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The coronavirus disease 2019 (COVID-19) pandemic has revealed how ill prepared our current state licensure and individual hospital credentialing procedures are to respond to a crisis, which requires hiring more physicians. In the past year, various states have been in desperate need of additional physicians to care for critically ill patients. Because physician licensure is by state, states had to waive this requirement to hire physicians licensed in other states. In addition, hospitals had to implement their disaster plans to streamline credentialing requirements to bring on additional physicians whether from in-state or out-of-state.
Along with increased demand for in-hospital physicians, the COVID-19 pandemic also saw a dramatic increase in demand for virtual visits of over 2000% between January 1 and June 16, 2020, among a national sample of persons with commercial or Medicare Advantage insurance.1 This increase unveiled another limitation of state licensure.2 Although an out-of-state patient can be seen in a physician’s office, that same physician cannot have a virtual visit with the same out-of-state patient. In many towns near a state border, patients may choose to get medical care in a different state; for example, people in eastern New Jersey commonly go to New York City for medical care. Existing state licensing requirements had to be waived to allow these visits to continue as virtual visits during the pandemic. In addition to state-based licensure requirements, physicians performing services for multiple hospitals, such as a radiologist reading digital films via teleradiology, would need to be separately credentialed and privileged at each hospital. Further complicating matters, closures due to COVID-19 resulted in challenges verifying primary sources of physicians’ information and documentation for credentialing.
By allowing physicians licensed in 1 state to practice in another, and using disaster credentialing standards, NYC Health + Hospitals was able to staff up to meet urgent needs during the pandemic. To strengthen the ability of the US to respond to future crises, better allocate medical personnel to areas of need and also reduce administrative costs, permanent ways of enabling physicians to practice in any state are needed, such as a national physician license. Reforms are also needed to make physician credentialing for individual hospitals less onerous while maintaining quality standards and minimizing fraud.
There are many strong reasons and precedents for establishing a national medical license in the US. As Mullangi and colleagues explain in their timely Viewpoint in this issue of JAMA Internal Medicine,3 the requirements for obtaining a state license are essentially the same (ie, graduation from medical school and passage of a federal licensure test) across the country. Also, although there are regional differences in medical care, they are not by design. The Department of Veterans Affairs already accepts any valid state license to practice in any of its facilities (federal laws supersede state laws) and the system works well. Nonetheless, as detailed by Mullangi et al,3 state licensure has deep roots in the tenth amendment of the Constitution, provides revenue to state governments and medical boards, and at times seeks to prevent competition from related health professions.3,4
Given that a national license is not imminent, Mullangi et al3 propose a good intermediate step: build on the Interstate Medical Licensure Compact (IMLC). At present, more than 25 states have joined the compact and agreed to the same licensure requirements and to accept each other’s review of the applicants.5 Were the federal government to require all states to join the compact, obtaining a new state license, if a physician already had 1 in another state, could potentially require only paying a fee (as opposed to each state medical board verifying credentials as well as other requirements). An advantage of state licensure may be to facilitate patients’ ability to report instances of alleged physician malpractice or inappropriate behavior. Patients may find it easier to contact a local authority than a national one, and hearings to consider physician behavior could be held at a local site.
Even if the US had a national physician license at the time that COVID-19 hit, hospitals would still have had to invoke their disaster plans to waive usual credentialing processes and immediately employ the physicians needed to staff for the pandemic. Credentialing is the process by which the education, training, licensure, registrations and certifications, sanctions, as well as work history, including malpractice litigation, are documented and approved by the medical facility where the physician intends to provide care. In the credentialing process, many of the same documents required for state licensure are reverified; recredentialing must be periodically performed, up to every 3 years, with elements subject to change reverified. The Centers for Medicare & Medicaid Services (CMS) requires credentialing of hospital-based physicians, but not physicians providing care in private physicians’ offices. Although physicians do not need to be credentialed for care in private physicians’ offices, they require hospital credentialing if they want the right to admit patients. In addition, all physicians must be credentialed by CMS to bill Medicare, Medicaid, and by insurance plans to submit claims. The requirements for CMS, and for insurance plans, are very similar to the requirements for hospital credentialing.
A key obstacle with credentialing is the requirement that each entity (hospitals and insurance plans) independently verifies credentials. In practical terms, no matter how many hospitals a physician has worked in, no matter how many states in which he or she holds a medical license in good standing, no matter how many insurance plans have previously enrolled the physician, each hospital or insurance plan must independently verify the credentials. It is this redundancy—that each hospital and insurer independently verify the data—that causes the long delays between when a physician accepts a position and when he or she can begin work and/or bill for services. For example, when one of us (M.H.K.) moved from California to New York in 2018, he had to first obtain a New York State medical license. Next, he had to submit much of the same information to be credentialed to see patients and bill insurance in the outpatient system of NYC Health + Hospitals; this second process took longer than obtaining a license.
