Experts outline how compact will improve Hawaii healthcare: Maui

The decision this year by Hawaii legislators and the governor to join the Interstate Medical Licensure Compact was not only “a practical win for people who are in pain and suffering and who need medical care, but …  also a philosophical win for those who want to celebrate the fact that economic freedom can help people in our society to thrive,” according to Keli‘i Akina,  president and CEO of the Grassroot Institute of Hawaii.

The Institute sponsored events on Oahu and Maui in late July that outlined how the compact will work and what benefits Hawaii residents can expect to receive from it. Akina, moderator of  the Oahu event, said its main advantage will be to help relieve the state’s longstanding doctor shortage.

The featured speakers at both events were Marschall Smith, executive director of the Interstate Medical Licensure Compact Commission, and Hawaii interventional radiologist Dr. Elizabeth Ann Ignacio, current chair for public policy and president-elect of the Hawaii Medical Association. Joe Kent, Institute executive vice president, moderated the Maui event.

Smith explained the origins and inner workings of the compact — which has grown to 41 U.S. states and territories since 2017. Ignacio addressed local concerns regarding telemedicine, culturally competent care, behavioral health services and more.

“I’m sure you’re well aware that we have serious problems with our provider recruitment and retention, and we’re very excited about the bill that has passed for the Interstate Medical Licensure Compact,” Ignacio told the Maui audience. 

Put simply, a state’s participation in the IMLC allows licensed doctors who meet the compact’s strict requirements to apply for additional licenses to practice medicine in any other member state without having to go through each state’s individual, often lengthy licensing process. 

“The thing that’s important for you and for Hawaii is now you have a nationwide pool of physicians that you can draw upon,” Smith said to the Maui audience. 

According to Smith, states that have joined the compact see, on average, a 10% to 15% increase in the number of new licenses issued in their states, and about 45% of the physicians that get licenses through the compact do so to provide services in rural and underserved areas. 

“It appears that approximately a quarter of all the new licenses issued in the United States are using the compact process,” he said during the Oahu event. “So it’s safe; it’s effective; it’s quick; physicians like it; [medical] boards like it; and it’s an economic boon to the state.”

To see the Maui event, click on the image below. A complete transcript follows. To see the Oahu event and its accompanying transcript, go here.

7-27-23 IMLC event, Maui

Joe Kent: Welcome to the Grassroot Institute of Hawaii. Thanks so much for being here. I’m Joe Kent, executive vice president of the Grassroot Institute of Hawaii, and today this presentation is being recorded for online use on YouTube and in the Akakū public access station as well.

And today we have a win that we want to talk about at the Grassroot Institute, which is the passage of a bill that will make it a little easier for doctors from certain other states to practice and work in Hawaii. So that’s really good because, of course, we have an extreme doctor shortage here in the state.

Now, I want to talk a little bit about how that bill actually passed in Hawaii. I was there, watching on the last day of the legislative session when we had about 15 minutes to spare, and we were about to gavel out a hearing, and we were saying, “Wait a minute, they didn’t pass the IMLC Interstate Medical Licensure Compact bill.”

And we were talking to the legislators like, “Go, get this!” And there was a legislator missing, I think it was Gil Keith Agaran. But so, then everyone was like looking for where did he go. And then they finally found him — and I don’t know where he was, but they found him — brought him back, they passed the bill with just minutes to spare.

And, you know, that’s how it works down at the Legislature. That’s what Grassroot Institute deals with, and we’re thankfully becoming a bit more influential. So, you know, hip hip hooray for that, right? [Applause] 

So — oh, thank you, yes, thank you — so this marks one of the major, first major wins of the Grassroot Institute, like the passage of this bill. And we’ve also passed a bill that would help lower taxes on businesses in Hawaii — at no cost to the state, by the way — and a few other measures. But today we want to talk about the Interstate Medical Licensure Compact. 

So now that we’ve passed it, what does it do? And we’ve got two experts today to talk about that. 

Dr. Elizabeth Ann Ignacio is a physician and resident of Maui, and she practices throughout the state. She’s a fellow of the American College of Radiology and the Society of Interventional Radiology, and she was — she is the statewide interventional radiologist and president-elect of the Hawaii Medical Association, and she’s long campaigned for tax and regulatory reform to help improve access to healthcare in Hawaii. 

And we also have Marschall Smith, who is the executive director for the Interstate Medical Licensure Compact Commission, which is the national organization that’s central to the new law. 

So, first we’re going to hear from Elizabeth about how, what the state is in Hawaii when it comes to the doctor shortage. And then we’ll hear from Marschall, and he’ll talk about what this means.

And then we’ll have about 30 minutes of Q&A at the end, so if you’ve got questions, then we’ll come around with the microphone. So, let’s welcome today, Dr. Elizabeth Ignacio. 


Dr. Elizabeth Ann Ignacio: Thank you. Yes, thank you, thank you. 

Kent: Make sure to talk right into that mic if you can. 

Ignacio: Yes, thanks. Hello there, and good afternoon — early afternoon — to you guys. Can you hear me OK? Thank you. 

Kent: I’ll move this a little closer even, like that.

Ignacio: Is that going to fall? 

Kent: Nope, it’ll be good. 

Ignacio: OK, alright, thank you. Thank you to Grassroot Institute of Hawaii for this invitation to speak with you guys today about the Interstate Medical Licensure Compact, about the challenges that we know very well.

If you’re here attending it, you’re in this room for this conversation, then I’m sure you’re well aware that we have serious problems with our provider recruitment and retention, and we’re very excited about the bill that has passed for the Interstate Medical Licensure Compact. 

