mr. Smith explained.
Another option is to pursue reciprocal licensure. During the pandemic, some states allowed physicians with active, unrestricted licenses from other states to practice during the COVID-19 emergency. However, reciprocity is different from an unrestricted license, Mr. Smith said, raising concerns about scope of practice, insurance billing, and malpractice insurance. The key factor to keep in mind about reciprocity, he said, is that it looks different in each state.
State legislatures have a variety of options for offering flexibility in inter-state medical care and the pathways are not mutually exclusive, said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association (ATA) and executive director of ATA Action.
“There is a lot of movement in this area,” he said.
Aside from the Compact, at least two states – Florida and Arizona – have licensure registration laws that allow physicians to register and pay a fee to practice medicine, provided they have a license in good standing in another state. There is also momentum around “common sense exceptions” to the strict enforcement of medical licensure, Mr. Zebley said, such as those for second-opinion consultations, follow-up care, care for students, and care received while traveling.
“These are the kinds of areas where some flexibility should be given to providers,” he added.
Quality of Care
The rapid expansion of telehealth offerings in hematology has led researchers to investigate whether cutting back on in-person visits affects the quality of care.
A systematic review of telemedicine in malignant and classical hematology, published in 2021, examined 32 articles that evaluated mainly video-based, telephone-based, and web-based interventions. The researchers concluded the use of telemedicine offered “similar or improved” care when compared with face-to-face encounters in both pediatric and adult populations. They found telemedicine was particularly useful for patients in rural areas, patients with less access to care, and patients with chronic conditions that needed routine monitoring and communication.6
Sherif Badawy, MD, MBBCh, of Northwestern University Feinberg School of Medicine and Lurie Children’s Hospital of Chicago and one of the authors of the systematic review, said the study confirms the overall benefits of telemedicine and provides lessons on how to tailor the approach to the appropriate patient.
“In hematology, the physical exam is key for some patients, but not for all. If you are just monitoring the labs and want to understand the symptom burden, [that] can be achieved through the telemedicine visit. For others, it may not be appropriate. It should be considered on a case-by-case basis,” Dr. Badawy said.
Another retrospective cohort study examined the effect of electronic consults between primary care physicians and hematologists at the Veterans Affairs (VA) system in Connecticut from 2006 to 2018, looking at both referrals to a subspecialist and patient outcomes. The researchers considered an e-consult to be successful if the primary care physician’s questions were resolved without a face-to-face visit with the hematologist. Overall, 83% of e-consults were resolved without a face-to-face visit with the subspecialist, and the e-consult did not adversely affect survival in cases where a new hematologic malignancy was diagnosed.7
Consults for pancytopenia, gammopathy, and leukocytosis, and for patients with an already-diagnosed malignancy were less likely to be resolved by e-consult, explained Talib Dosani, MD, of Yale School of Medicine and the VA in Connecticut and one of the study authors. Patients with these conditions may have needed a more extensive workup, including a biopsy. Additionally, consults for mild lab abnormalities were typically successful through e-consult, but severe abnormalities usually required a referral.
For patients eventually diagnosed with a hematologic malignancy, having an e-consult before a face-to-face consult did not affect survival, even if the time to diagnosis may have been delayed.
“Since a lot of the e-consults tended to be for milder abnormalities, if you were picking up a malignancy, it was likely to be at an earlier stage,” Dr. Dosani said.
Access and Equity
As telemedicine continues to be used, hematologists are refining how they use the technology to offer patients the best care and the most convenience.
Dr. Connors said she finds it easier to see patients via telehealth if they’ve already established a relationship than for an initial visit. A patient who has already had an in-person physical exam and lab work and has started a treatment plan can more easily be managed remotely, she said, and having the in-person visit first helps assuage concerns about potentially missing something.
In contrast, Steven Fein, MD, a hematologist in Florida, has started a practice that only provides telemedicine care. He founded the national practice, Heme Onc Call, as way to provide hematology consults to rural hospitals but has shifted his focus to outpatient hematology consults, primarily for women with iron deficiency and blood disorders.
“My specialty is reviewing and interpreting people’s blood tests,” Dr. Fein said. “I talk to them and teach them, but I don’t actually have to hold their hand or feel their pulse to know what their blood problems are.”