There are ways of reducing redundancy in the credentialing process short of a disaster scenario as with COVID-19. One is health care networks sharing credentialing elements among its member facilities. Another method is delegated credentialing, where insurers can assign credentialing verifications to delegated entities (such as health care facilities). Still another is credentialing by proxy in telemedicine, which enables originating sites (health care facilities where a patient is located) to rely on credential verifications by distant sites or telemedicine entities. Although these procedures increase efficiency, they require periodic audits (eg, an insurer will audit a subsample of physician credentialing folders to be sure that the hospital correctly credentialed the physicians) or other forms of oversight.
A more robust method for reducing inefficiencies and increasing accountability in medical credentialing builds on the suggestions of Mullangi et al,3 and others.6 Put simply, the US should have a single, national source of truth for physician credentials. At present, there are limited efforts in this direction. The Federation of State Medical Boards (FSMB) enables physicians to establish a repository of verified core credentials; this can be especially helpful for applicants who trained at postgraduate programs that have since closed. The FSMB also maintains a physician data center that is available to be queried by health care institutions; it includes physician medical school graduation, disciplinary actions by regulatory agencies, federal Drug Enforcement Administration (DEA) registration, and board certification, but not training, work history, or malpractice information. The American Medical Association also maintains a Physician Masterfile that includes information on medical education, residency training, and other professional certification. There are many credential verification organizations (CVOs), that for a price will check credentials. The National Practitioner Data Bank, administered by the US Department of Health and Human Services, is a repository of reports on medical malpractice payments and certain adverse actions against physicians, such as actions taken against their licenses and certifications, and negative actions by peer reviewers. For health care organizations that credential physicians, querying the National Practitioner Data Bank is a federal requirement. The CMS requires that additional databases are queried to ensure that physicians have appropriate credentials and are not excluded from practice or from billing: the CMS opt-out and preclusion list, the national plan and provider enumeration system (NPPES), Social Security Administration records, and the system for award management (SAM).
Although the use of credentialling databases and services may be more efficient than checking credentials against primary sources, these databases are not universally used. The reasons include the cost of querying the databases or the fact that there is not 1 database that has information on all the requisite credentials. Another possibility is that many institutions have employees whose jobs are to verify credentials; the institutions may not wish to either lay off these employees or to train them for other positions.
Given that all physicians must apply to CMS for a national provider identification (NPI) number as HIPAA covered entities, it would be sensible for CMS to establish a system of record for all physicians and to link it to the NPI. Starting with graduation from medical school, the diploma could be validated, along with scores on licensing examinations, residency completion, board certification, state license, special certifications, as well as the other requisite credentialing elements not currently included in the FSMB, AMA, and other services or databases. The exhibits could be available online for viewing, expiration dates could be included. These credentials should be in a secure, trusted digital format, directly issued by primary sources on a platform that enables digital sharing. The data on the platform could be used by CMS to enable physicians to bill Medicare and Medicaid without a separate application. The platform could also be linked to registration information from the DEA, with whom physicians register to be able to prescribe controlled substances. Another advantage of linking credentials to the NPI is that the system could then also be used to credential other clinicians, including but not limited to nurse practitioners, physician assistants, and pharmacists, all of whom have NPI numbers.
Implementing our proposals would not require a government subsidy. Individual physicians would pay to register in exchange for not having to submit their materials and medical education and practice histories multiple times. Hospitals and insurers would pay to access the system. Having a single national repository would not only smooth staffing burdens during either a pandemic or normal operations, but has been estimated to save more than $1 billion annually.6 Potentially, to be verified physicians would not even need to fill out forms with their professional information. Once their identity was confirmed, information would simply be downloaded onto a common form from the database.
In addition to credentialing, privileging is the process by which health care facilities grant a credentialed physician the ability to perform functions and procedures specific to a practice location, such as angioplasty or endoscopy. The privileges that health care facilities grant are subject to routine ongoing professional practice evaluation (OPPE), and—when there are questions of competency—focused professional practice evaluation (FPPE). Unlike licensure and credentialing, it makes sense for privileging to continue to be done at the hospital or health care facility level to assure physicians are experienced in the medical procedures they will perform. Compacts of hospitals could standardize what privileges would normally be granted physicians of different types, with the ability of an individual hospital to not grant a particular privilege to a physician on a case-by-case basis.
The COVID-19 pandemic has shown that the current US system of state licensure and hospital-based credentialing precludes the rapid hiring of physicians. Without waiving the usual license requirements and using disaster plans New York City would never have been able to respond to the COVID-19 pandemic. We can learn from these experiences so that we can more rapidly and flexibly deploy our physician workforce, decrease delays and administrative expenses, reduce fraud, and modernize physician licensing and credentialing.
Corresponding Author: Mitchell H. Katz, MD, NYC Health + Hospitals, 125 Worth St, Room 514, New York, NY 10013 (firstname.lastname@example.org).
Published Online: January 13, 2021. doi:10.1001/jamainternmed.2020.8705
Conflict of Interest Disclosures: Dr Bell reports discussing the development of technology to do digital credentialing with several companies. No money was earned. No other disclosures were reported.
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Bell DL, Katz MH. Modernize Medical Licensing, and Credentialing, Too—Lessons From the COVID-19 Pandemic. JAMA Intern Med. Published online January 13, 2021. doi:10.1001/jamainternmed.2020.8705
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