Telemedicine exploded in popularity after the hit of COVID-19, but the limits are coming back for care delivered across state lines.
This complicates follow-up treatments for some cancer patients. It can also affect other types of care, including mental health therapy and routine medical visits.
Over the past year, nearly 40 states and Washington, D.C., have ended emergency declarations that have made it easier for doctors to use video visits to see patients in another state, according to the Alliance for Connected Care, which advocates the use of telemedicine.
Some, like Virginia, have created exceptions for people who have an existing relationship with a doctor. A few, like Arizona and Florida, have made it easier for out-of-state doctors to practice telemedicine.
Doctors say the resulting patchwork of regulations is confusing 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 meetings.
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 does not have a specialist near her home outside of Denver who can treat her. These visits were done virtually during the pandemic.
She will travel without her husband to save money, but this poses another problem: if she receives bad news, she will manage on her own.
“It’s stressful enough to have a rare cancer, and it 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 it was before the pandemic, when video visits were still emerging.
“It seems so dated,” said MacDonald, who recently co-authored an article on the matter in the New England Journal of Medicine.
To indicate medical advice, the location of the patient 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 winter, said Dr. Lee Schwamm, vice president of Mass General Brigham Health System.
This does not help doctors like MacDonald who see patients from across the country.
Cleveland Clinic also attracts a lot of patients from out of state. Neurosurgeon Dr Peter Rasmussen is worried about how some will handle upcoming travel, particularly because winter can bring freezing weather.
A fall “could literally end the life” of someone with a condition like Parkinson’s who struggles to walk, he said.
Psychiatrists have another concern: finding doctors for patients leaving the state. This is especially difficult for students who are temporarily leaving home.
Most U.S. counties don’t have child and adolescent psychiatrists, noted Dr. Shabana Khan, chair of the American Psychiatric Association’s telepsychiatry committee.
“If we’re trying to transition patients, often there’s no one there,” Khan said.
Helen Khuri’s mother found a specialist to help her when the 19-year-old girl’s post-traumatic stress disorder 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 inside the hospital that offered it.
She rented an apartment with her father in order to be in the same condition for telemedicine visits, a situation she called “ridiculous”.
“It didn’t necessarily make sense to…uproot my life, just to receive this three-week treatment program,” Khuri said.
Even people who see doctors near them can be affected.
Dr. Ed Sepe’s pediatric practice in Washington, DC, has patients from Maryland who have started traveling a few miles across the border to connect via video. This saves them a 45-minute trip downtown for an in-person visit.
“That’s silly,” he said. “If you’re under a doctor’s care and you’re in the United States, it doesn’t make sense to have geo-restrictions for telemedicine.”
Sepe noted that low-income families tend to work in jobs that don’t allow time off for in-person visits. Some also find it difficult to move. Video tours helped overcome these barriers.
“It’s more important than just telemedicine,” he said. “There is a missed opportunity here to level the playing field.”
States can play an important role in the growth of telemedicine by guarding against fraud and protecting patient safety, according to Lisa Robin, an executive with the Federation of State Medical Boards.
But the federation also recommends that states relax certain restrictions on telemedicine.
This includes allowing virtual follow-ups for someone who has traveled out of state for treatment or for people who are temporarily moving but want to stay with a doctor.
States could also form regional pacts with their neighbors to facilitate cross-border care, noted Dr. Ateev Mehrotra, a Harvard health policy professor who studies telemedicine.
“There are so many ways to solve these problems,” he said.
In the meantime, patients who need care are now trying to figure out how to manage them.
Lucas Rounds doesn’t know how many visits he’ll make to see MacDonald in Boston to monitor his rare bone cancer. The 35-year-old Logan, Utah resident already spent months away from home earlier this year, undergoing radiation therapy and surgery.
Plus, he has a wife and three young daughters and expenses like a mortgage to consider.
Rounds says he has to think about taking care of his family “if the worst happens.”
“If I die of cancer, then all of these expenses that we’ve accrued…those are dollars that my family wouldn’t have,” he said.
The Associated Press Health and Science Department is supported by the Howard Hughes Medical Institute Department of Science Education. The AP is solely responsible for all content.