REPORT OF THE AMA YOUNG PHYSICIANS SECTION
GOVERNING COUNCIL
Report D: (I-99)
Subject: Physician Licensure: An Update of
Trends
Introduced by: Stuart Gitlow, MD, MPH
Traditional medical practice is being rapidly
transformed by such factors as managed care, the politics of
health care reform, and technological and other medical
advances. Such advances, which include telemedicine, offer
opportunities for improved health care delivery. One aspect of
these changes is that medical practice now may be conducted
over wide geographic areas. This challenges the current
state-based medical licensure system to facilitate the growth
of this evolving mode of patient care while maintaining a high
standard of medical care and ensuring public protection.
The Governing Council has issued this informational report
in an effort to proactively address young physician concerns
regarding the changing environment of medical practice,
increased mobility of the physician population, and new
technologies such as telemedicine that impact on physician
licensure.
Introduction
Each of the 50 states, the District of Columbia, and the
United States territories and their respective boards of
medical licensure have rules that govern the ability of health
care practitioners, including physicians, to practice
medicine. These laws were enacted under the police power
reserved to the states by the U.S. Constitution to adopt laws
to protect the health, safety and general welfare of their
citizens. This gives the states the ability to effectively
monitor the quality of persons wishing to practice medicine in
that area. In addition, most state statutes delegate authority
for enforcing licensure laws to the state Boards of Medical
Examiners.
Until recently, a physician could provide an opinion or
interpretation to a physician in another state who had primary
patient care responsibility, and this practice was not
regarded as practicing out of his/her state. Today, however,
the out-of-state practice of medicine without a license is
prohibited, whether the physician is treating the patient in
person or from a distant location. In this day and age, a
physician is considered to be practicing medicine in the state
where the patient is located and is subject to that state’s
laws regarding medical practice, which typically means a
license in that particular state is necessary. Thus, state
boards have denied requests from out-of-state psychiatrists,
for example, to conduct therapy with their patients located in
another state via telephone or videoconferencing. Imprecise
definitions regarding just what is "out-of-state" medicine
(e.g, phone calls from patients who live in one state, but who
seek care from an adjacent state, across a state line for
care) also abound. Some states consider all out-of-state
practice to be telemedicine, whether it utilizes phone calls,
e-mail or online discussions. Even definitions from
organizations such as the American Medical Informatics
Association, the United States Department of Commerce, and
various state and specialty medical societies vary
considerably.
Telemedicine in particular has crystallized the tension
between the states’ role in protecting patients from
incompetent physicians and protecting in-state physicians from
out-of-state competition, and the desirability of ensuring
patients’ access to the highest quality medical advice and
treatment possible, wherever located.
State Licensure
Historically, physicians have been held to the standard of
care practiced by the average member of the medical profession
practicing in the same medical specialty and same geographic
location. This community-based system allows state ladaptation
of regulations and requirements to local standards, needs and
expectations. The system also has created significant
variation in licensing requirements from state to state. The
attached charts from the AMA publication, "State Medical
Licensure Requirements and Statistics," illustrate the various
similarities and differences associated with state
licensure.
A physician who seeks multiple state licenses for whatever
reason may find the current system burdensome in terms of the
time, expenses and varying licensure requirements. A patchwork
of medical record, patient confidentiality, continuing medical
education requirements, and mandatory reporting laws, along
with differing medical practice acts, complicate the process.
Difficulties are further exacerbated for physicians who
practice telemedicine.
Licensure "by endorsement" is the process by which a
physician licensed in one state seeks a license from a second
state. A physician who physically practices in his/her home
state but provides consultative or telemedicine services to
patients in five other states, even adjacent states, must
complete one in-state and five out-of-state applications for
licensure, with six sets of accompanying documentation, and
pay six registration fees. Each state has an independent
application process with separate requirements. Fees for
licenses by endorsement, including processing, application,
and administrative fees, range from $1,108 in California to
$20 in Pennsylvania; the average is $339. Moreover, most
states require a physical appearance for some applicants
before the local licensing board, which contributes to the
time and expense.
Also, many states require the current licensing exam to be
taken and passed if it has been more than 7 to 10 years since
the applicant passed the then-current exam. There can be
considerable expenses in terms of time and cost associated
with preparing and taking the exam, particularly for
specialists, who have limited the scope of their practice and
who may have had no recent exposure to some areas covered in
the general exam. For physicians who have only one or two
years of postgraduate training, or who are international
medical graduates, the application requirements in some states
are more prohibitive.
Legislation Governing the Practice of Medicine
Across State Borders
A growing number of states have enacted legislation
specifically addressing the issue of physician licensure and
the practice of medicine across state borders. The
modifications made by these states have been either to require
a physician to obtain a special license to engage in
out-of-state practice of medicine or to obtain a full
unrestricted state medical license.
Alabama chose to restrict the practice of medicine
across the state border through a special license arrangement.
The practice of medicine is redefined to include the rendering
of a written or otherwise documented medical opinion
concerning the diagnosis or treatment of a patient or the
actual rendering of treatment to a patient located in Alabama
by a physician outside the state. Informal consultation
between a physician in Alabama and a colleague in another
state is not included in the new definition, provided that the
consultation is conducted without compensation to or the
expectation of compensation to either physician, and does not
result in the formal rendering of a documented medical opinion
by the physician outside of Alabama. Similarly, physicians who
practice across state lines in a medical emergency, or on an
irregular or infrequent basis (defined as less than ten
occurrences per year or involving less than ten patients per
year or less than one percent of the physician's practice) are
exempt from the special license requirement. Alabama added one
caveat that limits special licensure to only those physicians
who are practicing in states which have reciprocal legislation
permitting Alabama physicians to cross their state border to
practice medicine.
