Investigative Summary:

Facing a doctor shortage during the COVID-19 pandemic, Texas leaders entered a compact with dozens of other states to expedite licensing — largely allowing out-of-state physicians to utilize telemedicine to fill the gap. KXAN and its Arkansas sister station took a solutions journalism approach to closely examine the expected surge in applications and more broadly explore the nationwide program and its limitations.

WATCH: Q&A answering your #TelehealthQuestions

AUSTIN (KXAN) — Dr. Niki Davis logged on through her computer from Salt Lake City, Utah. 

The patient she treated started the telehealth appointment using their phone or computer in Austin. It’s how Dr. Davis now treats most of her patients. 

			Telemedicine during the COVID-19 pandemic pushed Texas to join a Compact with dozens of other states to expedite doctors’ licenses. (Courtesy Dr. Niki Davis)

Telemedicine during the COVID-19 pandemic pushed Texas to join a Compact with dozens of other states to expedite doctors’ licenses. (Courtesy Dr. Niki Davis)

She’s board certified in both family and lifestyle medicine and part of the team at Plant Based TeleHealth, which started during the pandemic. 

“People don’t have a lot of time to get into their car, drive to the doctor’s office, wait in the office for a while to see the doctor, see them very rushed in 10 or 15 minutes,” Davis said. “I get to see people for a full hour or a 30 minute follow-up.”

Davis is one of more than 1,300 doctors licensed in Texas since March of last year through the Interstate Medical Licensure Compact

“I added Texas as soon as I saw that it was in the Compact. You know, Texas is a big state for us,” Davis said. “We have a lot of patients in Texas who are looking for this kind of medicine, these kinds of doctors who are there to help walk them through making lifestyle changes, to feel better, lose weight, get off medications.”

Who’s coming to Texas?

The state law which made Texas part of the Compact went into effect in 2021 but applications weren’t accepted until last March. 

The Compact, which now includes 37 states, the District of Columbia and the Territory of Guam, expedites medical licenses — making it easier for doctors licensed in other states to treat patients in Texas. 

It also means Texas doctors can now more easily get licenses in other states in the Compact.

“Any time you can get more physicians in the state I think is the better because that provides more opportunities for the people of Texas to access care,” said Stephen “Brint” Carlton, Executive Director of the Texas Medical Board. “It has made it much easier for physicians to become licensed in Texas. And so it does lower the kind of regulatory burdens or hoops they may have to jump through.”

WATCH & LISTEN: The Texas Medical Board says the average days for physician licensing through the traditional process was 26 days in the most recent fiscal year, but the Interstate Medical Licensure Compact speeds up the process to 10 days or sooner. (KXAN Animation/Aileen Hernandez)

The Texas Medical Board, which oversees licensing for Texas physicians, explained the average time it takes for physician licensing through the traditional process was 26 days in the most recent fiscal year, but the compact speeds up the process and licenses can be issued in 10 days or sooner.

“Getting your license through the Compact doesn’t change what the standard of care is in Texas — so or any other state. All it is — it is — that voluntary, expedited pathway to get the license. Once you get the license, you are subject to each state’s individual standard of care requirements, and to be able to maintain the license and practice in that state,” Carlton added. 

TMB data KXAN investigators obtained shows doctors from Colorado, Illinois, Georgia, Arizona and Washington have been issued the most Texas licenses. The top specialties are family medicine, internal medicine, emergency medicine, psychiatry and neurology.

KXAN partnered with its sister station in Arkansas as the state weighs its own options for telehealth and joining the Compact. 

TapClick to see the number of doctors from the 37 states licensed to practice in Texas through the Interstate Medical Licensure Compact between March 1, 2022 and January 19, 2023. Physicians currently in Texas who did not previously have an existing license to practice medicine in Texas are able to obtain a license through the Compact. Darker colors indicate more licenses. Source: Texas Medical Board. (KXAN Interactive Map/Dalton Huey)

For some like Kenneth Soyemi from Illinois, getting a license in Texas has meant he can do his job in general.

He’s a medical director for Health Service Corporation, which is the parent company for Blue Cross and Blue Shield of Texas. He reviews medical records for Texas Medicaid patients to justify hospital stays and requests for service. 

“Utilization reviews are a necessary process to help ensure hospitals provide appropriate patient care and insurance companies cover the costs they are required to,” Soyemi said. “The compact system will make it easier to hire and credential providers in reasonable time.”

Texas Compact requirements 

Doctors can qualify to practice across state lines if they meet requirements including holding a full, unrestricted medical license in a Compact member-state.

They must select a State of Principle Licensure, or SPL — a home state where they hold a license to practice medicine and meet at least one of the following requirements: 

  • The physician’s primary residence is in the SPL
  • At least 25% of the physician’s practice of medicine occurs in the SPL
  • The physician is employed to practice medicine by a person, business or organization located in the SPL
  • The physician uses the SPL as his or her state of residence for U.S. Federal Income Tax purposes

Additionally, they can’t have any history of disciplinary actions towards their medical license, be under an investigation and have any criminal history. 

