All professional licensing laws have some component of trade regulation that is
driven by the affected profession’s interest in limiting competition. State
licensing agencies for lawyers have fought to prevent nonlawyers from helping
people with divorce filings, to prevent the publication of self-help legal books
on estate planning, and to limit the extent that real estate brokers can assist
with the documents for selling real estate. In medicine, trade restrictions were
the traditional focus of regulations. It is only in the last few decades that
medical licensing agencies in many states have even had the legal authority to
discipline a physician for incompetence.
Telemedicine has been promoted as a way to deliver medical services to
remote areas that would otherwise not have access to expert physicians.
Politically, this is the best way to diffuse criticism because it does not threaten
the livelihood of other physicians. Realistically, however, it will be impossible
to restrict telemedicine to such areas. If I am an insurer, I can lower costs and
perhaps improve the quality of care for my insureds by contracting with a
leading medical center for specialty consultations with local general
practitioners. Thus a patient in Atlanta might be able to get a consultation
from a Mayo Clinic physician, but at a lower cost than a local specialist because
the patient’s primary care physician will manage the consultation. The
specialists will be under pressure to price these consultations attractively. They
are already losing business because MCOs are unwilling to send patients to
regional centers for specialty care. The specialists can essentially extend their
franchise at the cost of a fast Internet connection, with no added office
expense or capital expenditures.
Given that many specialties have more practitioners than the patient flow
warrants, especially if the patients could shop over a broader region,
telemedicine is very threatening. This extends down to the primary care
physician level: one of the claims for telemedicine is that it will enable
communities that can only support a nurse to have physician care available
under the direction of the nurse. Once this is accepted, there is no reason why
MCOs would not want to use it for all their primary care patients.
Medical licensing agencies and medical care practitioner professional
organizations must work out a balance between the importance of hands-on
physician care and the obvious advantages of leveraging medical expertise.
Such leveraging can both reduce costs and increase the quality of patient care,
although at the expense of local practitioners.