An Arizona statute is a good example of a
consultation provision that creates an exemption from
licensing requirements. It expressly provides that the state
licensure requirements do not apply "...to any doctor of
medicine residing in another state, federal jurisdiction or
country who is authorized to practice medicine in that
jurisdiction, if he engages in actual single or infrequent
consultation with a doctor of medicine licensed in this state
and if the consultation regards a specific patient or
patients."
Colorado permits the Colorado Board of Medical
Examiners to issue a limited Colorado medical license to
physicians who are affiliated with Shriners Hospital for
Children and licensed to practice in another state to treat
Shriners’ patients either in the state or via
telemedicine.
Other states decided to require a physician providing
patient care from an out-of-state location to obtain full
unrestricted state medical licensure. In Arkansas, a
physician located outside the state but who performs any act
that is part of patient care initiated in Arkansas, including
interpretation of radiologic studies or pathologic material
that would affect the diagnosis or treatment of the patient,
is deemed to be practicing medicine in the state and now
requires full state licensure. Full licensure is not necessary
where the out-of-state physician is a medical specialist who
provides only episodic consultation services, or a physician
providing services to a medical school, or the service
provided is unavailable in Arkansas, or where the out-of-state
physician physically examines the patient in another
jurisdiction.
Hawaii law specifies that out-of-state physicians need
no state licensure where he/she is providing a consultation to
an in-state licensed physician and 1) the physician operates
no office in Hawaii or 2) he or she administers no treatment
to any patient except in actual temporary consultation with
the in-state licensed physician. Similarly, Idaho law
provides that a doctor licensed in another state or
jurisdiction is allowed "...to consult if called in
consultation by doctor licensed in Idaho or for medical
education purposes so long as he (or she) does not open an
office or appoint a place to meet patients or receive calls in
(Idaho)."
Georgia also modified its definition of the practice of
medicine. As a result, out-of-state physicians must now, in
most cases, obtain an unrestricted Georgia medical license to
provide any patient care service to individuals in Georgia via
an electronic medium that transfers patient data. Several
exceptions do apply. A physician outside Georgia will not need
a full license in the following situations: to provide
consultative services either requested by a Georgia licensed
physician and provided on a sporadic basis, or rendered in
emergency, or given without expectation of compensation, or
provided to a medical school approved by the board of
medicine.
Kansas was one of the first states to take action aimed
specifically at telemedicine. The Kansas State Board of
Healing Arts, at the behest of the Kansas Medical Society,
issued a regulation in 1994 requiring a physician who treats,
prescribes, practices, or diagnoses a condition, illness,
ailment, etc. of an individual who is located in Kansas to
obtain a Kansas medical license. Although the regulation does
not explicitly mention "telemedicine," it is widely referred
to as the "telemedicine regulation" in Kansas, in part because
it effectively prevents a physician legally practicing
medicine in a state other than Kansas from using telemedicine
to treat or diagnose patients located in Kansas if the
physician is not licensed in Kansas. Thus, any physician who
establishes a regular telemedicine link with that state must
obtain a Kansas license.
Mississippi chose to modify its state definition of the
practice of medicine. Now a physician who renders a medical
opinion or treats a patient in Mississippi, as a result of
transmission of patient data by electronic or other means,
must obtain a state license or risk disciplinary action. A
license is not necessary where the patient evaluation is
requested by a physician licensed in Mississippi who has
already established a doctor-patient relationship with the
individual to be treated by the physician outside of the
state.
Montana prohibits the practice of telemedicine without
a telemedicine certificate issued by the State Board of
Medical Examiners. New Hampshire requires state (NH)
licensure of physicians who provide contractual regular or
frequent teleradiology services in the state.
North Dakota similarly amended its Medical Practice Act
to define telemedicine and stipulate that such activities will
be regarded as the practice of medicine. Telemedicine does not
include a consultation provided by telephone or facsimile. The
bill also adds the practice of telemedicine without a North
Dakota license to the list of grounds for disciplinary
actions. A license is not required where the out-of-state
physician is in consultation with a licensed physician
physically located in North Dakota and who is primarily
responsible for the care of the patient.
Likewise, Oregon requires physicians providing
telemedicine services across state lines to obtain an Oregon
medical license for the practice of medicine across state
lines. The license issued is not considered a limited license,
but still does not permit the out-of-state physician to
practice in the state, except when engaging in practice across
state lines. The licensure requirement does not apply to
out-of-state physicians who render care across state lines in
an emergency or who consult on informal basis without
compensation or the exception of compensation and who do not
undertake responsibility for diagnosing or rendering treatment
to a patient.
Tennessee has amended its medical and osteopathic
medical practice acts to include the transfer of patient
medical information via electronic means to a person in
another state who is not licensed to practice in Tennessee as
grounds for license denial, suspension or revocation, except
in the following enumerated instances: second opinions
requested by a Tennessee licensed physician provided no
charges are assessed for the opinion or when such information
is used to treat a person seeking treatment outside of
Tennessee, to determine insurance coverage, to provide an
occasional academic consultation, or to execute a risk
evaluation or utilization review program by an insurer.
Texas established that a person who is physically
located in another jurisdiction but who, through the use of
any medium…performs an act that is part of patient care
initiated in Texas, including the taking of an x-ray…that
would affect the diagnosis or treatment of the patient, is
engaged in the practice of medicine in the state of Texas…and
is subject to the state medical practice law and appropriate
regulation by the board. The law exempts the following: a
medical specialist who provides only episodic consultation on
request to a person in Texas who practices the same medical
specialty; a medical physician who is providing consultation
services to a medical school; or institutions.