		Stephen 'Brint' Carlton is the Executive Director of TMB which oversees licensing. (KXAN Photo/Arezow Doost)

Stephen ‘Brint’ Carlton is the executive director of TMB which oversees licensing. (KXAN Photo/Arezow Doost)

To apply, doctors have to complete an online application, confirm eligibility, select their home state, pay an application fee and complete mandatory fingerprinting for a national criminal background check. 

“We go back, make sure they graduated from an accredited medical school, look at their residency where they completed the residency — did they do the required amount of time for that postgraduate training,” Carlton said.

It costs $700 to apply, plus additional fees for each state where they want to be licensed.

Doctors who qualify will then receive a letter of qualification and they’ll be able to select states where they want to get licensed. TMB said that doctors themselves are responsible for making a self-determination of eligibility before applying.

“It’s kind of a primer to them is, ‘Hey, before you start down this path, and pay the money to the compact, and start, you know, filling out the paperwork, make sure that you meet all those requirements.’ We’re obviously going to double check that you do,” Carlton explained. 

TMB said it has denied 35 applicants for reasons such as already having a full physician license in Texas, wanting to withdraw their application or duplicate applications. 

Breaking down barriers

The American Telemedicine Association, or ATA, based in Washington, D.C., believes the Compact helps break down interstate barriers by increasing access to care and helping with the physician shortages crisis. 

“When Texas does something, the rest of the country notices,” explained Kyle Zebley, Senior Vice President of Public Policy with ATA. “It’s a major leap forward for the Compact given the size of Texas — the number of patients that will now have increased access. It’s another great fork in the road for the telehealth community as we seek to really make sure that as many states as possible adopt as many of the Compacts as possible.” 

Earlier this month, the Texas Medical Association told KXAN investigators that while the state has seen strong physician growth, recruitment is still needed. 

“For instance, Texas still has a serious shortage of physicians. Despite having 8.8% of the U.S. population, the state has 7.3% of active U.S. physicians, according to data collected by TMA. And Texas’ ratio of 204.6 patient care physicians per 100,000 people is well below the national average of 247.5,” said a TMA publication in December 2022

Zebley said while the Compact has made it easier for doctors to join the Texas workforce, there are some limitations which could be streamlined. 

“Doesn’t automatically mean that a physician has access to every state that, you know, the more than two three dozen states that have adopted the Compact. That — it’s not like a universal recognition by all those other states. You still have to go through the oftentimes time-consuming process of getting a license in the individual state in question,” Zebley explained.

For instance, registered nurses and licensed vocational nurses have their own Compact and only need one multistate license. According to the Nurse Licensure Compact, they can practice in their home state and in other Compact states without having to get additional licenses. 

Another limitation some doctors pointed out is if they get licensed through the Compact, they are the only ones who can treat patients — not any other medical staff at their office unless they, too, are licensed through the state.

Chart listing the top five specialties of out-of-state physicians who have been licensed to practice in Texas through the Interstate Medical Licensure Compact between March 1, 2022 and January 19, 2023. Source: Texas Medical Board. (KXAN Interactive Chart/Dalton Huey)

More time with patients

“I think the success, a lot of it, is looked at how much are people using the Compact,” Carlton said. “Hopefully not, but in the event that there is some type of disciplinary action for someone that is a Compact licensee, you know, how smooth is that, that communication from us to other states and other states to us to make sure that everyone is doing what they’re supposed to do as far as disciplinary action.”

He added any investigation would be carried out by the medical board in the state where the patient who filed the complaint lives and any disciplinary action taken would be shared with all Compact states. 

WATCH & LISTEN: When a complaint is filed against a doctor licensed through the Interstate Medical Licensure Compact, any investigation would be carried out by the medical board in the state where the patient who filed the complaint lives, according to the compact’s website. Any disciplinary action taken. would be shared with all compact states. (KXAN Animation/Aileen Hernandez)

Since 2017, the Interstate Medical Licensure Compact’s Board said only 21 of their 15,000 licensed physicians have faced disciplinary action — lower than the national average. 

Davis is now licensed in 13 states. She said Texas’ process is more stringent than most.

“In Texas, they require that you take an exam. So that took a little bit extra time where I had to purchase some materials to study from and then I had to purchase this exam to take,” she said.

But she said being able to apply through the Compact has meant more time with her patients, and it’s a “game changer.” 

“As someone who is working mostly telehealth, it has made such a difference for me,” she said. “It allows me to focus more on the things that I love about medicine, which is working with the patients.”

WATCH: Q&A answering your #TelehealthQuestions

KXAN digital anchor Will DuPree, KXAN investigator Arezow Doost, KNWA anchor Perry Elyaderani and American Telemedicine Association Senior Vice President of Public Policy Kyle Zebley answer viewer questions about how telehealth works.

Investigative Photojournalist Richie Bowes, Graphic Artist Aileen Hernandez, Director of Investigations & Innovation Josh Hinkle, Investigative Producer and Reporter Dalton Huey, Digital Special Projects Developer Robert Sims and Digital Director Kate Winkle contributed to this report.