I’m gonna move forward here. As Mr. Kent mentioned, I am, I’m serving for the Hawaii Medical Association, presently as their chair of public policy. I have a lot of experience with the legislative work in our state related to healthcare, and I am now the president-elect of the statewide medical association, and we represent the physicians of Hawaii, and this was our list of our legislative priorities that we were addressing this 2023 session.

Sorry about the — there’s some formatting issues with my document there. But, to highlight some of those priorities, that included addressing the access issues, and that involves not just what we do to improve the number of physicians that can practice in our state, but also improve their ability to practice — whether it be the practice environment, the way we are reimbursed, the way we interact with the healthcare system and our other providers; scope issues that exist, and how to maintain quality and safety in our state for health care while supporting our physicians. 

We have other challenges, as you guys know well, in terms of behavioral health, and we also want to support — Hawaii Medical Association supported a lot of measures involved with screening and preventative care, as well as reproductive health.

So this was our priorities this year. And obviously the biggest problem that we are addressing — the biggest challenge that we have for our state, most particularly for Mau —i is our physician shortage. 

And this is a little chart that’s taken from the legislative report that is submitted every year by [University of Hawaii John A. Burns School of Medicine] and Kelly Withy — Dr. Withy, who leads that commission — to evaluate the shortages of our various islands. 

And overall, it’s a 22% shortage for physicians. But as you guys can see, Big Island and Maui have the highest percentage of shortages: 40%. That’s pretty substantial, and I’m sure everyone in this room — whether you’re a patient or a healthcare provider or professional — has experienced these shortages firsthand for your family.

SB674 — that’s the number of the IMLC compact bill that was passed. It was signed by Governor [Josh] Green in June, and June/July, we are slowly onboarding and beginning the process for this transition for Interstate Medical Licensure Compact. 

And we’re all very excited; physicians were on the edge of our seats as the legislative session was closing, conference session was in place, and everyone was trying to pass this through. 

Just so you understand, you know, the bill that went through, the wording had to be solid and unchanged — completely unamended — because it is language in that bill that is used for the other states as well. So we weren’t able to like, “Oh, you know, Hawaii doesn’t — we didn’t want this clause in here or we want to do some wordsmithing” or, you know, make any substantive changes. Because if we did, then that automatically would pull us out of eligibility for being a part of the Medical Licensure Compact. 

So there was a lot of advocacy that went into this from the health systems, from HBH [Hawaii Behavioral Health], Queen’s [Health System], a lot of the organized medicine groups, including HMA. We really appreciate Grassroot Institute and their hard work as well. 

We all were meeting with our leaders — with our representatives and senators — raising awareness and talking about the impacts of the IMLC, the potential positive impacts. So we were very excited, but on the edge of our seat near the end there when it was passed through.

So, I have some questions here just to start the conversation on what we want to talk about for you guys today. But of course, we welcome all your questions and comments. And these — as I’ve already spoken to Marschall Smith about — are some of the common concerns and questions that have come up to me, and it includes: Why do states even have differences in the professional licensure requirements? Shouldn’t we all have the same kinds of standards? 

Then also: What are the risks to our state of the IMLC for quality and safety? How will it change? Should providers apply for the IMLC so that they can provide telehealth everywhere else? Is that going to drain our resources here because everybody else will be, maybe they won’t want to practice here? Maybe they’ll be like, “We want to go to California or other places.” 

So these are concerns that have come up from both of our patients and our provider groups as this discussion has moved forward. 

I will be able to address any questions or concerns regarding how this impacts our telehealth world. Those are ever-evolving regulations for all the states. But it has been, you know, through the pandemic, there was this explosion of telehealth. There were challenges of licensure that were met because we had all these emergency proclamations in place that sort of allowed other physicians to help us in the mainland and provide care here, as well as nurses, other health care professionals.

But then, now that we are post-pandemic, we are bringing back a lot of those restrictions, and telehealth still is a giant that we want to make sure we control — that we still are very careful about how that provides care for our citizens here in Hawaii. 

There’s different ways that we can accomplish that. Different models that different states are using that we can go over in the discussion, and how IMLC may help with that integration of telehealth.

And before I am done, I just want to say that I’m really proud that, for the IMLC in particularly, we had a lot of voices working together in the physician world who supported this, including professional organizations like the ACOG [American College of Obstetricians and Gynecologists] chapter, that’s the OB/GYN chapter; the physicians of psychiatry; the ’Ahahui O Nā Kauka, which is our Native Hawaiian physicians; our radiology physicians; all our specialists.

A lot of us all were trying very hard to work together to make sure we had a lot of support for this and other bills to address the very complex and real problems with the physician shortage here in Hawaii. 

I also am prepared to chat about any of the other solutions that exist out there to address physician retention and improvement, but I’m going to stop here and we’re going to let Marschall come up.

Kent: Thanks Elizabeth. And now let’s welcome Marschall Smith. Yes, come up here. And let’s give him a round of applause too. Let me get your PowerPoint up.


Marschall Smith: So, while we’re getting the slides up, my name is Marscahll Smith, and I am the executive director of the Interstate Licensure Compact Commission. We are happy to be in Hawaii. I will start this off with kind of a general tone-setting thing. 

The compact itself provides a lot of solutions for physicians, hospitals, the oppottunity for patients. But those opportunities are solved by your local, the medical association, the hospital association, the local hospital, your medical board here in Hawaii. They will be taking the compact and the processes that we are offering and then finding the solutions that work for Hawaii. 

We’ve done this now in 39 states and the territory of Guam and District of Columbia, and this is the way that we approach this: The compact has a solution and each state at every opportunity presented to the various organizations in those states have taken that solution and found unique ways in which they can solve their unique problems to their states.