West Virginia requires state licensure for the practice
of telemedicine. A physician is not subject to the licensure
requirements in the following consultative situations: a
physician located at a tertiary care or university hospital
outside the state and engaged in the practice of telemedicine,
who acts in a consulting capacity at the request of a treating
physician engaged in the practice of medicine and surgery
within the borders of the state or a physician located outside
the state who treats a patient when the patient is physically
located at an out-of-state location, and when then through the
practice of telemedicine consults with a physician located
within the state for the purpose of follow-up or consultation
related to a treatment plan developed at the out-of-state
local. Any other physician located outside the state and
engaged in the practice of telemedicine who consults, or who
renders a second opinion, concerning diagnosis or treatment of
a patient within the state, who consults or renders the
opinion (I) in an emergency or without compensation or
expectation of compensation; or (II) on an irregular or
infrequent basis which occurs less than once a month or less
than twelve times in a calendar year, is except from
licensure.
Alternatives to State Licensure
The Telemedicine Report to Congress, prepared by a
federal Interagency Joint Working Group on Telemedicine,
recently identified in its report the following alternatives
to state licensure:
Consulting--With a consulting exception, a
physician who is unlicensed in a particular state can practice
medicine in that state at the behest and in consultation with
a referring physician. The scope of these exceptions varies
from state to state. Most consultation exceptions prohibit the
out-of-state physician from opening an office or receiving
calls in the state. Consultation exceptions to the licensure
laws were enacted in most states before the advent of
telemedicine. Although they may be well-suited to some
telemedicine situations, it is unlikely these exceptions were
intended to apply to regular, ongoing telemedicine
links.
Endorsement--State boards can grant licenses to
health professionals licensed in other states that have
equivalent standards. For example, health professionals must
apply for a license by endorsement from each state in which
they seek to practice. States may require additional
qualifications or documentation before endorsing a license
issued by another state. Endorsement allows states to retain
their traditional power to set and enforce standards that best
meet the needs of the local population.
Mutual--Mutual recognition is a system in which the
licensing authorities voluntarily enter into an agreement to
legally accept the policies and processes (licensure) of a
licensee’s home state. This approach has been adopted by the
European Community and Australia to enable the cross-border
practice of medicine. It also been successfully utilized by
the Veterans Administration, U.S. Military Branches, Indian
Health Service and Public Health Service.
Licensure based on mutual recognition is comprised of
three components: a home state, a host state, and a
harmonization of standards for licensure and professional
conduct deemed essential to the health care system. The health
professional secures a license in his/her home state and is
not required to obtain additional licenses to practice in
other states.
Reciprocity--Reciprocity denotes the relationship
between two states when each state gives the subjects of the
other, certain privileges, on the condition that its own
subjects shall enjoy similar privileges at the hands of the
latter state. A licensure system based on reciprocity would
require the authorities of each state to negotiate and enter
agreements to recognize licenses issued by the other state
without a further review of individual credentials. These
negotiations could be conducted on a bilateral or multilateral
basis. A license valid in one state would give privileges to
practice in other states with which the home state has
agreements.
Registration--Under a registration system, a health
professional licensed in one state would inform the
authorities of other states that he/she wished to practice
part-time therein. By so registering, the clinician would
submit to the legal authority and jurisdiction requirements
imposed upon those licensed in the host state, but they would
be held accountable for breaches of professional conduct in
any state in which they are registered. California has passed
legislation that would authorize registration but has not yet
implemented it.
Limited Licensure--A limited licensure system would
be a modification of the current system. Health professionals
would be required to obtain a license from each state in which
they practiced. However, the physician would have the option
of obtaining a limited license that allows the delivery of a
specific scope of health services under particular
circumstances. This system would limit the scope of practice
rather than the time period for practice as is currently the
case. The health professional would be required to maintain a
full and unrestricted license in at least one state.
National Licensure--A national licensure system
could be implemented at the state or national level. A license
would be issued based on a standardized set of criteria for
the practice of healthcare throughout the U.S. Administration
at the national level could be left to a national professional
organization.
A national licensure system implemented at the state level
would require states to voluntarily incorporate the national
standards into their laws. In such a system, the states would
be unable to impose significant additional standards. Health
professionals would still be required to obtain a license from
every jurisdiction in which they practiced, but a common set
of criteria would greatly facilitate the administrative
process. States could, however, possibly retain some
flexibility in the administrative process.
AMA Policy and Positions of Other Medical
Societies
American Medical Association
AMA policy firmly supports state-based licensure for
physicians (see appendix). The AMA also opposes national
licensure approaches for telemedicine. In 1995, Representative
Ron Wyden (OR) introduced an amendment to the then-pending
Communications Act of 1995 (HR 1555) that would have
prohibited restrictions in interstate commerce using advanced
telecommunications services. AMA comments raised a number of
concerns with this particular legislative approach, which
could open the door to a national licensure policy for
physicians administered by the federal government. The Wyden
amendment was ultimately withdrawn.
Other National Medical Specialty Societies
1994, the American College of Radiology recommended
that physicians who interpret teleradiology images maintain a
license "appropriate to delivery of radiologic service at both
the transmitting and receiving sites." On the other hand, the
College of American Pathologists has taken the stance
that a physician be licensed in the state where the patient is
located.
The American College of Cardiology has recognized
the complexities of licensure and the burden telemedicine
providers face in complying with multi-state requirements.
However, it has not yet decided whether it should develop
recommendations for licensure requirements, or support one
type of licensure over another. The College, however, does
educate its members about telemedicine and the accompanying
problems associated with licensure on its website.
The American Psychiatric Association has adopted a
position, "Telepsychiatry via Videoconferencing." The
Association favors establishment of clinical guidelines to
assist physicians in using the technology and to safeguard
quality of care, confidentiality, ethical practices and risk
management. but acknowledges that because communications
technology is changing rapidly and data from ongoing
demonstration projects are incomplete, it is too early to
establish clear standards. It urges physicians who provide
consultation to another physician, supervise a health care
professional or provide direct patient care across state
lines, to establish with the state medical board in that
patient’s state to determine whether a medical license from
that state is required to provide telepsychiatric
services.
