Treating Out-of-State Patients

Whether prompted by the need for specialized care or by limited healthcare resources in their home state, patients are increasingly likely to travel across state lines to obtain healthcare services. Also known as domestic medical tourism, this type of travel can offer many advantages. Patients may benefit from shorter wait times, reduced medical expenses, increased access to expert care, and better insurance coverage options. Traveling to other states to access care may also address health equity disparities across certain populations. More recently, variation in state laws may prompt patients to leave their home state to obtain care that is restricted or not available in their home states. 
 
Regardless of the reason, travelling to another state to receive healthcare can expose patients to risk. Patients may have health conditions that limit their ability to travel long distances or commit to essential follow-up care. Communication with the care team in the patient’s home state may be challenging due to technical difficulties, lack of expertise, time differences, or a reluctance to participate in the patient’s ongoing care. Unfamiliarity with resources in the patient’s home state may limit the out-of-state practitioner’s ability to respond to patients who need unexpected support or emergency treatment at home.
 
Practitioners who deliver healthcare to patients who will leave the state shortly after receiving care are also exposed to risk. While telehealth can be a useful intake, evaluation, and follow-up tool, state licensing and prescribing restrictions may limit its use in some circumstances. Conflicting state laws regarding reproductive, transgender, and assisted end-of-life care (among others) may expose the practitioner to legal liability if they provide services that are restricted or illegal in the patient’s home state. Federal and state law may impact interstate prescription processing and medication management, prompting special consideration for patients who require refills after they return home. Additionally, the delivery of care to out-of-state patients may impact medical professional liability coverage. 

Risk Management Recommendations 

 
Treating out-of-state patients is not a new phenomenon, but it can come with extra risk. Prepare to safely deliver services and minimize risk by crafting policies and procedures designed for the unique needs of out-of-state patients. Consider the following when reviewing your policies and procedures regarding the delivery of care to out-of-state patients: 

• Know the law. Consult an attorney to ensure that your policies for identifying and treating out-of-state patients comply with applicable state and federal laws for the practice of medicine, prescriptive practice, and telehealth. If your practice includes services that are restricted or illegal in another state, consult your attorney about the legal implications of providing care to patients from those states. Explore with your attorney the application of state shield laws (laws that protect practitioners from states’ attempts to enforce their laws beyond their borders) or other protections for your practice. Understand how shield laws work.
• Obtain proper licensure. Typically, practitioners must be licensed in the state where the patient is physically located, even for virtual visits. So, while telehealth may seem like a convenient option for screening or follow-up care, it may require licensure in multiple distant states. Review medical licensure laws in your state and in your patients’ home states to clarify licensure requirements and practice limitations. Explore whether your state participates in a consortium for cross-state licensing or in the Interstate Medical Licensure Compact, which offers expedited licensing in multiple states.
• Understand prescribing regulations. Review state and federal regulations regarding interstate prescribing, including interstate prescriptive practices for controlled substances, to ensure compliance. Understand how those regulations affect telephonic/electronic prescribing and medication management. Consider the impact on state prescription drug monitoring requirements. 
• Develop patient selection criteria. Design a screening intake protocol that considers the patient’s medical history and current clinical condition. Use the protocol to determine whether the patient is an appropriate candidate for the requested type of care and is safe for travel. Discuss the proposed treatment plan with the patient and/or caregiver to determine the level of commitment for aftercare and follow-up appointments. Consider potential legislative, logistical, and communication challenges. Investigate and address potential insurance hurdles. 
• Document thoroughly. Document all discussions with the patient and/or caregiver thoroughly in the medical records. Identify participants in decision-making and communicate the care plan with stakeholders, including the care team (practitioner, pharmacy, and emergency contact person or facility) in the patient’s home state.
• Design a detailed discharge plan. Utilizing plain language principles, create a written discharge plan that includes specific instructions for home care, directions for taking medications, instructions for whom to call to report problems and when to do so, and schedules for follow-up visits. Use teach-back techniques to verify that the patient understands the discharge plan Prepare for emergency situations by providing instructions for when to go to the local emergency department.
• Ensure adequate insurance coverage. Work with your insurance agent or broker to ensure that your insurance portfolio includes adequate coverage for the services you provide. 

A patient’s ability to travel across state lines and to other regions to obtain valuable healthcare services has expanded access to care in many ways. Practitioners can mitigate the risks of caring for this patient population by understanding associated risks and working with patients to make their trips safe and successful.