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Traveling with Medication

Written by: Chad Carlson, MD, FACSM

Traveling with a sports team to provide care is a routine activity for team physicians. Typically, these trips are short in duration, with very little interaction with anyone other than the athletes and staff of the team the physician is contracted with. However, the legal standing of physicians who engage in this activity is murky, and in some cases physicians could face allegations that they are practicing medicine without malpractice protection. 

There are two medicological issues to consider for the traveling team physician. First, what is the proper way to carry and dispense medications to athletes who require them, especially when such travel takes the physician across state lines? Second, what are the legal issues that are implicated by traveling across state lines to provide care?

In November 2014, a very visible effort by the United States Drug Enforcement Agency (DEA) to administer surprise inspections to various NFL medical staffs was undertaken. Through these inspections, the DEA made it clear that compliance with federal requirements for documentation and transport of controlled substances is an ongoing and general issue. Thus, it is incumbent on organizations which rely on traveling medical coverage to work with their legal counsel and the practitioners they employ to ensure that pharmaceutical use, regardless of location, is done within the confines of current law.

The transportation of medication across state lines involves both state and federal licensing authorities. Uncontrolled prescriptions remain under the authority of individual states, while regulation of controlled substances is done at both state and federal level. All prescriptions for controlled substances must be written from locations that are registered in advance with the DEA, and these medications can only be stored and dispensed from locations where prior authority has been granted. Thus, transportation of controlled substances by a team or team physician to an unregistered location may cause the physician to face allegations of being in technical violation of federal law. Current options for a team’s medical staff include pre-dispensing medication to specific athletes prior to travel, or delegating the dispensing of controlled substances to the home medical staff in the state of entry. Importantly, the NCAA Sports Medicine Handbook appropriately states that physicians cannot legally delegate dispensation authority to athletic trainers (See Guideline 2 g. Dispensing Prescription Medication). A legislative remedy has been unsuccessfully attempted to address this problem at the federal level. Congressman Pete Sessions of Dallas introduced an amendment to the Medical Controlled Substances Act into the 112th Congress in 2011. This bill was set forth to authorize that a physician enter into an agreement with the U.S. Attorney General’s Office, thereby authorizing the physician to transport controlled substances from one location to another for up to 72 hours, as long as the drugs transported were specified, and their dispensing recorded. This bill did not pass out of committee. At this time, there is no legislation pending that would provide a clear safe harbor for a physician to transport controlled substances.

In the United States, the regulation of medical licensure has always been the domain of individual states. Because medical education standards are federally mandated, and standardized medical test assessment and board certification testing is national in scope as well, the education standards of medical training are not state-specific. Despite this, states maintain differing requirements for maintenance of licensure. This patchwork of varying state requirements has made reciprocity of medical licensure difficult to achieve. At the same time, maintaining licensure in every state that a team physician or athletic trainer might conceivably travel to represents an extremely high administrative and cost burden.

Medical coverage for team travel is often viewed by state policymakers as similar in nature to telemedicine or to provision of emergency medical care across state lines in the event of a public health emergency. In reality, team physician coverage represents a unique niche in that while care is often administered in a state where the physician may not hold licensure (the “state of entry”), the patients being cared for are from the home state, or “state of origin” in which the physician is licensed. Over the years, some states have recognized this by approving time-limited reciprocity for traveling team physicians and athletic trainers – usually by adding this to a list of allowed exemptions in the state’s medical or athletic training practice acts. Because there is no natural in-state constituency to advocate for bills like this, passage of these state-based approaches has been problematic, and to date, only about 20 states have formal medical reciprocity. Currently, efforts are underway for the development of an interstate compact, which is intended to streamline provision of medical care across state lines by expediting the process to achieve full licensure in participating states. However, medical providers would still need to seek and maintain licensure in multiple states, with the resultant high-cost burden.[i] The interstate compact also would not impact licensed athletic trainers. 

Even if states removed licensure barriers for provision of interstate team coverage, however, there are still malpractice coverage issues to consider. A survey of professional liability companies that were asked whether they would consider coverage for medical care provided across state lines indicated that in the majority of instances, this care would not be considered activity that was protected under the insured clinician’s policy.[ii] Many professional liability companies confine their business to a limited number of states, and premiums are determined by underwriting criteria specific to the states in which these companies operate. This puts physicians in a precarious situation, because although the federal system prohibits national regulation of licensure, the malpractice issues described above could not be addressed at the state level.

The proposed remedy to provide uniform physicians with malpractice and licensure protection during periods of cross-state travel was addressed into the 113th U.S. Congress as US HR 3722 and SB 2220. This bill would provide protection to physicians and athletic trainers by designating their clinical activities as occurring in their home state of origin rather than any other state of entry, as long as care is confined to the team and staff with whom they are traveling. HR 3722 garnered significant congressional support following its introduction in December 2013, but failed to pass out of committee before the end of Congress’ session. It was reintroduced into the new Congress in February 2015 as US HR 921: Sports Medicine Licensure Clarity Act of 2015. Once passage of this bill is secured, the issue of providing a clearer means of medication transport can again be raised. Until then, it is wise to discuss these issues with your team’s administration, legal counsel and malpractice insurance carrier to protect yourself and your institution. 

About Chad Carlson, MD, FACSM

Chad Carlson, MD is the owner of Stadia Sports Medicine -- a private medical practice in West Des Moines, Iowa. Dr. Carlson completed a family medicine residency at the University of Michigan in 1997 and a fellowship in Sports Medicine at Ball State University in 1999. He currently is the chair of the clinical medicine subcommittee on the American College of Sports Medicine Health and Science Policy Committee. He also served on the Board of Directors for the American Medical Society for Sports Medicine from 2009 to 2013, concurrently serving as Policy Chair. Prior to coming to Des Moines, he served as one of the team physicians at the University of Illinois in Champaign.

[i]https://www.fsmb.org/Media/Default/PDF/Advocacy/Interstate%20Medical%20Licensure%20Compact%20%28FINAL%29.pdf

[ii] Viola T, Carlson C, Trojian T, Anderson J. A Survey of State Medical Licensing Boards: Can the Traveling Team Physician Practice in Your State? Br J Sports Med 2013;47:60-62.