Location Shouldn’t Matter When It Comes to HealthcareAugust 1, 2022
Sometimes when I’m doing a video visit, in my head I hear that line near the end of the movie “The Shawshank Redemption,” when the brilliant actor Morgan Freeman’s character Red says that for the second time in his life, he is going to commit a crime: in this case, breaking parole by crossing state lines.
Why, as we’re trying to take care of our patients, should where we are at the moment, and where they are, really matter? Back in the good old days, before video visits and telehealth, when my patients went on vacation and they got sick, they would be able to call our practice, receive some medical advice, and then we would be able to send a prescription to the pharmacy located wherever they happened to be. Did they develop a urinary tract infection while on a ski trip in Utah? We can call in some antibiotics. While hiking near their house in Connecticut, they found an engorged tick embedded in the back of their leg? We can e-prescribe a prophylactic dose to nip this in the bud.
There have even been more complicated cases, where we’ve had patients go to local facilities for x-rays and labs, and we’ve participated in co-managing an acute or subacute problem along with specialists on the ground where they were. And much of this is still fair game. But longitudinal care, chronic care, preventive medicine, annual visits? No way.
As the pandemic started to heat up, we pivoted much of our care in the outpatient world — for the most part all care that wasn’t COVID-19 — to telehealth and video visits. Due to the public health emergency, many of the rules surrounding billing for these episodes, including the concept of crossing state lines for healthcare, were put on hold. So, when our patients decamped from New York City and sheltered in place at their home in rural Pennsylvania, we were able to continue to provide them care for both their acute and chronic medical conditions.
Now, as the COVID-19 pandemic has lifted (or at least eased up a little bit), the regulatory people who control this stuff are starting to slam the doors again. Now whenever a patient schedules a video visit, they need to sign an electronic consent to certify that they will be in New York State at the time of the visit. And we have a macro to document in our notes that we are in New York and we need to reconfirm at the start of our visit that this is where the patient is — or else we cannot continue.
Is medicine so different from one state to the next that I can’t be trusted to practice medicine in my office when the patient happens to be in another state? Hypertension is still hypertension, diabetes is still diabetes, asthma is still asthma, depression is still depression, and we’re going to manage them pretty much the same no matter where you are.
Sure, there have always been regional differences in medical conditions, geographically distinct entities, and in medical school we learned to ask about travel history to find out whether patients might have been exposed to diseases that were endemic to only specific regions, helping us broaden our differential diagnosis. Rift Valley Fever. West Nile Virus. Rocky Mountain Spotted Fever. German Measles. Coxsackie Virus.
And now we have seen and learned the chilling negative consequences of using these names. Much of this geographic sub-specialization has blurred as travel has gotten easier, and diseases have become more widespread. As certain illnesses start to take off, such as COVID-19 and monkeypox, we looked for them first and hardest in the regional centers where hotspots of these diseases were being found. But then things spread. And as things spread, and as our patients move around, shouldn’t we be able to take care of them?
I know that states need to regulate medical personnel practicing there, and there are certainly implications for employment, taxation, billing, insurance, and malpractice. But if my New York State driver’s license lets me drive in any city or state, as long as I obey the posted speed limits and other local laws there, shouldn’t my medical license, which gave me the tools, the honor, the privilege, and the duty to take care of people, let me do that no matter where a patient is?
The world is changing, and healthcare is just not keeping up. Over and over, things get out of hand, things change, and every time we try to innovate and do the right thing, we come up against a wall of reasons why we can’t do it. Really, if you think about it, what is the harm of me taking care of that patient of mine who spends half their year living in another state? For continuity’s sake, wouldn’t it be better if I took care of them all year long, rather than having them having to find a doctor just in case they get sick while they’re away?
Of course, I have many patients who have permanently moved, who have relocated to a new city because of a job or family issues. Some stop in to see me once a year when they are in New York City for their annual checkup, but most of these I encourage to find a local doctor. They need to set up local relationships to make sure they get the best care they can.
Someday, as our ability to do virtual healthcare improves, and we can do virtual physical exams and remote testing and monitoring, maybe we’ll be able to do all of this universally. For now, it would be really nice if — instead of making me get a medical license in all 50 states — the license I have was recognized for what it was, the value it adds to society, and to our patients.
No matter where they are at the moment.