Feature Practicing in Multiple States May Get a Lot Easier PTs and PTAs who want to practice in multiple states can face piles of paperwork, long delays, and significant expenses. An interstate licensure compact system soon may offer a solution. By Troy Elliott | March 2016 Imagine you're going on cross-country road trip—Virginia to California, let's say. You gas up and head west. As you cross the border into West Virginia, you're pulled over immediately by the state police, who direct you to the nearest DMV, where you're told that your Virginia license is no good here. You must have a West Virginia driver's license if you want to drive in that state. To get that license, you'll need to produce proof that you're you (hope you brought along that passport and birth certificate!), as well as proof that you passed the Virginia driver's test and proof of insurance; and—oh yes—the West Virginia DMV will need to run a background check on you. (Your patience is appreciated; this will take a while). And you'd better hope that the driver education class you took when you were a teenager meets West Virginia's requirements—otherwise, you'll be turned around and sent home. On the bright side, if all goes well, in a few short (business) days you'll be able to drive through West Virginia—only to repeat the entire process when you cross into Kentucky. And then Illinois. Then Missouri, then Kansas, then you get the idea. Of course, everyone knows that's just crazy. Drivers' licenses don't work that way, thank goodness. You get a driver's license in your home state that's valid anywhere you drive in the United States. Licenses to practice physical therapy, however? That's a different story—one that plays out in ways fairly similar to the scenario described above: different states, different licenses, different applications, more fees, and no small amount of waiting. So, why can't licenses to practice physical therapy work like drivers' licenses? If the Federation of State Boards of Physical Therapy (FSBPT) and APTA have anything to say about it, one day, they will. This year, FSBPT and APTA, with the help of the Council of State Governments (CSG), are officially launching an initiative to create what's known as an interstate licensure compact system for physical therapists (PTs) and physical therapist assistants (PTAs). Called the Physical Therapy Licensure Compact (PTLC), it's an ambitious plan, to be sure—there's an infrastructure to create, awareness campaigns to manage, and state legislatures to convince—but the plan's creators think the prospects for success are good. Some PTs will tell you that the change can't come soon enough. What's the Problem? The simple and all-too-familiar fact of life for many licensed health care providers is this: Each jurisdiction has the right to regulate its professionals in whatever ways it believes best serve its residents. What that means is 53 different physical therapy licensing laws and, by natural extension, 53 different licenses. PTs and PTAs who are licensed in 1 state and want to practice in another have to apply to the second state almost as if they are newly minted professionals—fill out extensive application forms, send in transcripts, provide additional background information, submit to a criminal background check, and substantiate that they have passed the relevant National Physical Therapy Exam (NPTE). Some states even require an additional examination on their licensing law. The licensure board in the new state then collects and reviews this information and issues a license decision—sometimes requiring the applicant to wait until the board actually meets to make or ratify a decision. Because licensure boards typically are short-staffed and overworked, these approval processes can take weeks—months, even. Meanwhile, the PT waits in a sort of licensure limbo. And of course fees are involved. Bottom line: If you're a PT or PTA who works in multiple states, you need to maintain an active license in each. If you're a PT or PTA who happens to have a spouse or partner who often is required to relocate—is in the military, for instance—you must go through this application process each time a move occurs and hope you can return to practice as soon as possible. And if you're a PT or PTA who'd like to engage in telehealth, providing services to patients and clients across the country, good luck: Some states are still working out the details to regulate that type of practice. Even if you're just a PT or PTA who happens to be considering a job in another state—get ready to face a challenge. (PS: Don't forget that once you get these multiple licenses, you must maintain them, which means complying with each state's continuing education requirements. If you're a type-A sort or really attentive to detail, you'll be able to keep track of the varying license renewal dates.) But there's an even bigger issue associated with the state-patchwork approach to professional licensing, particularly when it comes to physical therapy: It limits public access to qualified PTs and PTAs. The current licensing system can pose real barriers when it comes to an individual's ability to receive physical therapy. For example, think of the rural resident, the understaffed clinic, or the homebound patient who could benefit from telehealth services. Finding a Solution Even though there are regular congressional attempts to do so, it's unlikely (and arguably unconstitutional) that there would ever be such a thing as a national license for PTs, PTAs, or just about any other regulated profession, for that matter. But there's a kind of workaround; namely, a system that allows states to maintain their power to regulate while eliminating (or at least minimizing) the bureaucratic and logistical barriers to mobility. One such model is the compact. (Drivers' licenses use a compact system.) The basic idea is that states adopt legislation saying they'll