One of the promises of telemedicine is to expand access for patients who live far away from specialized hematologic care or who cannot take time off from work for appointments. Continued coverage for audio-only appointments at a reimbursement rate equivalent to in-person visits will be critical to ensuring that some patients do not get left behind on telehealth, Dr. Connors said.
“There are a lot of patients who don’t have the technology to do video visits and rely on the telephone, or they don’t have a good smartphone. They tend to be older patients and those with a lower socioeconomic status,” she said.
There are many reasons why audio-only visits are an important telemedicine tool, Dr. Morton explained. The technology may fail, or patients may have limited internet access. In some cases, patients may not feel comfortable doing a video visit. Dr. Morton said a phone call is a more useful and personal alternative to sending patients messages through an online portal.
Whether hematologists and their patients prefer in-person or virtual visits may become moot since the state of medical practice is moving toward a more hybrid approach. If licensing complications can be solved and pandemic-era flexibilities maintained and even expanded, hematologists will be able to care for patients across the U.S., offering the potential for improved access to specialized care.
Mary Ellen Schneider is a medical journalist based in Setauket, New York.
- CY 2023 Medicare Physician Fee Schedule Final Rule. Summary of Major Provisions. November 1, 2022. Accessed December 29, 2022. https://www.hematology.org/-/media/hematology/files/advocacy/testimony-and-correspondence/2022/ash-summary-of-final-rule-cy23.pdf.
- Consolidated Appropriations Act, 2023. H.R. 2617. December 19, 2022. Accessed December 29, 2022. https://www.appropriations.senate.gov/imo/media/doc/JRQ121922.pdf.
- Joint letter to congressional leadership on telehealth flexibilities. American Society of Hematology. March 8, 2022. Accessed December 29, 2022. https://www.org/-/media/hematology/files/advocacy/testimony-and-correspondence/2021/joint-letter-to-congressional-leadership_telehealth_flexabilities.pdf.
- CBO Estimate for H.R. 2471, the Consolidated Appropriations Act, 2022, as Cleared by the Congress on March 10, 2022. Accessed on December 29, 2022. https://www.cbo.gov/system/files/2022-03/HR2471_As_Cleared_by_the_Congress.pdf.
- Young A, Chaudhry HJ, Pei X, Arnhart K, Dugan M, Simons KB. FSMB census of licensed physicians in the United States, 2020. Journal of Medical Regulation. 2021;107(2):57-64.
- Shah AC, O’Dwyer LC, Badawy SM. Telemedicine in malignant and nonmalignant hematology: systematic review of pediatric and adult studies. JMIR Mhealth Uhealth. 2021;9(7):e29619.
- Dosani T, Xiang J, Wang K, et al. Impact of hematology electronic consultations on utilization of referrals and patient outcomes in an integrated health care system. JCO Oncol Pract. 2022;18(4):e564-e573.
Virtual Care: The View From Europe
Countries in Europe relied heavily on telemedicine during the COVID-19 pandemic to provide necessary medical care during the shutdown periods. But telemedicine has not transitioned to become a critical part of hematology care, according to Ari Giagounidis, MD, a hematologist at Marien Hospital in Düsseldorf, Germany.
The lack of enthusiasm for video visits, for instance, may come down to the dense population of most European countries and nearly universal access to subspecialist care, Dr. Giagounidis explained.
“Patients tend to see their doctor in person because the doctor is not far away,” he said. “I don’t get regular questions about Zoom meetings from my patients.”
The inter-state practice environment is far different in Europe. For example, Dr. Giagounidis can use his medical license to practice anywhere in Germany. Even within the European Union, he can obtain a letter of equivalence fairly easily after submitting his credentials to other countries, typically within three months. Even without regulatory barriers, there is not a push from patients or doctors for greater use of remote visits.
One factor limiting physician demand for telemedicine in Europe is the heavy workload of most hematologists. Since the health care system throughout Europe essentially allows anyone to access subspecialty care for free, it increases the number of patients for each hematologist. Dr. Giagounidis said he and his colleagues would be hard pressed to find time for routine video consults, though he does brief phone follow-ups with patients as needed.
Where technology is changing hematology is in scientific collaboration and research meetings. Instead of traveling across the country or the continent, virtual meetings have become commonplace.
“It’s more of an inter-scientific approach than a doctor-patient approach that has developed,” he said.