The Pennsylvania Department of Health is moving at full speed trying to implement an extremely limited medical cannabis law, but there may be a poison pill planted by legislators: Making doctors join a special list.

Only two states operate a similarly draconian "physician registry" scheme for marijuana: New York and New Jersey.

This single provision has proved to be the most difficult obstacle for patients trying to gain access in both states because only a handful of doctors have joined.

Just 474 out of 38,500 practicing physicians in New Jersey and 1,123 out of 96,000 doctors in New York have signed on to write cannabis recommendations. Patients can't get into the program without one of those doctors. This has kept participation by qualifying residents in both states at a minimum.

Notably, there are no such registry lists for other drugs. We trust anyone with a prescription pad to have the knowledge to dispense an amazing variety of incredibly addictive and all-too-easily-obtained deadly drugs every day. But nontoxic marijuana gets singled out.

The fiscal notes for the N.Y. and N.J. laws envisioned hundreds of thousands of cannabis patients and the same was true with Pennsylvania's law, Act 16.

Now, years after actually opening the programs, the latest reports show that New York has 24,555 registered patients and New Jersey has just 13,200 with legal access.

Millions of people live with conditions that qualify in both of those states. The single bottleneck of the doctor registry has been immensely chilling.

Pennsylvania announced the physician registry for medical cannabis last week. Unless something changes, there may not be many customers for the small cartel of recently licensed Keystone State cannabis operators who are racing to open.

Building the wall

It's important to understand the origins of this formidable barricade because states that have more successful patient registration rates allow any doctor to write the recommendations.

Forcing doctors to register was a concept invented by the New Jersey Department of Health in 2011.  Gov. Christie was micromanaging the regulatory phase of the compassionate-use law that was passed just before his inauguration.

In now-familiar fashion, Christie railed against the plant while the health department issued hundreds of pages of the most onerous regulations in the country.

I had a front-row seat at the time and reviewed some of the drafts in a crowded conference room at the health department's headquarters in Trenton as a volunteer for the Coalition for Medical Marijuana New Jersey.

The meticulously crafted regulations put the state of New Jersey as arbiter of a nonprofit cartel. The six vertical operations grow and sell the products from the same sites. The Garden State had positioned itself to vigorously defend the precious crop from an onslaught of quack doctors and scam-artist citizens just looking to get high.

The state wanted a 10 percent cap on THC content and a 7 percent sales tax paid directly by patients. This wasn't in the law; neither was the new registry scheme for physicians.

In one of his regular Hugo Chavezesque appearances on NJ 101.5 FM, Christie admitted to using the regulatory process as a way to rewrite the entire compassionate-use law. Advocates, patients, legislators, and medical professionals immediately recognized the doctor registry requirement as a new and severe prohibition

Months later, during the public comment phase with N.J.'s health department, there was voluminous testimony gathered and presented in an attempt to eliminate that section. But the Christie administration almost seemed to revel in devising new restrictions and insisted that doctors get a special set of papers. The calculated move effectively put a wall between residents and their regular primary-care physicians when it came to medical marijuana.

Why doctors stay away

Despite being genuinely sympathetic to their patients and well-educated on the science, doctors have a wide range of reasons for not loining the registry, including the fear of losing the multiplicity of required insurance or relationships with major health providers.

The other factor is also practical, and a direct result of requiring a registry at all: Being on the list makes people call just for marijuana, possibly getting in the way of the rest of the practice.

An oncologist who joins the registry for a single cancer patient doesn't want to get flooded with calls from Crohn's disease patients seeking a recommendation. So they don't join.

In the last seven years of the Garden State's program, both the actual science of and national awareness about medical marijuana have increased exponentially. Still, based on the numbers, N.J. doctors have clearly shunned the registry process.

New Jersey and New York (eventually) made the participating doctor lists public, but many aren't taking new patients.

An added expense for patients

This puts qualifying residents in a tough position. If their regular doctor or specialist agrees with cannabis therapy but won't join the registry, they have to smile and dial their way down the list.

Dozens of patients in New Jersey have reached out to me about the experience: It sucks.

Patients have to pay between $450 and $700 for several office visits to establish a legally "bona fide" relationship. Because health insurance does not cover any aspect of medical marijuana, this cash comes directly out of the patient's pocket.

Only after the registered doctor approves can the patient then register with the state for access. That also has an annual fee. The recommending doctor sets a monthly quantity to be dispensed for 30-, 60- or 90-day intervals. Patients typically pay $100 for each follow-up visit to renew their recommendation.

Typically, N.J. patients say it costs about $1,000 per year to maintain legal status in the program. That's before they pay a single dollar for some actual buds.

What it means for Pennsylvania

The Pennsylvania Department of Health opened the physician registry last week.

Rachel Levine, physician general of the commonwealth, recently defended the registry in an interview with the Inquirer.

In order to qualify, Pennsylvania physicians had to write recommendations, known as "Safe Harbor Letters," to authorize families of pediatric patients to import cannabis products from other states until production starts in Pennsylvania. Levine pointed out that 282 "Safe Harbor" letters have already been issued by the health department. Pennsylvania physicians had to write recommendations allowing the families of pediatric patients to import cannabis products from other states until production starts in Pennsylvania. But, those "Safe Harbor" doctors didn't need to join a registry or take any special classes.

Levine concluded discussion of the doctor registry by saying, "It's an important component and ensures that physicians have the information to make a determination to see if the patient will benefit."

Meanwhile, we grant the power of every other prescription pharmaceutical to the very same doctors without any similar extra scrutiny.

What is immensely telling is the lack of large health networks and hospital groups in Pennsylvania standing beside the health department. They could be sending thousands of doctors to join the cannabis registry, but there's been nothing from that important sector.

The Pennsylvania Medical Society was aggressive in its opposition to the law itself, so it's doubtful it will be training its members for cannabis recommendations.

Taking down the roadblock

This is a big problem, and there are only a few solutions.

First (and best) would be for the Pennsylvania legislature to amend Act 16 to remove the doctor registry requirement. Slim chance there.

Next would be if the health department really won the buy-in of large networks of medical professionals so most patients could just see their own, regular doctors.

There are more than 55,000 practicing physicians across the commonwealth. If the registry proves to have a similar impact as we've seen in other states, we can expect only around 500 doctors to join the Pennsylvania cannabis list during the first year.

And, unless more than 1,000 doctors register, the reality is that most patients, unable to jump over the hurdles, will just stay in the underground marijuana market. That scenario leaves the legal cannabis oil dispensaries with empty shops.

This is the challenge of regulating cannabis. It's about crafting programs with the flexibility to ensure success and real-world access. That's why the Pennsylvania health department and legislators should rethink the physician registry.