participate in a system in which a professional with a valid, unencumbered license in 1 participating state—the state of primary residence—may practice as a licensed professional in any other participating state. The licensee must abide by each state's regulations and is subject to disciplinary action from any state in which she or he practices, not just the "home" state—just as a driver with a Virginia driver's license is permitted to drive in, say, Michigan, but must follow Michigan's traffic laws while in the state. But, appropriately, professional regulatory compacts aren't exactly like drivers' licenses. The higher stakes involved in professional regulation require more rigorous rules around who can and cannot practice within compact states, how oversight is handled, and what happens if a PT or PTA violates a compact state's practice act. The PTLC is not the first such system proposed. Nurses have been working on a similar system for a few years now, and other professions—physicians and psychologists, for example—have developed or are in the process of developing their own. Here's how the PTLC works: First, a minimum of 10 states must adopt the compact through state legislation in order for the compact to be active. Once active, a "compact commission" is established. This group comprises regulatory representatives—1 from each state that has enacted the compact legislation—and acts as the administrator and information center for the system. A PT or PTA with an active license in a compact state that also is his or her primary state of residence (we'll call this the "home state") and a clean disciplinary record for at least 2 years would apply to the commission, pay a fee (all online), and, pending the commission's review, receive a "compact privilege" to practice in any of the compact states she or he has selected. The state licensure boards in the compact, in turn, would be notified that the PT or PTA has received the privilege. From that point on, the PT or PTA could practice in any compact state. As for continuing education (CE) and renewals, he or she only would have to meet the home state's requirements, and—to make life easier—the compact privilege renewal would be set to coincide with the home state renewal schedule. This compact privilege turns on 2 very important points: (1) the PT or PTA must comply with each state's practice act when practicing in that state, and (2) "practice" is considered to take place wherever the patient or client is located at the time of the encounter—not where the PT or PTA is. If the PT or PTA violates a compact state's law while practicing or working in that state (and remember, "practicing in that state" would include providing remote services to a patient or client living in that state, no matter the PT's location), the compact state can take the same disciplinary action against the PT or PTA that it would take on any other provider directly licensed in that state. And if any disciplinary action is taken, all compact states are notified, and the PT's or PTA's compact privileges are stripped completely. Only the home state license remains, and even the home state could take action against the PT or PTA, if it chooses. "Any discipline in a compact state, and you lose that privilege, because it is a privilege," says Mark Lane, FSBPT vice president and a member of the task force that crafted the PTLC. "If you're disciplined it will be taken away. There's no 'could be'—it will be." The rules around discipline are tight, because they need to be so that state regulatory boards become comfortable with a system that introduces professionals who weren't initially licensed in that board's state. In turn, the compact states must provide the compact commission with all disciplinary, and potentially even investigatory, information so that a complete and accurate repository can be created—all to help the commission and its member states ensure that they know who's done what, when, and where. Lane explains that it's precisely this kind of rigor that will make the compact system extremely attractive to PTs and PTAs. One definite plus is cost, which Lane says will be less than the cost of getting (and maintaining) multiple licenses. "There will be a charge for the compact privilege, and that will go to the commission to cover costs. Participating states may impose additional fees that would be rolled into the overall cost," Lane says. "But we hope these fees will be kept low, so compact privilege costs less than it would cost to get a license [in each separate state]. Otherwise, other than the efficiency gain, a licensee might as well get a license in each state." Perhaps so, except for another attractive element: turnaround. There are almost always significant waits (weeks, sometimes months) associated with applying to a new state for a license. Not so with the compact. "Because the compact commission will maintain accurate, up-to-date records on discipline, as well as NPTE score data and other documents, there should be a quick turnaround for a compact decision—hopefully within a day," Lane says. How Soon Is Now? If you ask James Spencer, PT, DPT, OCS, CSCS, that kind of turnaround is the stuff dreams are made of. Of course, Spencer's career is itself like the stuff dreams are made of. He and his wife are traveling PTs who spend about 4 months of the year in Aspen, Colorado (wintertime, naturally), and the rest of the year responding to calls for PTs in other states—many in the Northeast, but they've also landed gigs in Hawaii. But it's not all hot cocoa and leis. "The licensing process has been a continual point of frustration," Spencer says. "It's a completely antiquated system. You need to fill out multiple forms by hand, send documents by snail mail, then wait for a decision—or wait for a board to tell you they need more information. I certainly would hope a compact system would move us ahead." Right now, Spencer