In 2018, the Association of State and Provincial Psychology Boards (ASPPB) held a PsyPact pitch meeting in Washington, DC, to recruit additional states needed to enact the interstate compact. Iowa invitees included a state senator and house representative, the chair of the Iowa Board of Psychology, and me, serving at that time as the Iowa Psychological Association’s (IPA) State Advocacy Coordinator. 

We all entered the meeting enthusiastic to broaden access to telepsychology, but some left concerned that aspects of the design needed to be improved. While there is the obvious purported benefit of increasing patient access via telehealth and temporary in-state practice, the Iowa Psychological Association has decided to oppose the passage of PsyPact in the multiple years it has been introduced.

     Interstate compacts for healthcare providers are not new. There are compacts for many professions, including physicians, nurses, social workers, counselors, audiologists, physical therapists, and even emergency medical providers. They come in different styles and qualities. Compacts allow for interstate practice without having to be licensed in multiple participating states. They are a substitute for national licensure or reciprocity agreements. By design, PsyPact requires the participating states to give up some control over the regulation of licensees.            Licensing requirements vary between states, and under PsyPact, someone who wouldn’t qualify for in-person practice in a receiving state could practice telehealth full-time in that state. If a state has specific continuing education requirements (e.g., cultural competence, ethics, or state regulations), a PsyPact psychologist does not have to meet those standards when practicing telehealth in another state. Further, while the current system is limited to doctoral-level psychologists, it has not been guaranteed that rules (governed by the PsyPact Commission) would not be expanded in the future to allow master’s level psychology practitioners to practice across state lines.

     To best understand the nuance of Iowa’s opposition to PsyPact, it is important to be aware of the definitions and rules in the compact’s model legislation (which cannot be amended or modified by individual states). First, it is important to differentiate the “home” state (where the psychologist resides) from the “receiving” state (where the patient is located). PsyPact rules state, “For the purposes of this Compact, the provision of psychological services is deemed to take place at the physical location of the psychologist.” This diverges from other compacts that state the service occurs in the patient’s location (i.e., receiving state). This is where things get muddy. Under PsyPact, although the service is deemed to occur in the home state, the psychologist must abide by the “scope of practice” and “health and safety” rules of the receiving state. If a disciplinary issue arises, the home state is responsible for investigating, asking that board to interpret another state’s rules. If, instead, the provision of service was in the receiving state, it would be more transparent for patients to understand which rules apply and better assure local accountability, driving home the imperative that providers follow the rules of the road wherever they (virtually) travel. This would also better mirror the in-person practice allowed under the Temporary Authorization to Practice (TAP) PsyPact credential and other occupational compacts.

     The health and safety of patients should be paramount in constructing a compact;

it was an afterthought for PsyPact. Interstate practitioners should be demonstrably

knowledgeable of receiving state laws, including required reporting of abuse, duty to

warn/protect statutes, and rules regarding involuntary commitments. Under PsyPact,

psychologists only have to say they are knowledgeable; however, there is neither a

method of ensuring competence of these laws nor a mechanism to track which

providers are practicing in different states. In my experience as IPA’s state legislative

advocate and a liaison to the Board of Psychology, even some resident psychologists

lack adequate awareness of their home state regulations. It seems hard to believe that

a provider working for a nationwide telehealth company could accurately identify these variations across the states where PsyPact is currently in effect. It’s also unlikely that these providers would be aware of the local referrals, social and emergency services, or other resources in the receiving states. For these reasons, regional reciprocity agreements or multi-state licenses may be safer methods of promoting inter-jurisdictional telehealth.

     There are also concerns from the perspective of boards of psychology. While other states may be different, Iowa’s Board of Psychology is solely funded by licensure fees and receives no additional state funding for investigations (like many states, Iowa’s board is underfunded). Though the home state is primarily responsible for investigating the psychologist’s behaviors under PsyPact, the receiving state still has the mandate to protect the public and would likely have expenses with no offsetting license fee to fund such obligations. Even one investigation could stretch resources thin for small state boards. Even without an investigation, there is a cost to the board to participate in PsyPact (a fee paid to ASPPB to use proprietary software).

     Finally, there is the question of whether adopting PsyPact would improve patient’s access to psychologists or just increase psychologists’ access to patients. The greatest beneficiaries of PsyPact may be corporate telehealth platforms that can avoid multiple license fees and access the most affluent patients. Some independent psychologists currently operating brick-and-mortar offices may pivot to virtual-only practices or move out of state. Adopting PsyPact may lead other local psychologists to reduce the number of hours dedicated to patients within the state. Providers may also use PsyPact to seek out high-value private pay markets in other states rather than serve Medicare and Medicaid patients. As a result, if Iowa were to pass PsyPact, it may decrease access and undermine workforce development.

     From Iowa’s perspective, the benefits of PsyPact are outweighed by the risks to patients, workforce retention, lack of tracking, and competency verification. PsyPact ultimately undermines a state’s ability to regulate the practice of psychology within its borders, something the Iowa Psychological Association has advocated zealously to enhance in the public interest. PsyPact could better prioritize patients, reset the location of service, and verify competence of the receiving state rules.