So, we’re really excited to be in Hawaii. I’m excited to be here; I get to be in Hawaii [laughter]

So let me throw a little bit out and start at a very high level and talk about the compact. It’s important to understand, as Dr. Ignacio was saying, the language that passed had to be the same, because it’s the same in every state that passed the compact, because it’s a legal agreement between the states. All of the states that have joined signed this legal agreement as to how they will process applications

Hawaii is actually a part of 22 different compacts. And compacts are in the U.S. Constitution. They are the — for those of you that like history, and I’m one of them — the federal government has only the authority granted to it in the Constitution. And anything else, like healthcare, that’s not mentioned in the Constitution belongs to the states to regulate and control.

The federal government and the Founding Fathers realized that they were going to need, there were going to be problems that could, had to be solved by the states working together. And therefore, that’s the compact clause of the U.S. Constitution. And that’s what we, our compact, is a part of.

The compact that impacts almost everyone is what is the Drivers License Compact. And that, what that compact does — it’s agreement between all 50 states and all of the U.S. territories — that if you have a driver’s license in a state or a territory, you can drive in any other state as long as you follow that state’s laws while you’re driving there.

It means that if you went to California for vacation and you rented a car, you didn’t have to go to the California [Department of Motor Vehicles] and get a driver’s license so that you could do that. But that’s only possible because the states have agreed and allowed this to happen, and so all 50 states are a part of that.

For physicians, the IMLCC process started in 2013 where the medical boards came together. At the time, the federal government was considering creating a national physician license, which would have created a national practice of medicine and all of those sorts of things. And the states came together and said, “Having a federal physician license is not a good idea.” People in the states that they live in want to control the medicine that they receive, and they control that through their state government.

And so the state [medical] boards came together and said, “Let’s find the common elements that we can all agree to — we as states — that we can all agree to. And if we agree to them, we will issue a license for the physician to practice in our state without following our normal or traditional licensure process.”

The primary source — which I highlighted there, verified — is so the information that is used as part of the compact process means that it’s come from the primary source. In other words, [for] a physician who has graduated from a medical school, we don’t rely on the physician saying, “Hey, I graduated from this medical school.” We get a transcript from the primary source from that medical school; they tell us that information. 

We know that about their board certification. We know that about the disciplinary history. We know that about the FBI background check. 

So all of it is primary sourced. The information that’s used in the compact has been verified by state entities that said, “This is true and correct, what’s on this application.”

So our process is only for physicians. That’s, there are different compacts, and I’ll cover some of those at the end. There’s different compacts for nurses; there’s a teacher compact that’s being developed; there’s all kinds of — dentists, veterinarians, EMS; all sorts of professions are now using this process to get licensed, professional licensure for their constituents. We do doctors of osteopathy and doctors of medicine — MDs and DOs. 

The IMLCC provides an expedited process so the physician gets a full and unrestricted license; there is no such thing as a compact license. The license that the physician will receive from the Hawaii Medical Board is the same license they would get as if they went through their traditional process.

And the way that, the example that are, or the explanation kind of how I explain how that works is if you go to the airport, everybody has to go through the X-ray machine. To get onto your airplane, you have to go through the X-ray machine. You have to have a license issued by the state to practice medicine in that state.

In the airport, you can do the TSA pre[check] and go quicker, or you can follow the traditional route. Either one gets you to the X-ray machine; either one is a legitimate decision for you to make. The compact works the same way. We have an expedited way that physicians can get to the licensure process. 

On average, a physician can get licensed in seven to 10 — get their licenses in seven to 10 days after they’ve completed the process. The process to get qualified takes about 45 days; but once they’re qualified, they can get licenses from as many states as they want a license and that they will pay for within seven to 10 days. 

Compare that to a traditional process for getting a license: Most states, it takes between three and six months to get a license issued from application to actual license in their pocket. 

That varies greatly. I know the Hawaii Medical Board does a very good job, and they’re working on expediting their own internal traditional process. But it still takes a long time to be able to do that because they’ve got to get all those documents from the primary source. 

So the compact itself, we are what’s called a governmental instrumentality. And I like throwing that around because it makes me seem like I know what I’m talking about. But a governmental instrumentality, what that means is when Hawaii passed the bill, the compact became a part of your state government.

We do not have police authority, which means we can’t enforce against any individual our processes. We can enforce them against the state because they are party to the compact and therefore are obligated to follow our rules. But what that means is that we are a part of the state government.

We act very much like a nonprofit. So we are not — we’re not state government; we’re not a not-for-profit; we’re not a for-profit; we’re this governmental instrumentality. 

In Colorado, where I’m from, there are a lot of governmental instrumentalities. Our water boards are governmental instrumentalities, so they’re quasi-government, and that’s what the compact is. We control our own destiny. Our member boards and our member states control the compact and what it does and how it spends its money and where we, where they let their executive director come and talk. So all of these things are controlled by the compact itself; there is no outside source that tells us how to run the compact. 

We became a legal organization in 2015, and we actually started processing applications in 2017. I started as the executive director; I’m the first and only executive director of the compact. 

When we started, we thought, “Wow, this is an incredible thing and it’s taken off,” and we were processing 75 applications a month, thinking, “This is incredible, this is — it’ll never get better than this.” 

Currently, we’re processing 2,000 applications a week. So, we have grown. It’s an important process by which physicians can get licensed, and it is beneficial to physicians, to patients, to hospitals and to states. 

I’m going to kind of go through some of this: Hawaii will have representation on the compact because you will — the board will appoint two commissioners. Those commissioners are voting commissioners. The compact runs, majority vote requires that action be taken and be approved by a majority of the commissioners. We have rulemaking authority, which means that we can establish rules that are effective and have the force of law in all of our states. And then we have an executive committee that runs our day-to-day — they meet monthly and they run the operations; I take care of the day-to-day stuff. 

This is our most recent map of the compact and our member states. 

