The Future of Licensure

By David Witmer posted 06-28-2016 09:54


Last August in this blog I asked if it was time for pharmacy to reassess its licensure model ( . Only a couple of you responded with comments. At the time I shared a report from President Obama’s economic team that had been released in July and discusses the economic burden of inconsistent state licensing requirements. The report is titled “Occupational Licensing: A Framework for Policymakers” and it remains a worthwhile read.  But I only touched briefly on the problems with pharmacy’s (and for that matter all of health care’s) antiquated approach to licensing health professionals.

Then at this year’s ASHP House of Delegates three separate delegates submitted recommendations that ASHP in some form or fashion should advocate for reform in how state boards approach licensure.  One recommendation from the Arizona delegation suggested timelier, “real-time” information exchange to ensure more timely reciprocity. Another from Past President Dan Ashby went further and suggested that ASHP consider pursing options such as the Nurse Licensure Compact model recommended by the White House White Paper. The most far-reaching recommendation came from Julie Groppi and colleagues from the VA that asked that ASHP explore a standardized framework for licensure and credentialing nationally.

So what is wrong with our current approach? Clearly one criticism lies with the burdensome process for reciprocating licenses between states. This can pose significant challenges for residency programs when residents are unable to reciprocate a license in a timely manner. But this is really just the tip of the iceberg. Let’s explore the concept of a state-based license and how it is really a round peg in a square hole in today’s health care environment.

Health care has evolved and is now organized and delivered through practitioners who are part of increasingly larger corporate enterprises. Hospitals and health systems have been merging into vast and far reaching enterprises that span multiple states and in more cases even multiple countries. Care within these enterprises is organized and managed by teams of health professionals. These health care enterprises seek to organize their staffing models in ways to are both efficient and utilize the skills of their workforce in ways that they can achieve optimal outcomes for the patients under their care. The problem is that with today’s patchwork array of state-based regulations it is difficult to fashion a model that can be deployed to scale nationally. Pharmacists’ scope of practice varies state by state and the role of technicians is also inconsistent. In short, they need to approach each state individually.

Health care is also not delivered exclusively in one location. Technology has evolved faster than our laws and regulations. Telepharmacy and telemedicine are enabling new ways to communicate with patients, collect and track patient data, and deliver medicines. The challenges of state licensure to telemedicine are highlighted in a June 26 piece in the Wall Street Journal entitled How Telemedicine Is Transforming Health Care. Rural hospitals may have pharmacy services provided by pharmacists located physically in another state. Pharmacists in mail-order facilities likewise provide care in multiple states. These pharmacists are required to obtain multiple licenses at considerable time and expense. There has also been some uptick in recent years in selected states requiring specific CE requirements to maintain a license adding further to this burden.

Why is health care regulated by states anyway? I suspect it harkens back to the days when solo physician practices were the norm and pharmacies were primarily owned and operate by a single independent owner. Health care was a much more localized enterprise. But today’s health care enterprise looks a lot more like interstate commerce. Health care is increasingly corporatized. While some mergers have been within a state, increasingly regional, national, and yes even international corporations are becoming the norm. Does it still make sense to regulate health care through the states? Is patient care really better served through this patchwork quilt of state regulations?

I know, I know… a discussion of a national license is not likely to get much traction. There are many barriers to achieving such a radical redesign of the licensing model. But we are well overdo to examine what could be done to streamline and better standardize licensing. The Nursing Licensure Compact is certainly a step in the right direction. At the very least it permits enhanced mobility of nurses to practice in multiple states without the burden of maintaining separate licenses and adhering to multiple CE requirements.

What do you think should be changed? How would you fashion a new model?

#credentialing #ResidencyProgramDirector #AmbulatoryCarePractitioners #NewPractitioners #PPMI #SmallandRuralHospitals #HouseofDelegates #PharmacyPracticeManagers #PharmacyStudents #BoardMembers #ASHPStaff #licensing #licensure #Resident #InpatientCarePractitioner #ClinicalSpecialistsandScientists #Advocacy #HealthCareReform #GovernmentAffairs #Accreditation #scopeofpractice



07-18-2016 09:55


Always good to hear from you! Glad someone is starting a conversation on this.

You're right of course that we no longer have hold out states (like FL and CA did for years) who maintain a separate exam to obtain licensure, but we still have separate indivudal licenses. A single exam is not the same as a single license.

For example, if your organization is serving rural hospitals covering the night shift remotely then you now need to have staff maintain multiple licenses in each state where care is provided. I recall one discussion a few years ago with someone informed me that they were paying for some of their staff to maintain over 15 separate licenses. And each of those licenses came not just with separate license fees, but with separate CE requirements. With increasing frequency I am seeing BOPs (or state legislatures) requiring separate and unique requirements such as HIV, Law, patient safety, etc. Of course, getting licenses reciprocated is cumbersome as well and creates challenges for residency programs when residents move from one state to another (especially when they are entering a PGY2 program in another state). And yet as you note the examination and basic requirements for obtaining a license are pretty standard.

The nursing compact states are an example of a significantly more modernized approach. You don't have to get a separate driver's license in each state you plan to drive in or register your car in another state before you drive there. State compacts recognize your license and allow you to utilize the license from your home state. You must abide by the laws of the state where you are driving and you are subject to legal punishments should you fail to do so. The nursing compacts take this approach. My wife practices in another state but did not need to take months to get licensed there. She has to meet the CE requirements in her state of residence and pay license fees to one state.

If there is a need for discipline to be administered locally (which could probably be an interesting debate on pros/cons on its own) then this approach would still accommodate it. States would still have the ability to administer discipline for practice in their respective states.

I don't see a national license happening in my lifetime if at all. And honestly I am not sure that it would even be the right answer. But I think the nursing compact model is worth a careful look. I think there are now 26 states that have adopted the compact model. Have you looked into this approach at all? Any thoughts?



07-15-2016 10:55


Sorry to have missed this earlier;  your thought-provoking blog raises some interesting questions. I have a few thoughts:

1) To a large extent, we already have national licensing since I believe that there are no longer any states that "roll their own" competency exams. I believe that now all states use the NABPLEX exam to evaluation professional competence.

2) Professional practice, however, is governed by state law, which means that demonstration of legal/regulatory competence is a state-by-state process.

3) Having presented at a variety of Board of Pharmacy (BOP) meetings over the last ten years, I observe that there appears to be an ongoing need for local discipline. Every one of the meetings I attended consumed over half its agenda with disciplinary action. I spoke yesterday with a pharmacist active in California who told me that her experience was not different.

4) That same experience taught me that BOP's tend to see protection of pharmacists jobs in their state as a mandate. So there are probably economic pressures to keep licensure local.

I agree that the new reality for pharmacy practice is that state boundaries tend to be somewhat artificial and limit the ability of providers to do where they are needed. The fact that there is now what is, fundamentally, a national examination would seem to make that practical.

Having said that, nationalizing pharmacy licensure would require changes to laws in all 50 states:

  • Would there still be a pharmacy practice act? Probably, pharmacies would probably still be licensed locally and the need for disciplinary action still exists.
  • How would disciplinary action on a state level affect national licensure?