Blogs

Last August in this blog I asked if it was time for pharmacy to reassess its licensure model (http://connect.ashp.org/blogs/david-witmer/2015/08/21/does-pharmacy-need-to-modernize-its-approach-to-licensure) . 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?