Federation of State Medical Boards
In 1996, the Federation of State Medical Boards (FSMB)
developed a Model Act (see attached) to regulate the practice
of medicine across state lines. This Act calls for an
abbreviated but effective licensure process for physicians who
will not be practicing physically within a state’s
jurisdiction but wish to provide services to patients within
that jurisdiction. The legislation allows a state to provide
regulatory control over physicians who provide services in
their state.
This Act would require physicians practicing medicine
across state lines, by electronic or other means, to obtain a
"special" license issued by a state medical board. This
"special" license would be limited to practicing across state
lines in another state and would not allow physicians to
physically practice medicine in the other state unless a full
and unrestricted license were obtained. This special purpose
license would only be required if a physician "regularly or
frequently" engages in telemedicine. Each state medical board
would define what "regular or frequent" means. A license would
not be required if a physician practices across state lines
less than once a month, or the practice is less than 1% of the
physician’s diagnostic or therapeutic practice or less than
ten patients annually. The Act would exempt physicians who
engage in practicing across state lines in an emergency.
The AMA has expressed its appreciation for the FSMB’s
efforts to address the difficult issue of licensure for
physicians who practice medicine across state lines. The
Association has iterated its concern that the model act could
intrude into traditional physician-to-physician consultations,
especially with its broad application beyond telemedicine.
State medical boards’ reactions to the FSMB’s Model Act to
Regulate the Practice of Medicine Across State Laws has been
mixed, and many boards have opted to require full and
unrestricted licensure.
The FSMB also recognizes that administrative inconsistency
and the general lack of medical board autonomy in key
operational areas pose grave threats to the future of
state-based regulation, and thus has crafted recommendations
to improve consistency and promote uniform standards for the
effective regulation of the medical profession. In 1998 the
FSMB adopted a report of its Special Committee on Uniform
Standards and Procedures. The FSMB strongly believes that a
state-based system retains a flexibility and sensitivity to
local concerns that would inevitably be lost in a national
system, and allows for the evolution and testing of a range of
new approaches to improve the regulation of the medical
profession in a number of jurisdictions at once.
Center for Telemedicine Law
The Center for Telemedicine Law (CTL) is a non-profit
entity founded by organizations committed to providing high
quality patient services through the use of telemedicine
systems throughout the United States and the world. CTL
founders include Texas Children’s Hospital, Mayo Foundation,
the Midwest Rural Telemedicine Consortium and the Cleveland
Clinic Foundation. The Center recommends a uniform interstate
licensure system. It advocates that such a system establish
consistent licensure requirements and allow physicians to
qualify for practice in another state without significant
delays. It also supports definition of which law governs the
professional conduct of a physician practicing across state
lines and holding a license in both states. Also, the CTL
believes that physicians should not be subject to the demands
of separate and inconsistent state laws.
Efforts Of Other Health Professions
Nursing--The National Council of State Boards of
Nursing (CNCSBN) has proposed a "multistate licensure
compact." This allows registered nurses who hold a license in
one state to practice in any other state which adopts the
compact, provided they follow the laws and regulations of the
state in which they are practicing.
In general, under the compact, any state participating in
the compact may take action against the multistate licensure
of any nurse who practices in that state; however, only the
home state may take action against the license itself. The
proposed compact calls for development of a Coordinated
Licensing Information System (and database) to be operated by
a non-profit group. However, the American Nurses
Association (ANA) has criticized this model for a number
of reasons, including its tying a license to the state of
primary residence rather than the state of predominant
practice, concerns about the privacy and confidentiality of
information in the CLIS, and the possibility of nurses facing
adverse actions from more than one state arising from the same
adverse incident. For example, if a licensee practicing in a
state other than his/her state of residence is involved in an
incident that leads to disciplinary action, both the state of
residence and the state of practice could bring simultaneous
action and share evidence for use against the licensee. The
licensee then must obtain legal counsel in both states, defend
himself/herself, as well as pay each state’s cost associated
with discipline. Other states in the compact where privileges
exist but where the licensee does not practice, also could
bring action against the same licensee. NCSBN estimates that
12% of nurses hold multiple licensure. ANA believes that the
greater the number of nurses holding licenses in several
states, the greater the potential revenue loss to state boards
of nursing, potentially resulting in reduced nursing board
services and/or increased licensure fees. ANA policy instead
calls on the Association to develop model guidelines for state
nursing associations that wish to pursue legislation that
allows agreements with other states to facilitating nursing
practice across state borders and assist in the resolution of
interstate practice issues in ways other than multi-state
licensure agreements such as compacts.
The Association of Women’s Health, Obstetric and
Neonatal Nurses similarly is opposed to the interstate
compact for mutual recognition of state licensure.
Attorneys--Like a physician, a lawyer may not
practice law outside the boundaries of the states in which he
or she is licensed. Some courts, however, have recognized a
few important exceptions to this rule, giving out-of-state
attorneys more leeway concerning transactional work and other
advice that does not involve a court appearance. Some courts
also recognize an "interstate practice" exception, which
applies when a particular matter necessarily involves two or
more states.
Social Workers--The American Association of
State Social Work Boards has recently developed a Model
Social Work Practice Act for upgrading and standardizing
social work license laws. The group plans to address the
issues of telepractice and interstate practice and develop a
new section to be added to the model law.
Conclusion
The changing environment of health care delivery has led to
the development of several issues that threaten the current
state-based system of medical licensure and discipline.