There are a variety of statuses of our states — and I’ll talk about them in just a second — and as much as I wish, as I had a magic wand that I could, you know, flick the wand or snap my fingers and turn a state from being a state that the legislation has passed to actively participating, I don’t have that authority. It will take time. 

The bill that passed in Hawaii requires that the bill be implemented by January 2025. That is a long way off. We’ve already started meetings and started the training with the medical board here in Hawaii. I did those meetings on Monday and Wednesday. The board is very excited about doing this, but they have to make sure they do it right, and that’s going to take time. 

And so the bill, as I said, has a — it must be in effect by January of 2025. I would, I would — well, this is a part you’re going to have to edit out of the tape — but it’s going to happen before then. I would imagine probably a year from now Hawaii will be actively participating in the compact. 

So we have, the dark blue states are what we call states of principal licenses and issuing licenses. So the way the compact works — and how we’re able to assure quality and that we’re getting good physicians into the process and we’ve created a high bar standard — is that physician must be licensed and hold a full and unrestricted license in a state already.

That state has already verified all of those requirements from primary source; they have them in their archives. And the physician, by using our process, holds that license; they have a states of principal licenses, or an SPL. Those dark blue states are allstates of principal licenses. 

They also will issue a license. That’s the other rule that will happen, so physicians who are licensed in Hawaii will be able to use the compact to get licensed in other states, and physicians in other states, using their states of principal licenses, will be able to get licensed in Hawaii using the compact process, and the board in Hawaii will do both rules and take care of both things.

We have two states that are not able to act as a states of principal licenses, and it’s because they can’t get authority to pull an FBI criminal background check. It’s a long and involved conversation, and there’s not enough alcohol in the world for us to go into that conversation right now. 

But the FBI has denied two of those states — two of our participating states — access to the FBI CHRI [Criminal History Record Information] criminal background [check]. So when you do your fingerprint background check and it comes back, they can’t get the results from that. We’re working with those states and their state police to get that to happen. But so far, we have two that are unable to do that. 

And there are currently five states that we’re working with and we’re onboarding. Those are Hawaii, Missouri, — Hawaii and Missouri just both passed the compact. New Jersey passed the compact and joined the compact in 2020— in early 2022. Pennsylvania actually joined the compact in 2017, and they have not yet been able to operationalize the process. 

And again, this is — as I said at the beginning — the compact does not have police authority. I can’t go to the state of Pennsylvania and say, “You must implement by this date.” We are their partner and we’ll help them do that. 

And then Rhode Island, which passed the compact in this last session also. 

So currently we’re working with Massachusetts, North Carolina and New York to hopefully get the compact legislation introduced and passed there. We’re also working with five or six other states to hopefully get them to introduce language in the next year and join the compact. But it really is becoming a map with more participating in the compact than are not. 

The thing that’s important for you and for Hawaii is now you have a nationwide pool of physicians that you can draw upon, your hospitals can draw upon, various organizations can draw upon to get — and especially for patients where there is a physician who has a specialty care and they’re located in one state. A lot of those physicians use the compact to be able to treat patients all over the country, and so this will open that gate to you. 

Guam is our — so Hawaii and Guam are our two non-contiguous member organizations. Guam has been part of the compact for three years now, and they are actively participating, and they’ve found that it’s helping alleviate some of the concerns that they have about their physician shortage.

So, this is how our process works, and I’m going to go over it real quick, just because you probably don’t care. 

But, so in order to select a states of principal licenses, you have to hold a full and unrestricted license there, and you have to have a relationship with that state. You have to live there, 25% of the practice takes place there, or your employer is located there. The last one is the military provision that does that. 

So you have to hold a license — this is how we ensure the quality of these physicians. You have to hold a license in that state, and you have to have some relationship with that state. 

Here are the nine criteria that the states came up with and said, “If these nine things are met and verified from primary source, we will issue a license and not follow our normal licensure process for the physician.”

So they have to have graduated from an accredited medical school; they could take no more than three attempts to pass the [United States Medical Licensing Examination] or the [Comprehensive Osteopathic Medical Licensing Examination], which are the exams used to determine physician competency. 

They have to have their graduate medical education taken place in the United States, which means that it can’t be Canada or Mexico or any other country — [Accreditation Council for Graduate Medical Education] and [American Osteopathic Association] only have authority in the United States — so they have to be, their GME, graduate medical education, had to take place in the United States; they have to be board-certified. 

They can have no prior convictions or criminal activity. Misdemeanors don’t count; it’s gross misdemeanors or greater, so a physician who was arrested for a misdemeanor firecracker or blowing up things when they were 10 years old doesn’t impact their ability to be a part of the compact. But anything above a gross misdemeanor or not disqualifies a physician from using the compact. 

They can have no history of licensure actions on their national practitioner data bank report; their [Drug Enforcement Administration] report has to come back clean, there can be no actions. There can be no active investigation by the states of principal licenses into that physician; and they have to do an FBI criminal background check. 

If these nine criteria are met, the state of Hawaii, by joining the compact, has said that a license will be issued to that physician by the medical board. The medical board will not follow their normal, traditional requirements and their normal or traditional licensure. This is the expedited way to get there. 

So here are some of our data, and I think it’s, to me, I think it really does demonstrate the value of the compact and the value of what we’ve been able to do around the country. As you can see in 2017, we had 553 applications, which means there were 553 physicians that wanted a letter of qualification from their states of principal licenses, and they were issued 745 licenses in that first year, our first year of operation. 

Through June of this year, we’ve had over 10,000 applications, and over 16,000 licenses have been issued through the compact process. We have over 16,000 physicians that use the compact that, to get licenses and to be able to practice. 

We were concerned when we first started this that what we were going to end up [with] is physicians we’re going to get their licenses, then move somewhere and then let their other licenses lapse. 

