ARKANSAS (KNWA/KFTA) — As Arkansas’ healthcare leaders focus on residencies to address the state’s growing need for more physicians, the state’s patients are looking for options. And Texas may have a solution.

“I think that we need all the help we can get,” said State Rep. Lee Johnson, the chair of the House Public Health, Welfare and Labor Committee.

“I think we’re going to all be drinking from the firehose, you know, in 5 to 10 years,” he continued.

Johnson said one way to expand healthcare access is through telehealth. But this pool of physicians is still limited by the number of doctors in the state.

“If there’s a physician in Wyoming that wants to provide healthcare to some patient in Arkansas, they have to be licensed in Arkansas. So it does create some licensure challenges,” he added.

That’s where Marschall Smith and his team want to come in.

“We’ve created a faster way to get that license,” Smith said.

Smith oversees what’s known as the Interstate Medical Licensure Compact, or IMLC, an agreement designed to make it easier for physicians to work across state lines.

“It turns a process that can take 3 to 6 months for a physician to get a license in a new state and boils that down to about 7 to 10 days,” Smith said.

How the compact works

When a state is a compact member, doctors go about getting their first license in their home state, and when that doctor applies to any participating state after that, they’ll get to take advantage of this faster track, becoming fully licensed in that state as well. Doctors still need to follow the specific laws of whatever state their patient is in.

“So each state doesn’t have to do its own licensing process. Another state has already done that. They accept that process and then issue a license,” Smith explained.

Smith says this ultimately improves the speed at which an out-of-state telehealth doctor could help patients in Arkansas, or an Arkansas doctor could expand their reach to new markets, potentially doing so when they wouldn’t have before.

But while 37 states have already agreed to participate in the compact, Arkansas isn’t one of them. Johnson says he wasn’t part of the state legislature in 2017 when Arkansas last considered joining the IMLC, but recognizes that several more states have since adopted the compact.

“I think it’s something we’ve looked at hard in the past and decided at that time it wasn’t necessarily the right move for the state, but I think it’s reasonable to start looking at that again,” Johnson said.

A solution-focused trip across state lines

While lawmakers weigh whether to enter Arkansas into the compact, KNWA/FOX24 traveled to Austin, Texas, where the state has been using the compact for almost a year, to see whether Texas considers that move a success.

“So far, it’s gone really well. It’s been pretty smooth,” says Stephen “Brint” Carlton, the executive director of the Texas Medical Board, or TMB.

As the Arkansas State Medical Board does for the Natural State, the TMB is the agency that gives physicians medical licenses in the Lone Star State. Carlton says since Texas entered the compact in March 2022, over 1,000 out-of-state doctors are now able to work in Texas. And since the cost to acquire a license through the compact funds the board staff necessary to facilitate this process, Carlton says it doesn’t cost Texas taxpayers anything to bring in these new doctors.

“We’re bringing in more revenue … than it costs us,” he said.

David Chepkauskas with the Texas Branch of the Patient’s Choice Coalition, says his organization represents hundreds of healthcare providers across multiple states and was an original advocate for the change. Like Arkansas, Chepkauskas says Texas needed more doctors and saw this compact as a chance to make it easier for physicians to work in the state.

“I mean, if the process is too burdensome on the provider, you don’t help with the workforce shortage at all. You actually exacerbate that,” Chepkauskas said.

“That’s what the compact was able to do. Help with the workforce shortage so that we have the providers needed for 30-plus million people,” he continued.

Ben Hisey, the Chief Legal Officer for SynergenX health, which relies heavily on remote appointments, admits that a state’s involvement in the IMLC is part of the discussion when deciding how to expand.

“It does factor into our decision,” Hisey said. “We look at it as a tool to appropriately create situations that might fast track some provider licensure, but it itself is not a compass for where we’re choosing to take our business in the future.”

Hisey says the compact is one element of a broader future for the expansion of telehealth, which depends on the kinds of deregulations that occurred under the COVID-19 public health emergency. And which states decide to make deregulation steps like the IMLC permanent may ultimately decide which states see more telehealth businesses grow.

“I’m trying to keep my eyes on the horizon of what is the regulatory environment look like post-public health emergency because that’s what you need to be planning for right now,” Hisey said.

Since the IMLC makes continuing care across state lines a permanently easier endeavor, Chepkauskas argued that the compact should be a part of any state’s efforts to appeal to doctors looking to move their business.

“They don’t even have to lose their patients. Their patients can still remain in the state that they’re moving from,” Chepkauskas said.

“When you look at the votes on this legislation, what you find is that it’s not controversial,” he continued.

Compact safety concerns

In the Texas legislature, the bill adopting the compact passed almost unanimously. And while the growing number of states joining the compact may offer nonmembers a rising sense of reassurance, the compact is still less than a decade old, beginning in 2014. Rep. Johnson thinks this likely contributed to Arkansas’ rejection in 2017.

