Telemedicine has become popular since the outbreak of COVID-19, but limits on care provided across state lines are returning.

This complicates the subsequent treatment of some cancer patients. It can also affect other types of care, including mental health therapy and routine doctor visits.

Over the past year, nearly 40 states and Washington, D.C., have ended emergency declarations that made it easier for doctors to use video visits to see patients in another state, according to the Alliance for Connected Care, which advocates for the use of telemedicine.

Some like Virginia, created exceptions for people who have a relationship with a doctor. Some how Arizona and Florida, have made it easier for out-of-state doctors to practice telemedicine.

Doctors say the resulting laxity of the rules creates confusion and has led some practices to shut out of state telemedicine altogether. This leaves follow-up visits, consultations, or other care only to patients who can afford to travel for in-person appointments.

Susie Rinehart is planning two upcoming trips to her cancer doctor Boston. She needs regular scans and visits to the doctor to monitor the rare bone cancer that has spread from her skull to her spine.

Rinehart doesn’t have a specialist near her home outside of Denver who can treat her. These visits took place practically during the pandemic.

She will travel without her husband to save money, but that presents another problem: if she gets bad news, she will have to deal with it alone.

“Having a rare cancer is stressful enough, and this only adds to the stress,” the 51-year-old said.

Rinehart’s oncologist, Dr. Shannon MacDonald, said enforcement of telemedicine rules now appears to be more aggressive than it was before the pandemic, when video visits were still available.

“It seems so antiquated,” said MacDonald, who recently wrote an article about the issue in the New England Medical journal.

Medical commissions claim that during a telemedical visit, the patient is in the place where the appointment takes place. One of MacDonald’s hospitals in Massachusetts requires doctors to be licensed in the patient’s state for virtual visits.

He also wants those visits to be limited to New England and Florida, where many patients spend the winter, said Dr. Lee Schwam, vice president of Mass. Brigham General Health System.

That doesn’t help doctors like McDonald, who see patients from all over the country.

Cleveland Clinic also attracts many out-of-state patients. Neurosurgeon Dr. Peter Rasmussen worries about how some of them will cope with the upcoming trip, especially since winter may bring icy weather.

A fall “can literally end the life” of someone with a condition like Parkinson’s, who has difficulty walking, he said.

Psychiatrists have another concern: finding doctors for patients who are leaving the country. This is especially difficult for college students who are temporarily leaving home.

Most counties in the U.S. do not have child and adolescent psychiatrists, noted Dr. Shabana Khan, chair of the American Psychiatric Association’s telepsychiatry committee.

“When we try to transfer patients, there’s often no one there,” Khan said.

Mother Helen Khoury found a specialist to help her when the 19-year-old’s post-traumatic stress disorder flared up last spring. But the Emory University student had to temporarily move from Atlanta to Boston for treatment, even though she had never set foot in a hospital that offered it.

She rented an apartment with her father so she could be in the same state for telemedicine visits, a situation she found “ridiculous.”

“It didn’t necessarily make sense … to kind of uproot your life just to get this three-week treatment program,” Khoury said.

Even people who see doctors close to home can be affected.

Dr. Ed Sepe’s pediatric practice in Washington, D.C., has patients in Maryland who have begun driving several miles across the border into the city to connect via video. This saves them a 45-minute drive downtown for an in-person visit.

“This is nonsense,” he said. “If you’re under a doctor’s care and you’re in the U.S., it doesn’t make sense to have geographic restrictions on telemedicine.”

Sepe noted that low-income families tend to work jobs that don’t allow time off for personal visits. Some also find it difficult to get to transport. Video visits helped with these obstacles.

“It’s more than just telemedicine,” he said. “There is a missed opportunity to level the playing field.”

States can play an important role in the development of telemedicine by protecting against fraud and protecting patient safety, according to Lisa Robin, head of the Federation of State Medical Boards.

But the federation is also recommending that states loosen some restrictions on telemedicine.

This includes allowing virtual follow-up for those who have traveled out of state to seek care, or for people who are temporarily moving but want to stay with a doctor.

States can also enter into regional treaties with their neighbors to facilitate cross-border care, noted Dr. Ateev Mehrotra, a professor of health policy at Harvard who studies telemedicine.

“There are so many ways these problems can be solved,” he said

In the meantime, patients who need help now are figuring out how to deal with it.

Lucas Rounds isn’t sure how many times he’ll visit McDonald in Boston to monitor his rare bone cancer. The 35-year-old Logan, Utah, resident already spent several months away from home earlier this year undergoing radiation and surgery.

In addition, he has a wife and three young daughters, as well as expenses such as a mortgage.

Rounds says he has to think about taking care of his family “if the worst happens.”

“If I die of cancer, all these expenses that we’ve accumulated … those are dollars that my family wouldn’t have,” he said.

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Follow Tom Murphy on Twitter: @thpmurphy

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