By Lori H. Kels, MD, MPH and Charles G. Kels, JD

The Interstate Medical Licensure Compact:

Balancing Licensure Portability and State Autonomy

By Lori H. Kels, MD, MPH and Charles G. Kels, JD

2022 marked Texas’s first year as a member state of the Interstate Medical Licensure Compact (IMLC). On June 7, 2021, Texas became the 33rd state to join the IMLC when Governor Greg Abbott signed House Bill 1616 into law.1 On March 1, 2022, Texas compact licensing became operational, with Texas physicians able to apply for out-of-state licenses and out-of-state physicians able to apply for Texas licenses via the IMLC mechanism.

The IMLC facilitates interstate practice, whether through telemedicine or in-person care such as locum tenens arrangements, by simplifying and easing the licensure application process between member states. The compact is also designed to enhance patient protection through additional layers of physician vetting, beginning with a requirement for the applicant’s home state to verify their qualifications for IMLC participation.2 Additional state licenses obtained via the IMLC are neither special purpose licenses (such as limited telemedicine licenses), nor new national or multistate licenses. They are unrestricted state licenses identical to the traditional (and historically more onerous) process of applying for multiple licenses directly. Accordingly, a physician’s practice in another state – whether in-person or virtual –remains subject to the oversight and regulation of the relevant state medical board based on the patient’s location.3 For qualifying physicians already licensed in a member state, the IMLC offers an additional pathway for multistate licensure that seeks to minimize redundancies and centralize administrative functions; more conventional licensure avenues remain available and in place.4

Arguably the greatest strength of the IMLC is its balance between streamlining physician mobility and preserving state regulation of medicine, which is a key tenet of federalism under US constitutional governance. Medical licensing is a quintessential exercise of states’ inherent authority to protect the health, safety and welfare of their inhabitants.5 Yet licensure barriers to cross-state practice can pose problems of inequity, complexity and perceived obsolescence in an increasingly interconnected world, especially since pandemics and other disasters do not respect artificial boundaries. These challenges have led to growing calls for upending the current state-based system through national or federal licensure, or alternatively through defining the telemedicine site of care as where the physician, rather than the patient, is located.6 Either option would inevitably erode state primacy in verifying the competency, qualifications and character of physicians delivering care to the local population.

In addition to advances in telemedicine technology, one of the impetuses for the Federation of State Medical Boards (FSMB) to steer the development of the IMLC a decade ago was its recognition that an innovative state-based solution was essential to maintaining states’ historical and constitutional role in regulating the professions and protecting the public. Previous efforts, such as the Federation Credentials Verification Service and uniform licensure application, proved helpful but ultimately insufficient to meet the emerging challenge.4 The ingenuity and enduring promise of the IMLC is that it provides an expedited pathway for physicians to obtain multiple licenses while keeping the traditional regulatory authority of state medical boards intact.

The IMLC addresses an identified barrier to access to care by leveraging, rather than enervating, a physician’s home state license through a clearinghouse function that streamlines multistate licensure while adding appropriate safeguards. The resulting licenses obtained by physicians seeking to expand their virtual or physical reach are full and separate medical licenses, reaffirming states’ jurisdiction over the conditions of practice impacting their communities but reducing unnecessary duplication and delay. Promulgated under the auspices of the FSMB and endorsed by the American Medical Association, the IMLC was designed to achieve license portability through voluntary mechanisms compatible with state prerogatives and physician self-policing through medical boards.3 The Texas Medical Association (TMA) had advocated for Texas to join the compact for multiple legislative sessions before the efforts came to fruition last year.

Although the IMLC model of expedited licensure is less robust than an automatic reciprocity system such as the Nurse Licensure Compact,7 its careful construction to obtain widespread buy-in among state capitals remains integral to the venture’s lasting success (Table). Adoption of the IMLC by remaining US states and territories is both a test of the flexibility of time-honored licensure mechanisms to meet emerging needs and an imperative to address geographical physician shortages, both during and outside of crises such as the COVID-19 pandemic.2 Since Texas adopted the compact last year, it has been joined by four more states, bringing the current total to 37 states, the District of Columbia and Guam.8 Table

Interstate Medical Licensure Nurse Licensure Compact (NLC) Compact (IMLC) Participation 37 states, District of Columbia, 35 states (awating implementation in Guam OH and PA) Texas Yes Yes membership Mechanism Expedited pathway through IMLC Multistate license / Automatic Commission reciprocity Process (1) Confirm eligibility Obtain multistate (compact) license (2) Apply through IMLC portal from primary state of residence (3) Receive letter of qualification (PSOR) in a compact state (LOQ) from state of principal license (SPL) (4) Select additional member states and pay state fees" Result Additional state license(s) Multistate (compact) license Lori Kels, MD, MPH is a board-certified psychiatrist and an Associate Professor at the University of the Incarnate Word School of Osteopathic Medicine, where she serves as the Psychiatry Clerkship Director. She is also a member of the Bexar County Medical Society (BCMS) and serves as the UIWSOM representative on the BCMS Board of Directors. Lieutenant Colonel Charlie Kels is an associate general counsel for the Defense Health Agency and a judge advocate (JAG) in the U.S. Air Force Reserve.

Disclaimer: The views expressed are those of the authors and do not necessarily reflect those of the Department of Defense or any of its components.

References: 1. Tex Occ Code Ann § 171. 2. Adashi EY, Cohen IG, McCormick WL. The Interstate Medical Licensure Compact: attending to the underserved. JAMA. 2021;325(16):1607-1608. 3. Steinbrook R. Interstate medical licensure: major reform of licensing to encourage medical practice in multiple states. JAMA. 2014;312(7):695-696. 4. Chaudry HJ, Robin LA, Fish EM, Polk DH, Gifford JD. Improving access and mobility: the Interstate Medical Licensure Compact. N

Engl J Med. 2015;372(17):1581-1583. 5. Dent v W Va, 129 US 114 (1889). 6. Slomski A. Telehealth success spurs a call for greater post-COVID19 license portability. JAMA. 2020;324(11):1021-1022. 7. National Council of State Boards of Nursing. Nurse Licensure Compact. https://www.ncsbn.org/nurse-licensure-compact.htm. 8. Federation of State Medical Boards. Interstate Medical Licensure

Compact. https://www.imlcc.org.