by Telemedicine exploded in popularity after COVID-19 hit, but the limits for care delivered across state lines are returning.
This complicates subsequent treatments for some cancer patients. It can also affect other types of care, including mental health treatment and regular checkups with a doctor.
In the past year, nearly 40 states and Washington, D.C., have ended emergency declarations that made it easier for doctors to use video recordings to see patients in another state, according to the Alliance for Connected Care, which advocates for the use of telemedicine.
Some, like Virginia, have created exceptions for people who have an existing relationship with a doctor. Some, such as Arizona and Florida, have made it easier for out-of-state doctors to practice telemedicine.
Doctors say the resulting patchwork of regulations creates confusion and has led some practices to shut down out-of-state telemedicine altogether. This leaves follow-up visits, consultations, or other care only to patients who can afford to travel for in-person appointments.
“So Dated”
Susie Rinehart is planning two upcoming trips to her oncologist in Boston. She needs regular scans and doctor visits to monitor a rare bone cancer that has spread from her skull to her spine.
Rinehart doesn’t have a specialist near her home outside of Denver who can treat her. These visits took place essentially during the pandemic.
She’ll travel without her husband to save money, but that creates another problem: If she gets bad news, she’ll have to deal with it alone.
“It’s stressful enough to have a rare cancer and this just adds to the stress,” the 51-year-old said.
Rinehart oncologist Dr. Shannon MacDonald said enforcement of telemedicine regulations appears to be more aggressive now than before the pandemic, when video visits were still emerging.
“It just seems so old,” said MacDonald, who recently co-authored an article on the subject in The New England Journal of Medicine.
For medical boards to state, the patient’s location during a telemedicine visit is where the appointment takes place. One of MacDonald’s hospitals, Massachusetts General, requires doctors to be licensed in the patient’s state for virtual visits.
He also wants those visits to be limited to New England and Florida, where many patients spend the winter, said Dr. Lee Swam, vice president of Mass General Brigham Health System.
That doesn’t help doctors like MacDonald, who see patients from all over the country.
The Cleveland Clinic also attracts many patients from abroad. Neurosurgeon Dr. Peter Rasmussen worries about how some will handle the upcoming trips, especially since winter may bring freezing weather.
A fall “literally could be life-ending” for someone with a condition like Parkinson’s who has trouble walking, he said.
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Psychiatrists have a different concern: Finding doctors for patients who move out of state. This is especially difficult for students who temporarily leave home.
Most U.S. counties lack child and adolescent psychiatrists, noted Dr. Shabana Khan, chair of the American Psychiatric Association’s committee on telepsychiatry.
“If we try to transfer patients, there’s often no one there,” Khan said.
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Helen Khuri’s mother found a specialist to help her when the 19-year-old’s PTSD flared up last spring. But the Emory University student had to temporarily move from Atlanta to Boston for treatment, even though she never set foot in the hospital that offered her.
She rented an apartment with her father so she could be in the same situation for telemedicine visits, a situation she deemed “ridiculous.”
“It didn’t necessarily make sense to … kind of uproot my life, just to get this three-week treatment program,” Khuri said.
Crossing the border
Even people who see doctors close to home can be affected.
The pediatric clinic of Dr. Ed Sepe in Washington, DC has patients in Maryland who have started driving a few miles across the border into the city to connect via video. This saves them a 45-minute trip downtown for an in-person visit.
“It’s stupid,” he said. “If you’re under a doctor’s care and you’re in the U.S., there’s no point in having geographic restrictions on telemedicine.”
Sepe noted that low-income families tend to be in jobs that don’t allow time for personal visits. Some also find it difficult to get transport. Video visits helped with these obstacles.
“It’s bigger than just telemedicine,” he said. “There’s a missed opportunity there to level the playing field.”
States can play an important role in the development of telemedicine by protecting against fraud and protecting patient safety, according to Lisa Robin, an executive with the Federation of State Medical Boards.
But the federation is also recommending that states loosen some telemedicine restrictions. This includes allowing patients who have traveled out of state to seek follow-up care virtually, or allowing virtual visits for people who move temporarily but want to stay with a doctor.
States could also enter into regional agreements with their neighbors to facilitate cross-border care, noted Dr. Ateev Mehrotra, a professor of health policy at Harvard who studies telemedicine.
“There are so many ways to address these issues,” he said.
Meanwhile, patients who need care now are trying to figure out how to manage it.
Lucas Rounds isn’t sure how many visits he’ll make to see MacDonald in Boston to monitor his rare bone cancer. Logan, 35, a Utah resident, already spent months away from home earlier this year, undergoing radiation and surgery. In addition, he has a wife and three young girls and consider expenses like a mortgage.
Rounds says he has to think about taking care of his family “if the worst happens.”
“If I die of cancer, then all these expenses that we’ve accumulated … those are dollars that my family wouldn’t have,” he said.
