At Crossover, our business is focused on “health as it should be.” It’s all about the care of our members, the relationships we build, the access we create, and the service we provide. One of the big shifts we have seen over the last 18 months is how the center of gravity has moved away from campuses, away from in-person care, and more towards hybrid care that crosses traditional time, space, and geographic boundaries.
One of the issues of this brave new world that doesn’t get much attention is the antiquated laws and regulations related to medical licensure across state lines. It is quite anachronistic that I am licensed in California but not able to practice in Nevada. The absurdity of this is exacerbated near state lines, like in Tahoe, CA where the state lines split the lake. I can provide care to the top of my license—unimpeded—to those on the California side of the lake, but that same care would be considered illegal if I stepped onto the opposite shore to treat someone there. Now, think about this in an even more populous place like the Tri-State area of New York, New Jersey, and Connecticut. You almost can’t help but cross state lines as you travel between your various providers, specialists, and health systems.
In my capacity as CEO, I am one of the licensed physicians that must get credentialed in every state in which we operate. I partner with both our Chief Medical Officer and Chief Nursing Officer to ensure that our teams are appropriately licensed so we don’t run afoul of these regulations, stay in compliance, and maintain continuing medical education. This situation is further complicated when you provide virtual care across the country—our virtual teams typically hold between 12-15 licenses per provider in each region we operate. Again, this isn’t just the physicians but also nurses, physical therapists, mental health therapists, and in some states, health coaches. This is a considerable (and considerably expensive) commitment, but one we choose to make in order to practice in accordance with the current laws.
But, when does technology or innovation outpace those laws, and how do the laws adjust and adapt to changing times, approaches, and new models? I thought I would share an interesting case study that highlights how this works as well as how the “spirit of inevitable” permeates our organization.
As we expand Crossover’s services nationwide, we are actively working state by state to ensure that our California-based professional medical corporation meets each individual state’s requirements for medical practice. In June 2020, I submitted an application for licensure to the Colorado Medical Board. The Medical Board advised me that, under the then-existing Colorado Medical Board rules, physicians were required to have been “actively engaged” in the practice of medicine, as narrowly defined by providing direct patient care, or at a minimum, to demonstrate continued competency in clinical practice. The Board’s interpretation of my personal “administrative practice” as CEO of Crossover fell outside of their original definition and I was therefore denied a license.
At this point, I had four choices:
- I would either have to undergo an assessment by the Center of Personalized Education for Professionals, or accept a restriction on my license in the form of a disciplinary stipulation that would be reported to the National Practitioner Data Bank (NPDB). Despite no wrongdoing of any kind on my part, this disciplinary action would be permanent, reportable, and effectively jeopardize my standing as a physician owner in our medical group. This was not an option.
- We could attempt to restructure our medical group corporate bylaws and come up with a new organization with new owners. This did not seem feasible since our governance has been well established for more than a decade, and any changes here would present difficulties to our established operating, accounting, financial, and equity structures. Given our equity structure, this was not an option either.
- We could just quit the application, move on to other states, and abandon our intent to provide our unique Primary Health services in Colorado.
- Or, we could challenge the requirement and help the state see an alternative path forward by changing the law.
Those who know me know exactly what we chose to do.
Therefore, in July 2020, I began working with our internal legal team to highlight that the “practice” of medicine takes many forms, including critical administrative functions such as medical leadership and oversight by physician and nursing executives. Another point in our favor was that the American Board of Physician Specialties recognizes administrative medicine as a specific discipline where physicians can maintain full, active licenses. The rationale for this is that in an administrative practice you are still required to have an intimate knowledge of treatment models, approve policies and protocols that apply to all of the providers within a medical group, participate in peer and utilization reviews, evaluate the quality of care provided to patients, and review individual patient cases to ensure care standards were met.
We then strategized with local Colorado counsel, writing opinion letters and making presentations to the Colorado Medical Board, and working on drafting language with representatives of the Colorado Department of Regulatory Affairs (DORA) as well as the Colorado Attorney General’s office. And we were “pleasantly persistent” over a 13-month period as we kept sharing an alternative perspective on how this would be good for Colorado citizens. By August 2021, we were finally getting some traction with DORA and the Attorney General’s office. At the invitation of DORA, we spoke at a stakeholders’ meeting regarding a potential rule change to remove the licensing barriers. In November 2021, we also spoke at a hearing in front of the Medical Board to urge them to adopt a rule change to increase patient choice and access to care.
Finally, in April 2022, after a nearly two-year sustained campaign, the Colorado Medical Board (to their credit!) adopted amendments to Rule 120 to permit the Board to use its discretion to grant licenses to physicians practicing administrative medicine. With this in place, Crossover was free to organize and bring our innovative healthcare delivery approaches to the people of Colorado without the licensing barrier that previously existed.
When the actual license arrived on May 18th, I was thrilled. Not just because we can now move forward in Colorado, but because this victory represented a collective effort of our in-house legal team (Fred Melendres and Christine Wessel), our outside Colorado counsel (Mark Fogg and Sierra Ward of Childs McCune), and the thoughtful discourse and decisions by the Colorado Medical Board members. It also highlights the level of collective energy and team effort required (patience + persistence) when you choose to climb mountains—or (re)move them when necessary—instead of accepting the status quo.
As care delivery continues to evolve, the laws will need to adjust along with everything else. There will be plenty more anachronistic mountains to ascend on the march to “health as it should be” but for a few minutes, we get to enjoy the view from this climb.
Many thanks again to the Medical Board of Colorado who have created a template for other state medical boards to follow in carefully considering changes to outdated policies while protecting the integrity of medical practice and promoting the safety of care delivery for Colorado citizens.