maintains 7 licenses, which means 7 sets of CE requirements, 7 renewal dates, and 7 different fees that need to be paid at various points along the way. Over the years, he's learned that the current system can range from mildly annoying to outright teeth-grinding, depending on the state in question (he names 1 state in particular as "notorious" for waits of 4 to 6 months to get a license). Still, Spencer believes the real victims in the current system aren't the PTs and PTAs so much as patients in need of physical therapy. "We travel to places where there is a need for PTs—facilities that are trying to work out a personnel shortage and need someone to step in while they get things in order," Spencer says. "We came to a clinic that had a 40-patient wait list, and by the time we left there was no wait list. That's great, but it's hard to do when you have to deal with all these separate licenses—all the delays and waits. A compact could really help us serve patient needs." Unlike Spencer, Leslie Adrian, PT, DPT, MPA, might want to settle down in 1 state for an extended period of time. But that's not happening anytime soon: Her husband is active-duty Army, which means he could be given orders to move at any time. And that's exactly what just happened—Adrian and her husband recently moved from the Washington, DC, area to Columbia, Missouri. Adrian barely had time to pack, let alone complete the process for a new license, before she had to hit the road. "People ask, 'Why don't you just plan ahead? You know where you're going. Do what you need to do for that state, have it all nice and tidy, and be licensed before you get there and hit the ground running.' But this recent move? My husband received his orders 17 days before he was supposed to report," she notes. Although there's a federal initiative to encourage states to expedite professional licenses for spouses of military personnel, Adrian says it's "hit or miss" as to whether a particular state does much to make the process easier. She thinks a compact would provide exactly the kind of service needed by PTs and PTAs in her situation. As FSBPT's director of professional standards, Adrian says she is not engaged in direct clinical encounters, but explains that the work she does is considered part of the PT scope of practice—at least according to FSBPT's model practice act—so she maintains licensure wherever she goes. Adrian was part of the staff team that helped to draft the language in the PTLC, and she knows a thing or two about the nuts and bolts of the model. She thinks that the compact will be particularly well-suited for military spouses because of its flexibility in what a PT or PTA military spouse could name as her or his home state: the family's home of record, the state in which the military member has orders to serve, or the state in which the family might live during that posting. She explains that before the move to Columbia, she and her husband lived in Virginia while he served across the river in Washington, DC—and all the while they maintained a home-of-record in Florida. "So, for me," Adrian says, "if the compact were in place and all these jurisdictions participated, any of those 3 could've been considered my home state." This accommodation applies only to military spouses. Like Spencer, Adrian thinks the most important benefit of the compact system is the way it could increase consumer access to qualified PTs and PTAs—all while ensuring that the public is well-protected by state boards that are keenly aware of who's allowed to practice in their states, and whether a PT or PTA received disciplinary action in other states. "When you think about potential access to physical therapist services, you definitely have some areas where you don't have the licensees you need to take care of the population," Adrian says. "And in cases of people who work on state borders or work in remote areas, rather than having to go through the whole process of becoming licensed, and all the fees they can incur and all the time that it takes, they can use the compact privilege, which would be a less costly and faster way of gaining authority to practice." It's exactly those connections that are important to Chris Peterson, PT, DPT. He's telerehabilitation program director for Hartford Healthcare in Connecticut, where he oversees multiple research studies that look at how telehealth in physical therapy can add value. He says that while good work in this area can be done under the current regulatory system, a compact would open up possibilities—and get needed telerehab services to more people, faster. "If we have a licensure compact in place, it will give us a tremendous amount of flexibility to provide care to patients across the country in areas and regions where we may not have as many physical therapists on hand, or when patients are seeking specialty physical therapy care," Peterson says. "You can bring in PTs to do that much easier by using telehealth across state lines." Right now, of course, telehealth is "all over the place" when it comes to how state licensing boards approach the issue, Peterson points out. Some states allow it, but only if it occurs within state borders. In other states, it's possible through special arrangements that allow for telehealth across state lines. Some states outright prohibit services delivered remotely. In a compact that says clearly that the location of the patient is where practice takes place, and pairs that idea with a privilege to practice in multiple states (at once), those complications begin to melt away. Peterson believes that while a compact won't magically resolve the mishmash of state approaches to regulating telehealth, it will help clear the air and allow the possibility for state regulators to retool their approaches. "I think [the compact] will be a big motivating element to get states to look at telehealth more closely," Peterson says. And he believes