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In part one and part two, I laid out my thoughts on barriers to entry centered around how we pay for telemedicine, some policy issues that exist, and potential solutions. In part three, I want to continue to discuss solutions in relation to state lines.

Make it easier for doctors to practice across state lines

States regulate which providers may care for patients within their borders. It is a task that they have done well to protect patients and families and hold providers to a high standard. One consequence of this vigilance is that providers must have a medical license in the same state in which the patient is currently located at the time of the visit to provide care. This issue puts a damper on treating a patient across state lines, and the time and paperwork to comply is a barrier to adoption and expansion.

There has been some progress, however. An Interstate Medical Licensure Compact was enacted in 2015 by 17 states, to expedite licensing for physicians who want to practice telemedicine in multiple states. It received funding from the U.S. Health and Human Resources Administration and is also supported by the American Medical Association.  

But state roadblocks still occur. I firmly believe it is the individual states duty to review and decide which providers practice within their borders. However, standardization of the process would go a long way to adoption and expansion. Every state has different forms, requirements, questions, and verifications.

For example, I have personally been fingerprinted more than 20 times between local, state, and federal requirements. My fingerprints don’t change. Standardization of the information required and where the information is stored would be a huge win.

A national clearinghouse for the data might be an interesting step. This would allow providers to answer the questions once and provide all the needed documentation to one location. States and health systems could pull data from this clearinghouse to support the application to practice medicine in the state or the facility. I’m sure it would pose its own challenges, but I doubt it would provide as many barriers as the current process. 


Reimburse for the same services regardless of state lines

If providers can practice across state lines, they face another interesting hurdle. The regulations governing what services can be billed and which cannot via telemedicine vary from state to state.

Virginia law1, for example, requires reimbursement for live video consultations. But it does not reimburse for email, phone, fax communications, or "store and forward" services—the transmission of patient data, such as a photo of a rash, from one provider to another.

California law1, on the other hand, requires payers to reimburse for store and forward. This mix of laws is simply another deterrent to incentivizing telemedicine across the board.

Use telemedicine to fill network gaps

When consumers want to find a provider or specialist, they usually look for one in their health care plan's network and one who is conveniently located. States rely on health plans' claims that their networks are adequate to serve their customers. In some regions, however, there may not be a doctor or specialist close by to serve the needs of the patient.

Telemedicine could be used to fill network gaps, and Colorado, for example, recognizes this. It factors in consumer access to telemedicine when determining that payers meet the state's networking adequacy standards. More states could follow this example.

Reimburse for doctor-to-doctor consultation

Reimbursement for telehealth services focuses almost solely on a doctor-to-patient scenario. Unfortunately, provider-to-provider consultations are generally not covered by insurance. These include doctors from larger healthcare organizations who advise smaller hospitals and charge a monthly fee. If these consultations were properly incentivized, we may see more providers and healthcare organizations offering this service. This service can be valuable because it can bring specific medical expertise to the bedside of the patient. As a provider, I can’t possibly know everything about the human condition. I need to be able to reach out for help to better support my patient and their family. Experts are willing to help, but to make it truly available and usable, payment will be necessary.


Virtual care has many interesting and unique use cases that can truly impact and improve care. It can help reach patients who might otherwise not receive the needed consult. It can help ensure compliance to the care plan and can provide an “extra set of eyes” to help ensure the patient’s journey is successful and without too many bumps. A few minor tweaks to the way we license and credential our providers and the way we currently decide what is covered could go a long way to ensuring quality care wherever the patient resides.


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1 Source: The Center for Connected Health Policy – 

Dr. Donald Kosiak serves as the Chief Medical Officer for Leidos. He is responsible for providing clinical subject matter expertise and perspective, knowledge, experience, leadership and direction to ensure collaboration and alignment to business strategy across the entire Leidos organization. Previously he has served as the Vice President for Medical Development and Executive Medical Director for Avera Health, a 32-hospital integrated medical system based in Sioux Falls, South Dakota, USA. In that role, he served as the chief medical officer of one of the top telemedicine programs in the United States. In addition, he has served as the elected Chief of Staff of the Avera McKennan Hospital, a 545-bed tertiary medical center located in Sioux Falls, South Dakota. Dr. Kosiak continues to serve in the United States Army Reserve as an emergency physician. He is a decorated officer having served three tours of duty in support of Operation Iraqi and Enduring Freedom. Dr. Kosiak attended medical school at the University of North Dakota. He completed his emergency medicine residency at the Mayo Clinic in Rochester, Minnesota. In 2010, he completed his Masters of Business Administration from the University of Mary in Bismarck, North Dakota. He is board-certified by the American Board of Emergency Medicine and the Certifying Commission in Medical Management.