Currently, doctors who want to practice medicine in more than one state must apply for a separate medical license in each state. A model state law drafted by the Federation of State Medical Boards, however, creates reciprocal agreements among states, allowing doctors with a license in any participating state to practice in all other participating states.  So far, only 10 states — Alabama, California, Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee and Texas — have enacted the model statute, according to the Center for Telehealth and E-Health Law.

A report financed by funds from the US Department of Health and Human Services, Office of the National Coordinator for Health IT (ONC) under a contract with the National Governors Association Center for Best Practices for the State Alliance for e-Health outlined models that may aid in reducing barriers to interstate practice >  Such models may include: <

• Endorsement: State boards can grant licenses to health professionals in other states that have equivalent standards. This model allows states to retain their traditional power to set and enforce standards. Since providers must apply for a license in each state within which they wish to practice, complying with diverse state requirements can be time consuming.
• Reciprocity: “Many states allow out-of-state licensed [providers] to receive an in-state license through abbreviated licensing processes such as endorsement, registration, or reciprocity. This does not necessarily eliminate the administrative and costly burden of obtaining licenses in multiple states, but it may reduce it. The physician, however, would be subject to multiple state medical boards' statutes and regulations upon abbreviated application approval.”
• Mutual recognition:  A system in which the licensing authorities voluntarily enter into an agreement to legally accept the licensure policies and processes of the licensee’s home state.
• Registration: A model that permits a health professional who wishes to practice part-time in another state to inform the board of the other state and agree to operate under the legal authority and jurisdiction of that state.
• Limited licensure system: A licensure model that limits the scope of practice by allowing for the delivery of specific health services under a defined set of circumstances.
• Certain licensure exceptions such as the consulting exception whereby a physician who is unlicensed in a particular state can practice medicine in that state at the request of, and in consultation with, a referring physician. 

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Changing Medical Reimbursement Policies

The absence of consistent, comprehensive reimbursement policies is another serious obstacles to the integration of telehealth into health care practice. This lack of an overall telehealth reimbursement policy is a product of the multiplicity of payment sources and policies that currently exist within the United States health care system. For telehealth technology to achieve sustainability, states must require Medicaid, a significant payer for medical services, to set the standard and reimburse providers for telehealth services. If Medicaid recognizes the value added by telehealth, private payers will soon follow suit. The Centers for Medicare and Medicaid Services' (CMS) web site notes that, “Medicaid reimbursement for services furnished through telehealth applications is available, at the state’s option, as a cost-effective alternative to the more traditional ways of providing medical care.” 

Currently, at least 35 states reimburse for telehealth services.  In a survey done in 2004, at least 27 states reimbursed for telehealth through Medicaid. What services were covered by Medicaid, however, looked different state to state:

• Medical consultations or treatments – 22 states 
• Psychological consultations or treatment – 12 states 
• Home health – 2 states 
• Case management – 2 states 
• Patient education (diabetes) – 1 state

In 2008, states continued to enact some form of telehealth medicaid reimbursement legislation, however, not ever bill covered the same level of services. 

• In Washington, SB 5930, which relates to high quality, affordable health care, was signed by Governor Gregoire on May 2. The legislation stated that the new state funded health care plan among other things needs to pay for e-mail consultations, , and telehealth when doing so reduces the overall cost of care, and identify any existing barriers and opportunities to support implementation, including needed changes to state or federal law.
• In Utah, HB 16allows used for certified services to be reimbursed under the State Medicaid plan.
• The Colorado state legislature passed SB 68, which permits Medicaid reimbursement for mental health care services.
  

It is important that not only Medicaid but private insurers reimburse for telehealth services for maximum gains from .  In at least five states— Louisiana, California, Oklahoma, Texas and Kentucky — lawmakers have passed legislation mandating that private payers reimburse for telehealth.  Hawaii prohibits private insurers from discriminating against telehealth services, while other states encourage third party payors to reimburse for telehealth services. For example, New Mexico SB 456 encourages health insurers, health maintenance organizations, managed care organizations, and third-party payors to use and provide coverage for telehealth within the scope of their plans or policies.

Even if they are not required to, some private insurers are starting to reimburse for telehealth services. In February of 2008, Aetna Inc., the nation's largest insurer, and Cigna Corp. have agreed to reimburse doctors for online visits. The virtual visits are considered best for follow-up consultations and treatment for minor ailments such as colds and sore throats. Additionally, some specialists, including cardiologists and gynecologists, also see e-mail as ideal for periodic checkups that do not require in-person visits.

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Conclusion

Telehealth is one of the more promising broadband applications, with the ability to save lives and increase access to quality health care at a reduced cost. It is dependent, however, upon development of faster and more ubiquitous high-speed services, and software applications that can link patients, patient records, doctors and medical facilities.  In order for states to be able to leverage the applications of tomorrow they must foster universal and affordable broadband strategies, as well as address licensing and Medicaid reimbursement issues.