Like many other 3-year-old boys, Braxton Davis is lively and at times playfully mischievous. But he might not have survived to that age if states hadn’t temporarily loosened medical licensing requirements during the pandemic. And the road ahead for many other children and adults with potentially life-threatening health issues might be more difficult if the door closes on more flexible medical licensing.
Braxton’s parents, Beth and Brent, live in a remote area of northern Georgia. Before Braxton was born, a routine fetal echocardiogram done near his home showed that something was amiss with his heart. The problem was diagnosed as tetralogy of Fallot, a congenital heart disease that is actually a combination of four heart defects that disrupt normal blood flow. Fixing tetralogy of Fallot can take multiple surgeries after birth, but just how many can’t be determined until the newborn is examined.
Braxton’s parents, already feeling the normal jitters related to pending parenthood, began preparing for the uncommon and unknown obstacles they would face once Braxton arrived.
When Braxton was born in January 2019, it became apparent that the first operation needed to be performed sooner rather than later. When he was a just 3 weeks old, I placed a shunt in his heart while I was working at Vanderbilt University Medical Center in Nashville (a three-hour drive for Braxton’s family) that helped blood flow from the left chamber to the right. This operation is typically followed by another one within four months. But Braxton’s case didn’t follow the usual trajectory: His left coronary artery crossed in front of his heart, and an incision would be required for this repair. So we decided to delay his next surgery to allow his heart to grow bigger and stronger, improving his chances for a successful operation.
The timing of Braxton’s second surgery was upended by the pandemic and complicated by my move from Vanderbilt to Johns Hopkins Children’s Center in Baltimore, 10 hours and four states away from Braxton’s home. Yet his parents wanted to continue his care with my team, some of whom came with me from Vanderbilt, because we held the medical history and experience with Braxton’s complicated condition — a natural hope for any parent managing so much complexity and stress.
In normal times, Braxton and his family would have come to Baltimore for several appointments before the surgery, some of which last only 30 minutes. Alternatively, I could have applied for and received a medical license in Georgia, an administrative process that can take up to eight weeks even for experienced, board-certified physicians. Following the surgery, Braxton and his family would have to return to Hopkins for at least two post-op checkups.
But as the pandemic gathered steam across the U.S., flexibilities in licensing granted by both the federal government and most state governments made it possible for Braxton’s medical team, including me and my colleagues in Baltimore and his specialists in Georgia, to be nimble and rapidly transform how Braxton’s care was delivered. These changes let medical professionals licensed in one state treat patients in other states. This was a critical change for telemedicine, since before the pandemic practitioners were able to provide care only for patients physically located in a state in which the provider had a license at the time of the visit.
My hospital and its health system, like many others around the U.S., were able to rapidly and safely scale up telemedicine services to reach patients in their homes throughout the crisis and beyond.
This combination of licensing flexibility and telehealth services gave clinicians more flexibility to meet their patients’ needs, regardless of where they live. In fact, thanks to telemedicine, I wouldn’t mind if all of my future surgical consults were virtual. Online meetings allow parents, grandparents, and other family members from across the country to process together what could be difficult news about an upcoming operation on a child and what the future holds, since many of my patients will need care for the rest of their lives.
Virtual preoperative appointments ensured that Braxton’s second operation, which was done in July 2021, was not delayed. During that surgery, we successfully completed a full repair of his heart. After a weeklong stay, he and his parents went home to Georgia, and I followed up with him afterward via telemedicine, checking the incision site on video. Braxton continued to see his local cardiologist.
During the summer of 2021, however, many states rescinded licensing reciprocity, forcing providers to cancel thousands of telemedicine appointments with established patients who live in states other than where the provider is licensed. These reinstated restrictions are interrupting the long-term care of patients, leaving many of them searching for new doctors and subsequently altering — and delaying — their care.
Though Braxton’s most recent surgery was successful, and there’s hope that he’ll never need have another, there’s still a crucial need for him to have regular checkups, many of which can be safely conducted via telemedicine. Yet as state licensing rules are put back in place, Braxton’s access to medical care is being restricted.
That different states have different licensing rules makes sense for certain professions. Traffic laws in Georgia might be different than right across the border in South Carolina, for example, so you probably would not want a lawyer from Charleston representing you for a speeding ticket in Atlanta. But a boy’s heart — or any body part, for that matter — is supposed to function the same no matter what state the boy lives in. Clinical care of patient does not change because he or she crossed a line on a map.
I don’t get why a doctor in good standing in Maryland with patients in different parts of the country must get licensed in all of those jurisdictions, a process that might take valuable time their patients may not have. If I can call a pharmacy in Georgia to prescribe post-operative medications for Braxton, why shouldn’t I be able to call him as his surgeon to check in following his operation?
People like Braxton, who live in remote areas, sometimes have no choice but to seek medical care over state lines to treat rare and complicated conditions because there’s no specialist where they live. This is particularly true for children, given the national shortages of different types of pediatric specialists.
Government officials need to permanently extend and simplify the state-by-state flexibilities in licensing that were temporarily granted in response to the Covid-19 pandemic. This move would make it possible for patients to receive telemedicine services wherever they are by their preferred providers. Potential solutions, such as the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act, are a step in the right direction.
Returning to the pre-pandemic days of limiting clinicians to caring only for patients physically located in their state of licensure would dissipate much of the progress that has been made to significantly increase patient access to care. The next child facing Braxton’s medical diagnosis, in other words, might not be as fortunate.
Bret Mettler is the director of pediatric cardiac surgery at Johns Hopkins Medicine. The views expressed here are his own.
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