Managed care, with its needs for flexibility and demands for
cost-effectiveness, licensure portability in an increasingly
mobile society, and telemedicine, underscores the need for
change.
Various AMA Councils and units are monitoring interstate
licensing, and various issues related to telemedicine:
licensure, practice standards or guidelines, medical liability
and confidentiality of patient information. The AMA-YPS
Governing Council similarly plans to keep a close eye on such
trends, and welcomes debate from the Assembly.
RELEVANT AMA POLICY RELATED TO NATIONAL LICENSURE
H-275.973 State Control of Qualifications for Medical
Licensure
(1) The AMA firmly opposes the imposition of federally
mandated restrictions on the ability of individual states to
determine the qualifications of physician candidates for
licensure by endorsement. (2) The AMA actively opposes the
enactment of any legislation introduced in Congress that
promotes these objectives. (Res. 84, I-87; Reaffirmed: Sunset
Report, I-97)
H-255.982 Equality in Licensure and Reciprocity
The AMA (1) reaffirms its policy that it is inappropriate
to discriminate against any physician because of national
origin or geographical location of medical education; (2)
continues to recognize the right and responsibility of states
and territories to determine the qualifications of individuals
applying for licensure to practice medicine within their
respective jurisdiction; and (3) supports the development and
distribution of model legislation to encourage states to amend
their Medical Practice Acts to provide that graduates of
foreign medical schools shall meet the same requirements for
licensure by endorsement as graduates of accredited U.S. and
Canadian schools. (Res. 69, A-89)
H-275.955 Physician Licensure Legislation
The AMA (1) reaffirms its policies opposing discrimination
against physicians on the basis of being a graduate of a
foreign medical school and supports state and territory
responsibility for admitting physicians to practice; and (2)
reaffirms earlier policy urging licensing jurisdictions to
adopt laws and rules facilitating the movement of physicians
between states, to move toward uniformity in requirements for
the endorsement of licenses to practice medicine, and to base
endorsement of medical licenses on an assessment of competence
rather than on passing a written examination of cognitive
knowledge. (CME Rep. B, A-90)
H-275.967 Licensure by Endorsement
The AMA opposes national legislation which would mandate
licensing reciprocity by all state licensing authorities.
(Res. 42, A-88)
H-275.956 Single Examination For Licensure - Requirement
For Demonstration Of Clinical Competence
It is the policy of the AMA to (1) support continued
efforts to develop and validate methods for the assessment of
clinical skills; (2) continue its participation in the
development and testing of methods for clinical skills
assessment at the national level; and (3) support the use of
these methods in evaluation for licensure, when the methods
have been demonstrated to be valid, reliable and practical.
(CME Rep. E, A-90)
H-275.962 Proposed Single Examination for Licensure
The AMA: (1) endorses the concept of a single examination
for medical licensure; (2) urges the NBME and the FSMB to
place responsibility for developing Steps I and II of the new
single examination for licensure with the faculty of U.S.
medical schools working through the NBME;
(3) continues its vigorous support of the LCME and its
accreditation of medical schools and supports monitoring the
impact of a single examination on the effectiveness of the
LCME;
(4) urges the NBME and the FSMB to establish a high
standard for passing the examination, comparable to those in
use at present for the National Board Examination, the
Federation Licensing Examination (FLEX), and the Foreign
Medical Graduate Examination in the Medical Sciences
(FMGEMS);
(5) strongly recommends and supports actively pursuing
efforts to assure that the standard for passing be
criterion-based; that is, that passing the examination
indicate a degree of knowledge acceptable for practicing
medicine; and
(6) urges that appointing graduates of LCME accredited
medical schools to accredited residency training not be
dependent on their passing Steps I and II or the single
examination for licensure. (CME Rep. B, I-89)
H-215.981 Hospital Employed Physicians
The AMA vigorously opposes any effort to pass
federal legislation preempting state laws prohibiting the
corporate practice of medicine. (Res. 247, A-91)
H-480.969 The Promotion of Quality Telemedicine
(1) It is policy of the AMA that states and their medical
boards should require a full and unrestricted license in that
state for physicians, with no differentiation by specialty,
who wish to regularly practice telemedicine in that state.
This license category should adhere to the following
principles:
(a) application to situations where there is a telemedical
transmission of individual patient data from the patient's
state that results in either (i) provision of a written or
otherwise documented medical opinion used for diagnosis or
treatment or (ii) rendering of treatment to a patient within
the board's state;
(b) exemption from such a licensure requirement for
traditional informal physician-to-physician consultations
("curbside consultations") that are provided without
expectation of compensation;
(c) exemption from such a licensure requirement for
telemedicine practiced across state lines in the event of an
emergent or urgent circumstance, the definition of which for
the purposes of telemedicine should show substantial deference
to the judgment of the attending and consulting physicians as
well as to the views of the patient; and
(d) application requirements that are non-burdensome,
issued in an expeditious manner, have fees no higher than
necessary to cover the reasonable costs of administering this
process, and that utilize principles of reciprocity with the
licensure requirements of the state in which the physician in
question practices.
(2) The AMA urges the FSMB and individual states to
recognize that a physician practicing certain forms of
telemedicine (e.g., teleradiology) must sometimes perform
necessary functions in the licensing state (e.g., interaction
with patients, technologists, and other physicians) and that
the interstate telemedicine approach adopted must accommodate
these essential quality-related fu
nctions.