What we found is that the physicians are renewing over 95% of the licenses they get. So these physicians are getting these licenses, and they’re keeping them, and they’re continuing to use them and where they can have the most impact. 

We know that over, it’s about 45% of the physicians that get licenses through the compact obtain those licenses so they can provide services in rural and underserved areas. So there’s a high percentage of the physicians who use the compact to be able to provide that level of service to patients. 

The other thing is [during] COVID — we were the right solution in the right place at a very, very horrible time. We, as you can see, before COVID hit, it was about a one-to-one ratio. The number of applications we were receiving, physicians were getting one to two licenses. COVID hit, and it almost doubled, and then the second wave of COVID, it doubled again. 

So, we’ve been able to do that. We have all kinds of really great stories of where we’ve been able to help. There was a, my favorite one was there was a hospital in North Dakota that was going to have to shut its doors because its physician population contracted COVID, and they had no physicians to run, to come into their hospital, and it was a remote part of North Dakota.

We worked with the Montana board, the Colorado Medical Board, the Wyoming Medical Board and the South Dakota Board; we got those physicians licensed, and they were able to keep the hospital open and staffed. And we were able to do that in less than a week. And that was something I’m very proud of, that what we were able to do and accomplish.

So what does being part, what is Hawaii being a part of the compact really mean to individuals and to physicians? One is it means that what you’re getting is a high-bar physician. These are board-certified positions with no discipline. When I worked at the Colorado Medical Board, I was the executive director there, we used to call these the “squeaky clean applications”. 

There really is, this is a good physician who’s practiced well and is able to do their job well. And so, you’re getting highly qualified physicians. You’re not getting a less-than-highly-qualified physician; I think that’s the nice way to say that.

The other part that I would point out is, so as I said, we have over 16,000 physicians that are using the compact; 28 physicians have ended up being disciplined. So once they started the compact process, some adverse action took, or incident, took place, and they were disciplined. 

So there’s 28 physicians that have lost their ability; they lost all of their licenses they obtained through the compact, and they are no longer eligible to participate in the compact. They must follow the traditional process for all of the states where they want to get licenses to practice. 

So when you receive your treatment in Hawaii, your care is covered by the Hawaii Medical Practice Act. So if you’re receiving telemedicine services from a physician located in, physically located in Colorado that’s treating you here in Hawaii, that physician must be licensed in Hawaii, and they must follow the Hawaii Medical Practice Act, and that’s an important thing.

That means if you have an issue or a concern or an adverse event takes place, you can go to the Hawaii Medical Board, look that physician up and follow the complaint or those processes there. It’s not done in Colorado, where the physician is physically located; it’s done where their license is held, and it complies with the practice act of that state. 

So [for] Hawaii, the care you’re receiving from a physician who gets a license through the compact process is following the Hawaii Medical Practice Act.

It’s going to start, you will see this to, well, the expansion will start happening because the physician being licensed — a lot of solutions that other hospitals in other states have used, especially in rural and underserved areas, is they use the compact to provide, they will get a physician, they can expand the hours by which they provide services, and those physicians can then also enter into collaborative agreements and provide care through advanced practice nurses, PAs, all of that sort of thing. 

So you’ve got one physician who may or may not be physically located in Hawaii, but they’re supervising and collaborating with other healthcare practitioners and providing safe care. And so you’ll start to see that ripple effect, and you’ll start to see the ability of that to happen. 

I wish it was going to happen overnight, but it won’t. But this starts giving hospitals, it starts giving physician groups, it starts giving all of these people these solutions that they can start to use.

It provides opportunities for treatment locally from national resources. One of the things about that, and I’ll use that example — and I think I’m starting to run out of my time, aren’t I? I love the compact, and so, you know, unfortunately we’re here until 4 o’clock tomorrow morning, right? 4 a.m. Colorado [time]? 

So one of the things that happened, and it was one of those opportunities that one of our member board hospitals found and started, and is now starting to catch on. MD Anderson is a national cancer treatment center in Houston, Texas. Before, if you were receiving care at MD Anderson, what you did is you flew — if you didn’t live in Houston — you flew there for your pre-treatment care. You may go back two or three times for that. You went there for your care and the procedure that you had to take place, and then you came back there two or three times post treatment. 

What MD Anderson did was they created process, a new — they changed the way in which they provide care to patients. The physician can determine — and again, it’s so it’s safe for the patient — but what they do is if you’re in Hawaii and you’re receiving care and treatment at MD Anderson, there is an option to where you can go to your local physician’s office and do your pre and post care in that physician’s office because the physician at MD Anderson is going to be licensed in Hawaii, and they can consult directly with your physician in the office here in Hawaii. And so it cuts down on your travel time, it cuts down on expenses that you have. It also is cut down on the costs that MD Anderson has for as their process.

So telemedicine will be happening. One of the advantages to the compact about, is that it is a full and unrestricted license. It isn’t a telemedicine license; it isn’t anything like that. And so it helps physicians because they’re getting the full license. And you know that even if you’re getting telemedicine care, you’re still getting care from a fully licensed physician.

Yeah, I better end. All right, so let me — real quick — there are other healthcare compacts, and those are coming here to Hawaii, and they will be introduced and, but there are all kinds of those. And with that, I’m going to finish.

Kent: OK, let’s have a round of applause. Thanks you.

Smith: Thank you. 

Kent: OK, just for the sake of getting some Q&A in to learn more about this, I have a few questions. And if you’ve got questions, we’ll come around with a microphone as well. But thank you for enlightening us on this process. 

Elizabeth, you have a mic there too, right? OK, good.

OK, well, I mean, I have a question about telehealth. You said at the end that this doesn’t really change how telehealth works in Hawaii. Is that right, Marschall?

