In every state, it is a crime to practice medicine without a license. But a medical license is good only in the state that issued it after a rigorous credential and background check.
The result, many experts say, is an outmoded, red-tape-laden medical licensing system that is hampering efforts to relieve physician shortages, improve health-care access, and expand telemedicine.
The Interstate Medical Licensure Compact aims to streamline matters by allowing doctors licensed in a state that belongs to the compact - a sort of treaty - to quickly and easily get privileges in other participating states.
Two years ago, the compact was little more than a paper proposal developed by the nonprofit Federation of State Medical Boards, which represents all physician licensing boards in the United States. Early this year, seven largely rural states enacted laws to join the compact.
Four more states have joined since then. And 20 states - including Pennsylvania but not New Jersey - have introduced legislation to do the same.
The Hospital and Healthsystem Association of Pennsylvania has come out in support, while the Pennsylvania Medical Society, which represents doctors, is on the fence.
State Rep. Jesse Topper (R., Bedford) introduced the bill last month. "I'm from a very rural district. We understand we have a shortage of physicians. Telemedicine is becoming more and more prevalent," he said, and could help relieve shortages.
But there is opposition to what is known as license "portability." The politically conservative Association of American Physicians and Surgeons has expressed concern that itinerant abortion doctors will become even more mobile.
Confusion is another problem, despite the federation of medical boards' efforts to explain the compact through a website (www.licenseportability.org) and YouTube webinars. Topper, for example, said in an interview last week that interstate licensure would apply only to telemedicine - the remote care of patients using telecommunications technology. It wouldn't.
"It will be a full and unrestricted license," said Lisa Robin, the federation's chief advocacy officer. "It will not be limited to telemedicine."
Federal agencies, notably the Health Resources and Services Administration, have been pushing for interstate licensing arrangements for years. Indeed, the federation of medical boards developed the compact plan using a federal grant.
Here's how the agreement will work: A physician applies for a "principal" license in his home state, which does the usual credential and background checks. The physician selects compact states for licenses that are essentially automatic.
Physician demand for the service is unclear. Last year, 78 percent of the nation's 916,000 physicians were licensed in only one state, 16 percent were licensed in two, and 6 percent were licensed in three or more, according to the federation of medical boards. But those figures may be less an indicator of desire than of the hassle and costs of the current process.
Thomas Jefferson University, for example, launched its four-month-old telemedicine program, JeffConnect, in just three states after calculating the licensing barriers to going national. Licensing a handful of Jefferson physicians in the majority of the states would have cost about $1 million, required four full-time clerks to do the paperwork, and taken at least 18 months, said emergency medicine physician Judd Hollander.
"It's just ridiculous," said Hollander, who was recruited to lead JeffConnect.
The University of Pittsburgh Medical Center, which has invested $1 billion in telecommunications and information technology over the last five years, sees compact licensure as a way to expand services to rural areas that straddle state lines.
"We've been offering tele-maternal-fetal medicine for over a year to women at a community hospital in Steubenville, Ohio," said Natasa Sokolovich, UPMC executive director of telehealth. "These high-risk pregnant patients often forgo care," she said, because specialists are so far from their homes.
But the Ohio Medical Board announced in July that it was not pursuing legislation to join, concerned about "loss of self-determination, financial issues, legal issues, and the administrative burden associated with additional bureaucracy and lack of operational clarity."
Another potential snag: discipline of physicians with interstate licensure. Critics foresee a potential legal mess, because if a doctor's principal license is suspended or revoked, so are the compact licenses. Yet the doctor has had no chance to defend himself in the compact states.
Conversely, if there are communication gaps between states, dangerous doctors may exploit the system to keep practicing.
"There is a big disparity in disciplinary rates between states," said physician Sidney M. Wolfe, cofounder of Public Citizen's Health Research Group, a consumer advocacy organization. "If nothing is on the doctor's [principal license] record, and he wants to get a license in a second state, the second state doesn't have any clue" about misconduct.