Fighting America's looming shortage of doctors

Navy Seaman Cierrajaye Santella prepares to administer one of the first Moderna COVID-19 vaccines at Naval Hospital Bremerton/Navy Medicine Readiness and Training Command Bremerton, Washington, Dec. 23, 2020. (U.S. Navy photo by Chief Petty Officer (Select) Kyle Steckler)

[Editor's note: This story originally was published by Real Clear Health.]

By Dr. David N. Bernstein
Real Clear Health

Imagine that you are a newly minted doctor. You completed medical school at a fully accredited institution. You passed all three parts of the United States Medical Licensing Exam (USMLE). And you finished years of additional medical training as part of a well-respected residency training program in your dedicated specialty.

Imagine that you cleared each hurdle with flying colors. You should be able to get a license to practice high quality medicine anywhere in the United States. Your services are in demand, just about everywhere.

Question: Can you easily practice in all 50 states and America’s territories easily?  No.

Why? Because each state has its own medical board to issue physician licensing within its boundaries. Thus, in order to practice medicine in any state, you are almost always required to hold an active medical license in that specific state. To secure out of state licensure costs an exorbitant amount of time and money. Exceptions are few and far between.

The consequences are costly- to patients. For example, a world-renowned cardiologist with an active medical license in Massachusetts is currently barred from providing life-saving care or consult to others in surrounding New England states or across the United States. Worse, such legal restrictions exist - in many cases - even if the physician is willing to provide invaluable clinical insights via telehealth.

Medical experts do indeed recognize the need for more licensure flexibility across state lines. For example, the Federation of State Medical Boards (FSMB), a non-profit organization that represents 71 state medical and osteopathic boards, has made a great deal of progress on the Interstate Medical Licensure Compact, an initiative that streamlines the process for physicians to obtain medical licenses in participating states and territories. Currently, 29 states, the District of Columbia, and Guam partake. Unfortunately, however, the Compact only streamlines the process of acquiring multiple different state medical licenses; it does not allow for portability of a single license. Thus, notable barriers remain.

Defenders of the status quo claim that this antiquated approach to medical licensure protects patients, ensures revenue from licensing fees, and reduces reimbursement-related confusion. In fact, this reasoning is deeply flawed, the current situation hurts patients and undercuts their access to high quality medical care across the United States. Patients most hurt are those who don’t have routine access to highly specialized medical expertise.

First, let’s address the concern about patient safety.

Today, the United States Medical Licensing Examination (USMLE) already aims for one consistent and common standard path to medical licensure across the United States. The examination sequence, or “steps”, are created by national medical education experts and physicians. Their goal is to ensure that all physicians practicing medicine in the United States demonstrate a minimum competency level for safe and effective patient care.

Today, nearly all state licensing authorities deem passage of the USMLE as an indication that a doctor can provide safe and effective patient care. If this is already the stated goal of the USMLE and the examination is already used by most state medical licensing authorities, it is illogical to insist that a physician who acquires a medical license in one state - based on the passage of the USMLE examination sequence - cannot provide safe care in another state. This is especially the case if both states already grant doctors medical licenses based on physicians passing the USMLE examination sequence. This logical failure hurts - not protects - patients.

Second, let’s tackle state concerns that medical license portability will reduce state revenues from licensing fees.

Today, a person obtaining a medical license to practice in a state or territory must pay the required fees to each individual medical board. Typically, this is a state agency tasked with overseeing the licensure of medical professionals. These fees are not waived if a physician holds a medical license in another state. Thus, in essence, these are state-level taxes on doctors who are aiming to provide clinical care to patients seeking medical guidance, including those who may not otherwise be able to receive care.

Granted: medical license portability would, in fact, reduce state revenues from licensing fees. But all policy options involve trade-offs. So, do we really want to tax physicians, able and willing to provide safe and effective care, to all the Americans, wherever they reside, who need it? In the proposed case of increased medical license portability, the state a physician calls “home” will still receive the initial fees required to obtain a medical license.

Lastly, let’s review the concern about reimbursement confusion.

Of course, in today’s health care marketplace, states and territories not only have their own Medicaid-related reimbursement regulations but also their dominant private insurers and coverage plans and rates. This may pose a challenge for physician reimbursement, but it also creates an opportunity for innovative, yet practical solutions. For example, one possible solution is that physician reimbursement could be based on the home state of the patient seeking care. While this would require improved and increased data-sharing across state lines, and a better Information Technology (IT) infrastructure to support reimbursement and portability of medical licenses, those challenges should not be a reason to deprive patients of health care access.

When America’s Founders authorized Congress to regulate interstate commerce in the United States’ Constitution, their intention was to break down state barriers to commerce and promote interstate economic transactions, not restrict them. Congress could simply reaffirm that physician practice across state lines, based on interstate medical licensure, is an interstate transaction protected by the commerce clause.

This would not be a federal “takeover” of medical licensure. As noted, the USMLE in conjunction with completion of an accredited residency training program, which - one should note - is also provided by a national accreditation organization, already provide the consistent national standard that can be used to assess physician competency for safe and effective clinical care. Thus, these accomplishments bring a level of confidence in medicine among all patients seeking care in the United States. Indeed, this is why nearly all state and territorial medical boards independently utilize these milestones in their decisions to grant medical licensure. In fact, this proposal would not change much - if anything - in that regard, including states’ rights and traditional authority. Additionally, the states’ power of oversight over physician practice within state boundaries can and should continue to remain with each individual state.

America is facing a current and looming physician shortage. By the end 2018, many American citizens - especially those in rural areas - had a lack of health professionals in their area.  By 2033, experts project a worsening of this shortage, with a shortfall of up to 139,000 physicians possible. Removing bureaucratic obstacles to allow for highly qualified physicians to deliver safe and efficient clinical care across state lines - whether in person or via telehealth - will not fix the shortage of health care professionals in this country. It will, however, provide a measurable level of much needed relief for America’s patients.

David N. Bernstein, MD, MBA, MEI is a resident physician at the Harvard Combined Orthopaedic Residency Program at Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, and Boston Children’s Hospital.

[Editor's note: This story originally was published by Real Clear Health.]

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