(3) The AMA urges national medical specialty societies to
develop and implement practice parameters for telemedicine in
conformance with: Policy 410.973 (which identifies practice
parameters as "educational tools"); Policy 410.987 (which
identifies practice parameters as "strategies for patient
management that are designed to assist physicians in clinical
decision making," and states that a practice parameter
developed by a particular specialty or specialties should not
preclude the performance of the procedures or treatments
addressed in that practice parameter by physicians who are not
formally credentialed in that specialty or specialties); and
Policy 410.996 (which states that physician groups
representing all appropriate specialties and practice settings
should be involved in developing practice parameters,
particularly those which cross lines of disciplines or
specialties). (CME/CMS Rep., A-96)
FEDERATION OF STATE MEDICAL BOARDS
An Act to Regulate the Practice of Medicine
Across State Lines
Section I. Legislative Findings and Purpose
The legislature hereby finds and declares that, because of
technological advances and changing practice patterns, the
practice of medicine is occurring with increasing frequency
across state lines and that certain technological advances in
the practice of medicine are in the public interest. The
legislature further finds and declares that the practice of
medicine is a privilege and that the licensure by this State
of practitioners outside this State engaging in such medical
practice within this State and the ability to discipline such
practitioners is necessary for the protection of the citizens
of this State and for the public interest, health, welfare,
and safety.
Section II. Definition
The practice of medicine across state lines means
1. the rendering of a written or otherwise documented
medical opinion concerning diagnosis or treatment of a patient
within this State by a physician located outside this State as
a result of transmission of individual patient data by
electronic or other means from within this State to such
physician or his agent; or
2. the rendering of treatment to a patient within this
State by a physician located outside this State as a result of
transmission of individual patient data by electronic or other
means from within this State to such physician or his
agent.
Section III. License Requirement
No person shall engage in the practice of medicine across
state lines in this State, hold himself out as qualified to do
the same, or use any title, word, or abbreviation to indicate
to or induce others to believe that he is licensed to practice
medicine across state lines in this State unless he is
actually so licensed in accordance with the provisions of this
article.
Section IV. Issuance of License
The Board shall issue a special purpose license to practice
medicine across state lines upon application for the same from
a person holding a full and unrestricted license to practice
medicine in any and all states of the United States or its
territories in which such individual is licensed, provided
there has not been previous disciplinary or other action
against the applicant by any state or jurisdiction. In the
event of previous disciplinary or other action against the
applicant, the Board may, in its discretion, issue a license
to practice medicine across state lines if it finds that the
previous disciplinary or other action does not indicate that
the physician is a potential threat to the public. An
individual shall submit an application to the Board on a form
provided by the Board and shall remit to the Board a
reasonable fee for such license, the amount of the fee to be
set by the Board. A special purpose license issued by the
Board to practice medicine across state lines limits the
licensee solely to the practice of medicine across state lines
as defined herein. The special purpose license in this State
is valid for the term of _____ years (to be set by the Board
to conform with renewal requirements for full and unrestricted
licenses) and is renewable upon receipt of a reasonable fee,
as set by the Board, and submission of a renewal application
on forms provided by the Board.
Section V. Effect of License
The issuance by the Board of a special purpose license to
practice medicine across state lines subjects the licensee to
the jurisdiction of the Board in all matters set forth in the
Medical Practice Act and implementing rules and regulations,
including all matters related to discipline. In addition, the
licensee agrees by acceptance of such license to produce
patient medical records and/or materials as requested by the
Board and/or to appear before the Board or any of its
committees within _____ days (to be set by the Board)
following receipt of a written notice issued by the Board.
Such notice will be issued by the Board pursuant to any
complaint or report filed or any complaint initiated by the
Board or any of its committees when records and/or materials
are deemed relevant to said complaint or report.
Failure of the licensee to appear and/or to produce records
or materials as requested, after appropriate notice, allows
the Board to suspend or revoke the licensee's special purpose
license at its discretion. Notwithstanding any provision of
State law to the contrary, such suspension or revocation of
such license may be effected prior to a hearing, after
appropriate notice and if the Board finds an ongoing and
continuous threat to the public. Such action taken by the
Board shall be deemed a disciplinary action, for purpose of
action by any other state.
Section VI. Patient Medical Records
Any licensee licensed under the provision of this act shall
comply with all laws, rules, and regulations governing the
maintenance of patient medical records, including patient
confidentiality requirements, regardless of the state where
the medical records of any patient within this State are
maintained.
Section VII. Exemptions
A physician who engages in the practice of medicine across
state lines in an emergency, as defined by the Board, is not
subject to the provisions of this act.
A physician who engages in the practice of medicine across
state lines on an irregular or infrequent basis is not subject
to the provisions of this act. The "irregular or infrequent"
practice of medicine across state lines is deemed to occur if
such practice occurs less than once monthly or involves fewer
than ten patients on an annual basis, or comprises less than
1% of the physician's diagnostic or therapeutic practice.
A physician who engages in the informal practice of
medicine across state lines without compensation or
expectation of compensation is not subject to the provisions
of this act. (The practice of medicine across state lines
conducted within the parameters of a contractual relationship
shall not be considered informal and shall be subject to
regulation by the Board.)
Section VIII. Sanctions
Any person who violates the provisions of this Act is
subject to criminal prosecution for the unlicensed practice of
medicine, and/or injunctive or other action authorized in this
State to prohibit or penalize continued practice without a
license.
Nothing in this Act shall be interpreted to limit or
restrict the Board's authority to discipline any physician
licensed to practice in this State who violates the Medical
Practice Act while engaging in the practice of medicine within
this or any other State.