a closer look is needed, and soon. "If you consider how many of us use technology in our lives, then you think about how we use it in health care, there's quite a gap," Peterson notes. "In the next few years we're going to see that gap close, and I see that as a way to improve the connection that we as physical therapists have with our patients." Making It Happen If her FSBPT inbox is any indication, Adrian says, PTs and PTAs are ready to make the licensure compact a reality. "I get emails on a regular basis from licensees asking, 'Hey has this passed yet? How do I get involved?'" she notes. "I have to tell them we're not quite there yet, but they should contact their state legislators or state boards if they're interested in making this happen." It won't be a light or quick lift. For a state to join a compact, that state's legislature has to approve the system and the governor must sign off. The PTLC can't officially begin until at least 10 states have joined—and, obviously, the more the merrier. But nothing can happen until laws are on the books. That means it's time for action, says Justin Elliott, APTA vice president of government affairs. "The pieces are in place, so now is the time for APTA's state chapters to have conversations with their state licensing boards and state legislators about implementing the compact in their states," Elliott says. "This is something that both the chapter and board must agree that they want to pursue. And, if so, it should be a priority on the legislative agenda." And yes, Elliott says, we are talking about legislatures and new language and all the rest, but the actual mechanics of the changes might not be as difficult as you'd imagine: The language creating the compact is designed to exist outside of a state's practice act, meaning that implementing this change does not require "opening up" the licensure law itself and exposing the PT or PTA scope of practice to unwelcome changes. "This is a very commonsense solution to current problems with licensure portability," Elliott says. A further reason for hope is that, in at least some states, the legislative wheels already were greased, so to speak, when those states adopted other compact arrangements such as the one used in nursing. That's part of the reason Lane is cautiously optimistic about the prospects of the PTLC. "Certainly, given that we're dealing with the reality of legislation, it's not a quick process," Lane says. "But times have changed, and I think the road ahead will be much quicker. I think that within 5 years or so we could have a substantial number of the states in the compact." Whether or not it happens quickly, one thing remains clear, according to Elliott: This is a big deal. "The creation of a compact for PTs and PTAs is truly going to transform the state licensure process," he says, "which will, in turn, be transformative for patient and client access, licensure portability, telehealth, and other areas. And all while maintaining and even improving the level of public protection in the compact states." So yes, the road may be long. But it's worth the drive. And when you arrive, you may need only 1 license. What a trip. Troy Elliott is contributing news editor for PT in Motion.Updates: PTLC Progress!Shortly after this feature was published, Oregon made physical therapy history by becoming the first state to join the PTLC. [March 8, 2016]Getting Started: 5 Things to KnowThe Physical Therapy Licensure Compact could transform the way state licensing—and mobility for PTs and PTAs—works. But, because it represents such big change—and because that change requires approval from state legislatures—PTs, PTAs, and other compact supporters need to have a solid understanding of the system in order to make their case.Start by learning as much as you can about the details. APTA offers background and links at its Interstate Licensure Compact for Physical Therapy webpage, and the Federation of State Boards of Physical Therapy webpage on the subject goes into extensive detail. Both are worth your time.And while you're preparing to make the case for a compact, keep these 5 things in mind:1. You must comply with each state's laws. Just as you must follow each state's driving laws when you're driving in that state, you must follow a compact state's licensing laws when you're practicing in that state. For instance, if dry needling is permitted in your home state but not permitted in a compact state, you're not allowed to engage in dry needling in that state. Same with direct access or any other provisions that vary from state to state.2. Practice takes place where the patient is. This is really important, given number 1 above. The location of the patient is what matters—not where you are nor your home state of licensure. This is of special importance in telehealth settings, where you need to be sure you understand the laws of the remote state, should your services (electronically) cross state lines into another compact state in which you have a privilege.3. Discipline in any compact state = loss of compact privileges in all non-home states. If a participating state's licensing board finds you in violation of its law, all of your compact privileges are immediately revoked for at least 2 years. Your home state license is unaffected—but your home state board still may take action.4. Nothing can happen until 10 states join the system. A critical mass must be achieved before the system can launch. That's why it's important to begin learning about and discussing the compact now.5. Boards and chapters need to be on the same page, and no editing the legislation. Adoption of a compact has the best chance of happening if the professional association and the regulatory board are in complete agreement to move ahead. And, because the whole concept turns on the idea of a process that's identical in each participating state, the compact language must be adopted unaltered.