Smith: Yes. So what it does is that the practice act that Hawaii puts in place with regards to telemedicine applies to all physicians, and so it will have the same impact. It will have an impact, but it has the same impact to the physicians, whether they are licensed traditionally or through the compact.

Does that make sense? So it’s in a sense, telehealth laws that are passed in Hawaii apply to all physicians equally. Does that make sense? 

Kent: So if I am in Hawaii and I am wanting to see a doctor on the mainland, but they’re not licensed in Hawaii, then am I able to under — but they are licensed under the IMLC — then am I able to see them via telehealth? But if they’re not licensed under the IMLC, then I presumably can’t?

Smith: So the key there is: There are two key parts to that. So the physician must be licensed where the patient is receiving the care. So if you’re in Hawaii and you’re receiving care here in Hawaii, the physician has to be licensed here in Hawaii.

If you’re going to California — California is not a part of the compact, so let’s use Washington. And I’m from the Midwest, and there is an R in that word. [Laughter] So let’s say you’re going to, let’s say you go to Seattle. You’re now receiving your care via Seattle, so that physician must be licensed in Washington, OK? 

If your physician is physically located in Washington, and you are receiving care via telehealth here in Hawaii, you’re located in Hawaii; that physician has to be licensed in Hawaii. 

Kent: I see. Elizabeth, you mentioned before about the governor — Gov. [David] Ige during the pandemic era — having to lift the rules to allow for nurses and doctors from the mainland to come here.

Can you talk a little bit more about how, what that actually looked like and how that helped and if there were any problems or anything like that? 

Ignacio: I think this is working? Yeah. So I think we all remember that when the pandemic happened in 2020, we already were suffering with provider shortages here in Hawaii in our state. Especially in the neighbor islands: Maui, Big Island and Kauai. 

And then, with the pandemic, you were getting, our patients were getting sick, but also our providers were getting sick too. And so, there were such severe shortages, and a lot unknown in terms of what is, you know, what kind of exposures we were going through, like, we were taking care of patients in the inpatient setting or even the clinic, and you’re like, “How do I handle my home life? Do I go home and stuff?” So that really curtailed hours and offerings for providers. 

So, as you guys may recall, we had already been short about 700 physician providers in our state. But even our nursing providers, our nurses in our inpatient facilities and stuff were short. 

And so, When Gov. Ige lifted those restrictions on licensure, they weren’t saying, “OK, now everybody go crazy and come over here, and there’s no quality control,” but they were saying that, you know, “We’ll do our best to have some reciprocity of licensure, like so your state — you’re already functioning in other states, and you have proof of your licensure in another state; we’ll recognize that for now, and we’ll let you come over here and help us because we really need our help.”

And as you guys may recall for the last, like, probably a good eight or 10 months of 2021, most of 2020 and 2021, we had 600 to 800 providers coming over — nurses and doctors — to come help us with our provider shortages. Presently, it’s about 800 providers short for physicians for our state. 

That’s, you know, that’s a general term and those, that’s not even accounting for the fact that, which ones, where our deficits are for our specialties, for example, because you might know that, for example, here in Hawaii — or here in Maui — we have a real shortage of OBGYN here. We have a real shortage for allergists, rheumatologists, in our county. 

So we talk about these general shortages of providers, but what do you do if you have a really bad — if you have a complicated pregnancy going on and you live here in our county? And there’s like, you know, no one to see? Do you fly somewhere? So the realities of the shortages — we can talk about the numbers, but during the pandemic they were substantial, and they were definitely worse than that.

So we were excited, we were like glad, “OK, we’re going to lift these restrictions for now, all these people are gonna come help us.” But then, we have to come back to some baseline of quality and safety, and we can’t just do emergency proclamations forever. 

So it is a good thing that we reinstated quality and safety measures of our licensure so that we could protect our citizens and have good quality and safety in our healthcare, but we continue with these shortages.

And I’m excited because when I talked to Marschall Smith about what we could expect possibly in terms of workforce for our state, it sounded like we might get substantial influx — 15%, 20% increase — which would be a real gain for our state. 

Kent: Is that a 15% increase? Is that what you’ve seen typically in other states that have passed this?

Smith: Yes, states that have joined the compact see, on average, a 10% to 15% increase in the number of new licenses issued in their state. So if they’re issuing 100, they join the compact, they’re now issuing 110. 

Kent: Let’s go to the audience if there’s any questions. Yes, right here. Sheila. Sean has a mic right there, yep. 

Sheila Walker: Thank you so much, Marschall and Elizabeth, for being here today. I appreciate you and the information you’re sharing with us. So I have a question: Do all states have the same criteria for determining how many doctors are needed? And how is that determined here in Hawaii?

Ignacio: Every year, the University of Hawaii JABSOM School of Medicine issues a legislative report that’s submitted to the Legislature to let them know the status of our physician shortage, right? The modeling that they use to establish demand in our state is a very complex one, and I won’t pretend to understand all the factors that go into it, but they use a model that is generated for, you know, similar to what other states use.

It has to do with not just, like, how many people in your state are above the age of 65, for example, or how many people have diabetes. It also has to do with other known risk factors for cultural and ethnic issues in your state, which may be different for Texas or California or New York. 

And it’s one of the reasons why a lot of states want to retain control of licensure, by the way, when people were — I think that was one of the questions that came up — is that because different states might see different incidents or have different experiences with different pathologies.

I’ll give an example. I’ll make up an example and say if you were in a state that for whatever reason you had a high incidence of malaria, you know, then you would have to do, donate — not donate — you’d have to put forth more resources towards education and providing care for that. And it would also change the profile of maybe the kind of physicians that you need and what you’re short in your state. So that’s the reason why it might not — Hawaii’s profile might not be the same as Florida or North Carolina. 

So I can share [with] you a copy of it because it’s a very complex modeling where they talk about what we need in our state, and sometimes I wonder if it’s, you know, understating the significance of the problem, that we actually need more than that.

