This piece was originally published by The University of Utah on Jun 23, 2021.
Utah has made tremendous strides in easing excessive licensure-related barriers to health care professions. The next step for Utah should be the reduction of the administrative burdens imposed on practitioners by licensing. This should involve the lengthening of current licenses’ duration as well as the creation of a telemedicine registry for out-of-state providers.
The benefits and perils of health practitioner licensing
The purpose of licensing regulations is to ensure a minimum standard of quality, protecting consumers from charlatans and quacks. And, indeed, there is evidence that licensure has been successful in doing so with regard to health practitioners. The establishment of licensure of physicians and midwives in the late 19th and early 20th centuries has been linked to meaningful quality improvements, including lowered mortality.
However, the restrictions and administrative headaches imposed by contemporary state-licensing regimes often go beyond what can be defended based on the evidence. There are three areas where state licensing regulations tend to run amok. The first is needlessly difficult licensure requirements, such as more difficult licensing exams. Evidence is lacking that filtering out applicants beyond basic education credentials and the like results in improved quality. To illustrate, states with more stringent licensing of dentists appear to have simply charged more without delivering better quality. The second area where licensing regulations tend to fail is providing insufficiently flexible “scope of practice,” which defines what health care services a given licensed practitioner is authorized to do. For instance, easing restrictions on practice scope for highly-trained non-physician practitioners such as nurse practitioners and physician assistants has been repeatedly shown to improve access without sacrificing quality, reducing emergency care utilization as well as costs for insurers and consumers. The third way in which licensing regulations can be poorly designed is by imposing excessive barriers to cross-state practice. Given that licensing is administered by states, incompatible licensing requirements or onerous administrative processes can often delay or outright prevent practitioners’ ability to work in a state they’ve moved to or to offer cross-state telemedicine services.
Utah leads in terms of licensing reform, but room for improvement remains
Utah has placed itself largely at the forefront of evidence-driven regulatory reform for health practitioners in recent years. Licenses for health professions in Utah uniformly avoid the needlessly onerous requirements found in some other states. Legislation enacted earlier this year expanded practice scope for physician assistants and nurse practitioners, granting them the flexibility and autonomy necessary to better serve Utahans’ health care needs. Additionally, Utah has signed onto more interstate licensure compacts for health professions than any other state. Compacts are agreements between states that ameliorate cross-state licensing barriers, including the Interstate Medical Licensure Compact and Nurse Licensure Compact, which ease migration for physicians and nurses, respectively. Utah has also similarly signed onto compacts for physical therapists, psychologists, and emergency medical technicians. Additionally, health professions not covered by compacts benefit from Utah’s 2020 law stipulating that professions licensed in other states are generally eligible for licensure in Utah without undergoing additional training or credentialing.
However, while Utah’s licensing regime for health practitioners is better than in much of the country, there is still room for improvement. Current rules still impose administrative headaches that go beyond what can be defended on the basis of quality, particularly with regard to out-of-state practitioners looking to serve Utahans via telemedicine.
The benefits of recognizing out-of-state licenses are generally limited by the fact that multi-state practitioners are still required to maintain licenses in multiple states. Recognition through licensure compacts or other means merely streamlines the licensing process while leaving intact the need to obtain multiple licenses in order to practice in multiple states. The notable exception here is the Nurse Licensure Compact, which comes close to creating a genuine free-trade zone in 30-plus states, allowing nurses licensed in, say, Colorado, to work in Utah or any other member state without additional hassle. Nurses in compact member states need only to apply for a new state’s license upon changing their location of permanent residence.
This status quo for physicians and other practitioners is costly not only for those looking to move to Utah, but often also for those practicing in communities near state borders. Multi-state licensure is particularly costly for practitioners looking to provide telemedicine services. To illustrate in the case of physicians, the Interstate Medical Licensure Compact merely grants an expedited licensing process, maintaining the need to become approved and pay additional fees for each state that they practice in. Currently, over 22 percent of physicians are licensed in at least two U.S. states and 7 percent of physicians maintain licenses in three or more states. But only 14 physicians in the entire country are licensed in all 50 states. Achieving physician licensure throughout the entire U.S. would cost well over $10,000 in renewal fees every couple of years. With Utahans making up less than 1 percent of the nation’s population, the paperwork and fees involved in obtaining a separate Utah license make the state a relatively unattractive market to expand telemedicine services.
Next Steps for Utah Health Practitioner Licensing
The Department of Veterans Affairs (VA) provides a useful model for reforming Utah’s licensing rules here. In order to work for VA facilities, physicians, nurses, and other health professionals need merely to be licensed in any one of the 50 states. And VA telemedicine providers require just a single state license to provide services anywhere in the country. This is because the VA utilizes its federal authority to bypass state-level restrictions that run contrary to ensuring patient access. A Government Accountability Office report found that imposing state-by-state licensing on the VA would likely result in tangible difficulties with hiring and telemedicine operations while producing no discernible benefit. Though no state has thus eased restriction on cross-border medical services as much as the VA on a permanent basis, Colorado has done as much temporarily in response to COVID-19. Given evidence suggesting health care practitioners such as nurses responded to the pandemic by moving to virus hot spots, it’s likely that licensure liberalizations of this sort were effective.
Utah could mimic the VA by allowing health care providers to practice in Utah on an out-of-state license, superseding the flexibility granted under existing compacts, at least within Utah. Under such a move, licenses from out of state would remain valid until expiry, at which point licensees would be required to obtain a Utah license if that was their place of residence. This would represent merely an expansion of an existing Utah practice. Under Utah’s current law, physicians licensed in other states with at least 10 years of professional experience may legally provide care without applying for a duplicative Utah license. The current catch, however, is that such care may be provided solely on a charitable basis. By expanding this exception to physicians in commercial settings, as well as to other practitioners, Utah law would provide unparalleled freedom from needless barriers to cross-state practice. Not only would this benefit practitioners moving into Utah and those residing near the state’s border, but it’d also provide Utahans with unparalleled access to innovative telemedicine services provided by licensed practitioners anywhere in the country.
A more limited path for reform would involve carving out an exception for telemedicine specifically. Currently, nine states, including neighboring New Mexico and Nevada, carve out an exception to state licensing laws for out-of-state practitioners engaged in telemedicine services. In Florida, for example, health practitioners licensed and residing outside the state may provide telemedicine services with no fees and minimum hassle by simply signing up through the state’s telemedicine registry.
Finally, Utah should consider at least doubling the duration of its licenses. Under current Utah law, licensed physicians must submit paperwork regularly to maintain practice rights while paying related fees that can add up to between $1000 and $1500 each decade. This need to file paperwork every couple of years provides zero discernable benefits to patients. In fact, licenses for providers in European countries such as Sweden never expire, barring disciplinary action. Doubling Utah license durations would cut such fees in half, effectively cutting taxes for all practitioners in the state. And truth be told, health care practitioners have enough paperwork to deal with as part of their job.
Utah is further along in easing unnecessary licensing burdens on health care practitioners than most states. But that doesn’t mean that its work is done. The next steps should involve easing restrictions on practice by out-of-state providers and increasing license durations in order to minimize unnecessary fees and paperwork. Doing so will provide Utahan with better access to care and make Utah a more attractive state for providers, particularly with regard to the rapidly developing field of telemedicine.