In order to practice medicine in Missouri, physicians must apply for and be granted a license by the Missouri Board of Registration for the Healing Arts. This license is valid for practice only within Missouri, and licenses from other states do not currently qualify a physician to practice in Missouri. HB 2046, passed in 2020, established licensure reciprocity, allowing physicians who hold a valid out-of-state license to apply for and receive an expedited license for practice in Missouri so long as they have been licensed for at least one year in their current state of practice. SB 300 would enter Missouri into the Interstate Medical Licensure Compact (IMLC). Under this agreement, which has been joined by 29 states as of April 2021, physicians who wish to move to a new state to practice medicine or wish to practice in multiple states are eligible for an expedited licensure process. The IMLC enacts a uniform set of requirements for license eligibility, including background checks. The IMLC would also allow out-of-state physicians who apply for licensure in Missouri to practice telemedicine across state lines. Executive Order 20-04, issued in March 2020 during the COVID-19 pandemic, temporarily allows out-of-state physicians to practice telemedicine in Missouri without a license in the state, but this order is set to expire in August 2021.
In order to practice medicine, physicians must pass a national qualification exam and be licensed by the state medical board where they reside. As a result, physicians must seek additional licensure if they move to a new state, wish to practice in multiple states, or wish to practice telemedicine across state lines. To streamline licensure in these cases, 29 states and Washington, D.C. have enacted legislation entering them into the Interstate Medical Licensure Compact (IMLC). The IMLC establishes a uniform set of eligibility requirements for additional licensure in its member states, including 1) medical licensure in their current state, 2) no prior disciplinary actions, criminal history, or ongoing investigation, and 3) participation in a criminal background check.1 Traditional physician licensure would remain the responsibility of the Missouri Board of Registration for the Healing Arts if the IMLC is adopted.
Currently, out-of-state physicians who wish to become licensed to practice in Missouri are eligible to do so under an expedited process, so long as they have been licensed in another state for at least a year.(20 CSR 20150-2.030) By joining the IMLC, physicians in Missouri would be eligible for an expedited licensure process in other states, allowing them to work physically or remotely (i.e., using telemedicine) across state lines. The number of telemedicine visits nationwide has increased by as much as 150% over the course of the COVID-19 pandemic, and the number of licenses sought by physicians in IMLC states also increased by over 150% from February to October 2020.2,3
Figure 1. Map of states that have joined the IMLC or have proposed legislation to join. As of 2021, 29 states and Washington, D.C. have entered the IMLC. Several states have passed legislation to enter the compact but have not yet implemented it, and several other states have proposed legislation to join. Map reproduced from www.imlcc.org.
Despite the large number of professions with state-specific licensure, few studies have carefully quantified the effects of interstate licensure agreements on outcomes such as inter- or intrastate migration, employment, or wages. The Nursing Licensure Compact (NLC) is legislation similar to the IMLC and currently contains 34 states, including Missouri. A study of its impacts finds no evidence of increased migration of nurses following adoption of the NLC. However, this study did not examine changes in telenursing or commuting across state lines, so there may still be effects on labor supply and medical care availability that have not yet been described.4 Additionally, it has been reported that nurses and physicians migrate at relatively higher rates than those in other professions that also have national qualification exams and state-specific licensure, suggesting that this licensure process may not be the main barrier to nurse and physician mobility.5
Peer-reviewed research in this area is scarce, but a new preliminary study (which has yet to be peer-reviewed, confirmed, or replicated) finds that adoption of the IMLC may have different effects in urban and rural areas. Specifically, this work finds that the average rural hospital experiences a loss of 90 inpatients annually and a 3.5% drop in inpatient revenue following entry into the IMLC. However, rural hospitals also report increases in inpatient satisfaction levels and reduced rates of mortality following entry. In contrast, urban hospitals gain 2.8% in outpatient revenue after entry, and experience no improvement in treatment quality. Future studies and review of this work will be needed to confirm these findings.3