Kent: And my dad did a calculation actually. He just, I asked him, “Hey dad, I work at this think tank and I was wondering what you want me to study, you know, if I could study one thing.” And he said, “Find out why it’s so hard to get a doctor in this state, you know.” 


And so there’s, we can just see that there’s a doctor shortage, you know. We feel a nursing shortage too. 

And I wanted to — oh, first of all, are there any other questions from the audience? Let’s go there. Yeah, go ahead.

Audience member 2: I would like to, yeah.

Kent: There, yeah, go ahead.

Audience member 2: Oh, OK. I’m a nurse; I actually came here from the Hawaii State Center of Nursing — I asked for invitations for BJ and I. And the reason why is that we were considering joining the nurse licensure compact. I was on the board of nursing for years and years working towards this, but we’ve come with two big things.

No. 1: We already streamline it. All nurses in the United States and in Canada take the same test after they graduate. So it’s the same board, and it’s been like that since the early ’90s. 

The other issue is criminal background check; we’re already doing that. So we have a speedy one. 

But the nurse license compact states that if you get your license in Missouri, and we’re part of it, you don’t have to get a license in Hawaii.

We have no idea if you’re here practicing or not. You just come, and you work. And then if there is a safety issue or something against your license, it goes back to Missouri. It’s not — it doesn’t go through the Board of Nursing here. 

That is a huge sticking point with us, and we’re wondering: Is that where you guys are headed — where one license as a doctor in, say, the state of Missouri will be good in Hawaii? OK, so it’s almost like we’re apples and oranges. 

Smith: Yeah, it — oh, go ahead. 

Ignacio: No, no, I’m — that’s very interesting because people were asking me. We knew that a bunch of those compacts were moving through the Legislature this past session and I was like very excited about the nursing one. I was like there’s a nursing one, there was a physical therapy one, there were a bunch of them, and I was like, “Yes, yes, let’s get those all in there.” 

But my nursing colleagues let me know; they were just like, “No, no, no, no, no, we don’t support that one.” But that’s a very interesting and important point. I don’t think that we were, we’re trending towards that in terms of a national licensure.

That was a movement prior, but you want the states to maintain their policing and their quality, their authority to control safety issues and quality issues. So, yeah. 

Audience member 2: Absolutely, that’s why we’re here, and it’s good to hear that you have figured a model out that works better. And if that’s the model that we have from the National Council of State Board for Nursing, we could agree with it. But …

Ignacio: Very interesting. 

Audience member 2: We don’t have that so… 

Ignacio: I see.

Audience member 2: Thank you for being here and thanks to the Grassroot people for having it.

Smith: So — and I have it at the top of the slide too, but — so the, on the previous one. 

Kent: Oh, should I go back? How’s that? Or this one?

Smith: Yes, this one. Right there. So there are, in a sense, two models that take place with regards to compacts. The physician model is what’s called an expedited licensure model. So we expedite the process for a physician to get a license in the state in which they intend to practice.

And where compacts that, you know there are — where the compact value comes to the practitioner, whether it’s a nurse or a physician, is there’s a single place in which you can do that. So yes, Hawaii has a — and I would imagine that you do have a very quick turnaround time for nurses and for physicians, and you have an effective process.

But the issue becomes if you are, for physicians — and I can, I really can and should only speak for physicians and the physician process — but in order for a physician to get licensed in multiple states, they have to apply to each state, and it costs on average, about $480 to apply for a physician license in a state.

The compact costs $700, but you can apply for all of the states that you want. It’s all done online. It’s all done in a single source. All of your licenses are renewed through the compact process, and so rather than having to know all of the states — and there are still physicians that do it, and it’s still an option for physicians — but that’s the value that the physician, that the compacts bring to the practitioners. 

The nursing compact and all of the other — there’s a PA compact that’s out there now that just has been introduced, the nursing compact — all the other compacts do what is called a “privilege to practice compact,” and it’s different than reciprocity. 

Reciprocity is very much the concern that you raised, which is the nurse is licensed in another state; they’re coming here; everything has to go back to that home state to take care of anything. 

Where the compact is a bit different — and again, I’m speaking for the nurse compact, and I’m not authorized to do that and, you know, you’re listening to me at your own risk, I guess I would say — but the difference is that in a nursing compact, the nurse has to register him or herself with the compact in order to come and practice in Hawaii. 

And that Hawaii, the nursing board here in Hawaii, can query and can obtain reports from the central compact about “So how many nurses are practicing in Hawaii? Where are they from? Who they are?” 

So there’s the ability to query and obtain that information. It’s not, I don’t believe, it’s not automatically said or told to a state, but a state has the ability to come back — Hawaii would have the ability to go to the nursing compact — and say, “How many nurses have registered themselves to practice in Hawaii?”

And the discipline, yes, does go back to the nurse in their primary state because the primary state retains the authority — the policing authority — over that license. The reciprocity or, I’m sorry, the process — this mutual-recognition process — it is this if they do have a full license to practice here. So it’s legally the same, even though it’s not issued by the Hawaii board. 

By joining the compact, you’re saying it is a legal authorization to practice just as if they get a license. 

So the fear — and I’m not advocating one way or another — but the fear and what you’re talking about really is reciprocity. That’s the reciprocity process. A compact process is different than that.

Ignacio: And just to reemphasize what he had said before, remember that, like, so through this, if you apply for your — when you’re going through this licensing process with IMLC, you’re gonna get seven — like if you apply for seven — you’re gonna get seven licenses. That still means that when you, when you do the service in Hawaii, you are subject to the regulations of Hawaii. And so that when there’s something — an adverse outcome or something like that — the Hawaii board is going to be bringing you up. 