REPORT OF THE AMA YOUNG PHYSICIANS SECTION
GOVERNING COUNCIL
Report: G (I-99)
Subject: Collective Bargaining: An Update on AMA Activities
Introduced by: Stuart Gitlow, MD, MPH, Chair
Background
At the past several meetings, the Young Physicians Section,
in response to actions taken by the AMA-YPS Assembly, has
actively advocated through the AMA House of Delegates that our
AMA adopt policy that would allow physicians the option to
collectively bargain. At A-99, your AMA-YPS submitted two
resolutions to the AMA House of Delegates that asked the AMA
to immediately begin activities that would incorporate
collective bargaining for physicians into its Private Sector
Advocacy Activities. Your AMA-YPS was successful in
incorporating the recommendations it passed at A-99 into
Substitute Resolution 901, passed by the AMA House of
Delegates at A-99:
RESOLVED, That all activities of our American Medical
Association regarding negotiation by physicians maintain the
highest level of professionalism, consistent with the
Principles of Medical Ethics and the Current
Opinions of Council on Ethical and Judicial Affairs; and
be it further
RESOLVED, That our AMA immediately implement a national
labor organization under the National Labor Relations Act to
support the development and operation of local negotiating
units as an option for employed physicians; and be it further
RESOLVED, That our AMA immediately implement a national
labor organization to support the development and operation of
local negotiating units as an option for resident and fellow
physicians who are authorized under state laws to collectively
bargain; and be it further
RESOLVED, That our AMA continue to support the development
of independent housestaff organizations for resident and
fellow physicians and be prepared to implement a national
labor organization to support the development and operation of
local negotiating units as an option for all resident and
fellow physicians at such time as the National Labor Relations
Board determines that resident and fellow physicians are
authorized to organize labor organizations under the National
Labor Relations Act; and be it further
RESOLVED, That our AMA continue to vigorously support
antitrust relief for physicians and medical groups by actively
supporting federal legislation consistent with the provisions
of the Quality Health Care Coalition Act of 1999 (H.R. 1304
introduced by Representative Tom Campbell, R-CA and John
Conyers, D-MI), aggressively working with the Department of
Justice and the Federal Trade Commission, and continue
providing model legislation and information on the
state-action doctrine to state medical associations and
members; and be if further
RESOLVED, That our AMA be prepared to immediately implement
a national organization to support development and operation
of local negotiating units as an option for self-employed
physician and medical groups when the current principles of
the Quality Health Care Coalition Act of 1999 (H.R. 1304)
become law; and be it further
RESOLVED, That our AMA continue to advance its private
sector advocacy programs and explore, develop, advocate, and
implement other innovative strategies, including, but not
limited to initiating litigation, to stop egregious health
plan practices and to help physicians level the playing field
with health car payors; and be it further
RESOLVED, That should the Board of Trustees determine that
the Quality Health Care Coalition Act of 1999 (H.R. 1304) or
similar legislation will not become law, our AMA immediately
pursue the creation or adoption of new antitrust legislation
to achieve the same goal.
Update on Collective Bargaining
Activities
Attached is Board of Trustees Report 13-I-99 that will be
presented to the AMA House of Delegates. This report outlines
AMA’s activities in forming the national negotiating
organization, Physicians for Responsible Negotiations (PRN).
To summarize, the AMA Board of Trustees initially appointed
five members of the PRN governing body, and then asked for
nominations from the federation. The five initial appointees
interviewed other candidates, many of whom were young
physicians, and selected the remaining four members of the
governing body. Two young physicians were appointed to serve
on the PRN’s governing body: Michael S. Katz, MD, an
anesthesiologist from Delaware and Jerry D. McLaughin, II, MD
(current YPS Assembly delegate), an obstetrician and
gynecologist from New Mexico.
PRN, a labor organization under the National Labor
Relations Act and the Federal Labor Management Reporting and
Disclosure Act, is a totally separate and unincorporated
association. The AMA provided PRN with a model draft
constitution, which the PRN governing body adopted with minor
alterations, consistent with Council on Ethical and Judicial
Affairs principles. The PRN will initially be funded by a loan
from the AMA.
PRN organizing activities will begin with an organizational
phase when a physician group decides that it wants to
collectively negotiate with management. The procedure then
requires that the group obtain signatures from at least 30% of
eligible physicians for employee physicians expressing a
desire to be represented by PRN. PRN is divided into three
divisions: Public Sector Physicians Division; Employed Private
Sector Division; and Resident and Fellows Division.
B of T Report 13-I-99 provides additional detail and
summarizes the actions the AMA has undertaken to carry out the
activities mandated by Resolution 901 (A-99)
Private Sector Advocacy Activities
In addition to asking for a national negotiating
organization, your AMA-YPS was successful in passing policy
that asks the AMA to increase physicians’ awareness of the
private sector advocacy activities. The Private Sector
Advocacy Group has undertaken the following activities to
create stronger visibility of its activities:
- Strengthened both employer and patient outreach through
800 number and website. In addition, the Private Sector
Advocacy Group has been in contact with 40 states and
on-site in 22 to states.
- Developing model employment contract to assist AMA
member physicians when negotiating employment contracts.
- Strengthened negotiating leverage through contract
review, model contracts and collective negotiating
activities.
- Challenged government activities in the area of Fraud
and Abuse. AMA is creating an interactive website to educate
AMA member physicians. This site is expected to be
operational by the end of this year.
- Worked with local medical societies to challenge market
consolidations (i.e. Aetna/Prudential Merger).
- Identified emerging trends and acts proactively. One
example is AMA’s work with four states to eliminate
mandatory hospitalist programs.
Conclusion
Your YPS Governing Council will continue to monitor the
activities of the PRN and the AMA’s Private Sector Advocacy
Group to ensure that the interests of young physicians are
addressed, and to continue to update young physicians on these
activities.
REPORT OF THE AMA YOUNG PHYSICIANS SECTION
GOVERNING COUNCIL
Report: H (I-99)
Subject: Increasing Membership Recruitment and
Membership Retention Activities to Young
Physicians
Presented by: Stuart Gitlow, MD, MPH
Over the past decade, membership in the American
Medical Association has been declining steadily. Of particular
concern to your YPS Governing Council and the AMA is the
decline in the number of young physicians joining the AMA.