“At that point, there weren’t as many states participating,” Johnson explained.

He points to some things that may have improved since then.

“I know the [compact’s] commission has changed. Some of the rules may have changed since they started and since this was examined five years ago. And so, I think it’s reasonable to look at it as a possibility,” Johnson said.

While Johnson said he supports the idea of reducing barriers to telehealth, he also suggested surrendering some level of direct medical regulation may be a hard pill for the state to swallow.

“The biggest questions with the compact become, you know, loss of regulatory control. There’s that concern that if you are licensing people in an expedited license fashion through the compact, that you’re giving up some potentially some of your primary source verification ability,” he said.

But, Smith with the compact’s commission said its record of providing quality physicians to states has been solid.

Since 2017, the commission says only 21 of its 15,000 licensed physicians have faced disciplinary action, a rate lower than the national average.

Smith believes that this isn’t by accident. He says applying doctors must have a clean criminal record and can’t have a history of disciplinary action from the DEA or present in their NPDB file, which is a national reporting database.

Finally, Smith adds if a compact physician receives disciplinary action from one state, all state medical boards participating in the compact are notified within 48 hours. And, if a physician’s license is suspended, it’s automatically suspended in all member states for 90 days, or until a state’s board decides the offense doesn’t rise to the level of suspension in their state.

In this way, Smith argues that entering the compact may actually prevent doctors from hopping state-to-state to avoid disciplinary action. That issue was the subject of KXAN’s “Still Practicing” investigation into how some physicians have come to Texas to leave their pasts behind.

“Now if they do that, they’re going to be caught in all of their states,” Smith said. “All of their licenses are going to be impacted by that.”

The TMB says patient safety hasn’t been a concern for them since Texas entered the compact, since they’ve been able to exercise their regular state laws on those doctors.

“So by joining the compact, it doesn’t change a state’s ability to control or regulate medicine in that state,” it said.

Flexibility and its costs

Smith admits the compact’s flexibility may also be its greatest limitation. Since out-of-state doctors still have to follow their patient’s state laws, ensuring you’re following these laws can be a daunting task.

“If you’re licensed in 10 states,” Smith said, “you’ve got 10 states to keep track of all of these requirements.”

To improve this, Smith says they’re working on a new internet-based information center for their doctors.

“We’re kicking off that effort, and hopefully will have implemented in the next six to nine months, is what we’re calling a physicians portal. So, a physician will be able to log into one place and see all of their licenses and understand all of the requirements of those different states,” he explained.

With more flexibility for telehealth doctors, some may also worry about the expansion of telehealth itself, and that it may replace in-person visits if its growth is fostered. But Dr. John C. Rubinow, a psychiatrist and professor at the University of Arkansas for Medical Sciences who practices medicine through both telehealth and in-person visits, says he doesn’t see that replacement happening.

“I don’t see how it could,” Rubinow said.

“As comfortable as I am with telehealth, I do like having in-person visits. It’s really nice to be able to have that. There’s a difference that’s palpable,” he said.

Instead of fearing the growth of telehealth options, Rubinow hoped people see it as a way to reach people who healthcare hasn’t been able to reach before.

“My career has been spent trying to figure out how to make care more accessible, how to make it easier for people to stay in care, to get care, to accept care, to not see it as a burden, but an addition to their lives,” Rubinow said. “And so for me, it’s really important. I really do hope that we are able to keep this around. It’s absolutely beneficial. And I see it every day.”

A potential solution, but not a silver bullet

Though the IMLC, working in tandem with telehealth, may bring some Arkansans the healthcare they need, it’s still inherently limited in what it can offer without further changes.

Rubinow notes that many treatments and prescriptions still require in-person visits, either due to a medical requirement, or a legal one.

“I can’t prescribe controlled substances if I haven’t seen somebody in person. So that’s a requirement there,” he explained. “And I do need to see people [in person] at least every six months if I’m prescribing controlled substances…even if I see them by video in between.”

Hisey says he supports the compact as a start. But the compact only affects physicians, and since much of his business operates using nurse practitioners who don’t have as widespread of a compact, they can only expand their care so far.

“So, while we see it as a boon and as a benefit to the physician side of things, a lot of our business centers on these mid-level providers, and we just simply don’t see that same level of involvement with those professionals,” Hisey said.

“It’s not the silver bullet,” Smith acknowledged. “It’s not going to solve every problem that you have completely; it’s not going to take care of the physician shortage that every state has. But it goes a long way towards that solution.”

And at the time of this reporting, the Texas Medical Board’s director says he agreed.

“Each state is going to have to look at it on an individual basis and make sure it’s something that is right for them,” Carlton said. “But, I can say it has been good for Texas, and I’m glad that we moved forward with it.”

This in-depth series was made possible in part by a grant from the Solutions Journalism Network.