Interestingly, what also came up in discussions with Marschall that I thought was interesting, was the fact that during the investigative process, if you are part of a compact, you are able to share information about an ongoing investigation on a provider instead of waiting for outcomes because we have a database already that also already shows what actions have happened against a specific provider. So when consumers are shopping around, they can see that, “OK, this person is board-certified and there’s been no actions against them in this state.” 

Well there might be some pending; you just don’t see them. And you might even know yourself as the consumer, you’re like, this is, this person is really awful as a provider, and I need to find out what their history or track record has been. But with the compact, they would be able to share information in active investigations, which I think is an important core collaborative effort to keep quality and safety maintained.

Smith: Right. And for the physician compact, it is a bit different, but it’s not that much different between whether it’s a privilege to practice or a licensing process.

One of the other things: By joining a compact, your state is now authorized through the compact — because we’re a member, we are a part of your state government — you’re allowed now to share your investigative information. 

So, to use your example — and again, putting caveats out there like crazy — but again, so even though this nurse, let’s say you have a nurse that came here from Missouri and has been practicing and then starts having adverse events. The Missouri board will be doing the investigation and potentially limiting that license. But the Missouri board investigators have the authority to speak with and obtain and use the Hawaii Nursing Board investigative staff. Without the compact, they can’t. 

I know from being in Colorado, the Colorado Medical Board cannot — and our investigators — cannot acknowledge any sort of investigation, anything that’s going on, and they can’t talk to other investigators. Under the compact process, you can.

The investigators are allowed to exchange — and I’ll give you a quick example of one where I consider it, again, an incredible success story, that we had a physician who was practicing and had obtained 26 licenses through the compact. He was being investigated for sexual misconduct with patients in four of those states, and the four states were having problems putting together the information and being able to do it. 

We — compacts, and these, these are our terms — but under the compact, the states have the ability to form what’s called a “joint investigation,” which means all of the investigators. So the investigator from Hawaii has a seat, so all 26 states’ investigative staff had a seat at the table, and they investigated this position. He lost all 27 — 27 licenses because his state of principal license — he lost all 27 licenses in three months. 

So from the start of the joint investigation to that action taking place happened quickly, and it allows that. So that is another advantage to being a part of the compact is that yes, Missouri will be doing the investigation, but they have access to the Hawaii information. 

Kent: So we’re at time right now, but we have one more question. Go ahead. 

Hema Subbaratnam: Aloha, Mr. Smith. Thank you for — could you go back to your slide for step one for a moment? I had a question about your process. 

Uh, yes. So I’m a Hawaii licensed physician. My principal residence is in Hawaii, and I’m an independent contractor, so I’m in my second career as a physician. I’ve been approached by telemedicine companies, and if I’m not actively practicing in Hawaii, and I’m doing telemedicine in other states, could I even go through the IMLC? 

Smith: So yes. If, so, if you’re located in Hawaii, you’re — you don’t meet the first bullet. You’re not going to qualify for this one because you’re not in, Hawaii’s not yet operationalized the compact. 

Subbaratnam: OK.

Smith: If 25% of your practice — so let’s say you’re doing telemedicine in Hawaii, or let’s say you’re practicing in Hawaii, Washington, Colorado, and a third of your practice takes place in all three of those states, you can select Washington or Colorado to be your state of principal license.

The other thing is that your employer is located in the state of principal license. So if your telemedicine company is located in Colorado, then they are your employer. They’re authorizing you to practice medicine; they can act as, Colorado could be your state of principal license.

Subbaratnam: Yeah, but I’m an independent contractor.

Smith: And employer is, yes, so we defined employer. So yes, you would be able to that. That’s the short answer to that.

Subbaratnam: And then under the compact, you pay $700 to be registered with the compact and get your licenses, but you still have to pay individual licenses in every state and the [continuing medical education] credit for every state is completely as well. 

Smith: And you have to pay the renewal fees and all that. So again, the compacts charge a set — that’s how we we operate. $300 of that $700 goes to the state of principal license to verify the application and to issue the letter of qualification, which is the key to getting in; $400 comes to the compact itself so that we can be operational.

It is economically beneficial to the physician if they’re applying for two or more licenses to use the compact. 

But it does, yes, you have to pay — I mean, you’re getting a license from that state. You’re going to pay that cost whether you’re, you’re doing it or not. If you go to the last slide, it’s got my contact information. 

Also, you can go to our web page, which is IMLCC.org. We have a customer service — we have the best customer service agents in the entire world. We have four people that are dedicated to do that; we’re there from 6 p.m. Eastern [time] to 6 p.m. Pacific [time]. And when Hawaii joins, we will be expanding our hours so that we’re open and someone is available for you to speak to during your 8-to-5 work day.

Carolann Guy: I know we’re at time, I just have a real quick question. How has the insurance — [Hawaii Medical Service Association] or Kaiser — reacted to out-of-state licensing and reimbursement?

Smith: So the question is, how are insurance providers reacting to the compact? They love the compact because it simplifies; they love the physician compact because it simplifies it. They like the nursing compact. Insurance companies like compacts because it’s easy. “Do you have a license in that state?” “Yes, I do.” “OK, you’re a provider.” 

Reciprocity again, there’s nothing wrong with reciprocity. It’s a great concept. It works in conjunction with what we do at the compact. But where we have, where our strong advantage is that it doesn’t matter to that insurance company where that physician is physically located. It matters that they’re licensed where they’re practicing and they’re billing. 

Kent: OK, well we are at time now, so thanks for going over a little. Let’s have a round of applause for our guests again. They’ll be here for more questions. 

And thank you for following our work. If you haven’t yet subscribed to our newsletter, go to grassrootinstitute.org, and we’d love to hear your comments about how we did today. We’ve got little comment cards on every table. So thank you, aloha. 


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