To help address the AMA’s declining membership; your AMA
Board of Trustees formed a membership subcommittee that
included the young physician trustee as an active participant.
Additionally, the AMA House of Delegates passed policy that
authorized the formation of a Membership Task Force.
Currently, John H. Armstrong, MD, AMA-YPS Immediate Past
Chair, chairs the AMA Task Force on Membership and former
Governing Council member David M. Shapiro, MD is a member of
the task force. Both the Board Membership Subcommittee and the
AMA Task Force on Membership are addressing global membership
issues. Your AMA-YPS Governing Council also has been actively
studying this issue.
Discussion
Last year, your Governing Council developed a membership
business plan that identified current activities and programs
that could be considered as young physician member benefits.
Your governing council further analyzed the strengths and
weaknesses of each of these programs or products. Based on
this analysis, your Governing Council is working with the AMA
and its Membership, Sales and Strategy Development Group to
identify membership recruitment and retention activities that
can be tailored to current young physicians members and to
attract new members.
Your YPS Governing Council identified several AMA programs
that directly or indirectly impact young physician membership
recruitment and retention activities:
- Policy Development/Advocacy.
Your YPS has a 90%
success rate in getting policy passed in the AMA House of
Delegates on emerging issues impacting young physicians and
the practice of medicine. However, we have been relatively
unsuccessful in communicating these activities to our young
physician members.
- YPS Membership Outreach Programs
. Our Assembly
members have been successful in recruiting new young
physician members. With the expansion of the program to
provide credit for membership retention activities, we
anticipate even greater success among the AMA-YPS members.
- Member Service
. Despite the limited number of young
physician members who utilize this service, AMA member
service centers provides a defined point of contact for
members and a clearinghouse for information to young
practicing physicians.
- Communications to Young Physicians
. The AMA-YPS has
plans to increase is communication efforts to all AMA young
physician members in the upcoming year, and is exploring the
opportunity of increasing communication activities to
nonmembers as well.
- Leadership Development.
Your AMA-YPS has been
successful in identifying and promoting young physicians for
leadership positions to AMA elected and appointed positions.
However, we would like to increase activities to help
identify young physician leaders in the federation of
medicine who are not actively involved in the AMA.
- Following its review and analysis of the current
programs, your Governing Council identified potential
opportunities to increase communications with its
constituents and to develop targeted membership recruitment
and retention activities to increase membership among young
physicians.
Increasing Value to Young Physician Members
In an effort to address the declining membership among
young physicians, your AMA-YPS has determined that young
physicians do not perceive value versus cost in belonging to
the AMA. Your AMA-YPS is working to identify new programs and
services that will help our AMA provide value to young
physician members. Initial conversations have included
creating a new and enhanced loan consolidation program;
financial planning services and practice management education
programs. Your AMA-YPS Governing Council will continue to stay
involved in the development and implementation of new young
physician initiatives. Assembly input is also welcomed.
Increasing Communications to Young Physicians
Your Governing Council has identified many opportunities to
increase communications with young physicians:
- Beginning in 2000, the AMA-YPS will develop and mail a
quarterly newsletter to all AMA young physician members.
Plans are underway to develop a newsletter that will allow
AMA young physician members input on issues.
- We are planning to increase access to young physician
member e-mail addresses to expand bi-weekly communications.
Additionally, your AMA-YPS is exploring opportunities to
identify young physician non-members e-mail addresses and to
begin to communicate relevant activities, along with a
membership recruitment message.
- Your AMA-YPS will continue to incorporate young
physician messages on key issues in AMNews, state and
specialty society YPS communications vehicles and other
publications.
- Your AMA-YPS will continue to inform assembly members of
key issues and ask that our assembly leaders communicate
with their constituents.
Membership Recruitment and Retention
Activities
Your AMA-YPS is committed to increasing young physician
membership in the AMA. This year, we had one of the highest
number of participants in the AMA Outreach Program with a
successful number of new members recruited. Yet, despite our
efforts, AMA membership among young physicians continues to
decline.
Your AMA-YPS is communicating with the AMA Board of
Trustees subcommittee, the AMA Taskforce on Membership, and
the AMA Membership, Sales and Strategy Development Group to
identify membership recruitment and retention activities that
will help increase membership. Your AMA-YPS Governing Council
has proposed the following:
Despite current membership figures, your Governing Council
is optimistic that the planned and proposed activities will
have a positive impact on the recruitment and retention of
young physician members. We will continue to work with the AMA
Board Membership Subcommittee, the AMA Task Force on
Membership and staff to identify membership opportunities and
will continue to update assembly members on our activities and
progress.
Subject: Report of the Special Advisory Committee to
the Speaker of the House of Delegates"Improving the
Functioning of the House of Delegates"
Presented by: Stuart
Gitlow, MD, MPH, Chair
At the 1998 Interim Meeting, the American Medical
Association House of Delegates adopted as amended the final
report of the Ad Hoc Committee on Structure, Governance and
Operations. AMA-YPS delegate Melissa Garretson, MD, was a
member of this ad hoc committee. One recommendation of the ad
hoc committee was "That the Speaker of the House of Delegates
initiate an evaluation of the functioning of the House of
Delegates and make recommendations for improvement." The
Speaker appointed an advisory committee to propose
suggestions. The committee’s report is attached for your
information.
Your Governing Council urges all Assembly members to
carefully review the attached report, discuss it with their
colleagues, and share those comments with their AMA-YPS
representatives to the AMA House of Delegates. This input will
allow your delegate and alternate to testify before Reference
Committee F when this report’s recommendations are debated.
Contact information is as follows:
Alternate Delegate: A. Patrice Burgess, MD
(208)
367-6046
e-mail:
pburgess@micron.net