AAPS letter to HHS: new requirements for Maintenance of Licensure threaten access to care

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The Honorable Daniel R. Levinson
Inspector General
U.S. Department of Health & Human Services
330 Independence Ave, S. W.
Washington DC 20201

March 20, 2012

Dear Inspector General Levinson:

I am writing you regarding the current attempts of the Federation of State Medical Boards (FSMB), The American Board of Medical Specialties (ABMS), and multiple medical specialty societies’ current attempts to introduce requirements for renewal of state license to practice medicine, based upon ABMS “board certification and Maintenance of Certification (MOC) programs” referred to as Maintenance of Licensure (MOL). Board certification to date has been a mark of excellence well beyond basic licensure requirements. These organizations intend to introduce significantly greater costs in time and dollars, which will be added to current healthcare expenditures, without any proof that this will in any way improve medical care. These measures rather will very likely drive physicians into early retirement as well as reduce overall clinical availability, due to the bureaucratic impositions to submit to extensive compliance to the ABMS’s ever increasing mandates for certification.

The ABMS and affiliates can expect a significant increase in gross receipts (currently in excess of $300 million per year) and true monopoly now, not only on “board certification” (which they maintain is voluntary), but on approval for state licensing itself. While the American Board of Physician Specialties (http://www.abpsus.org/) has also been certifying physicians for decades in the U.S., they are to be excluded and are actively excluded today by ABMS activities, for example in Texas.

In your statements before Congress from March 2, 2012, you state your concerns about billing for unnecessary procedures as well as kickbacks and other abuses. I believe that there is collusion by the above-named companies to engage in practices that constitute waste and unjustified burdens. There is collusion to create the equivalent of a monopoly, one requiring all physicians to pay large sums of money yearly to “participate in prescribed MOC programs” (none of which have ever been demonstrated to improve care) under a false guise of MOL now being pushed onto physicians under the pretext of state board inadequacies.

I believe you testified in response to Senators Baucus, Hatch, and Grassley’s February 15, 2012, letter indicating inadequate appropriate activity by State Medical Boards. But what is inappropriate is how individual state medical boards (including Ohio, which specifically addressed MOL in a meeting March 15-16) seek to subcontract “competency assurance” to the ABMS or other companies, to defray criticism of being “soft on physicians.” Physicians and patients will pay the increased charges for services the state medical boards already are mandated to provide. These measures may interfere with interstate commerce (physician availability), be violations of the Sherman and RICO acts, and have distinct similarity to “selling security” after first creating the danger of distress. Collusion is clearly evident and oddly enough, the FSMB and ABMS avoid paying taxes as “non-profit” organizations. This is a historically imparted privilege, one which also may deserve revision by the IRS, given the vast amounts of income and no real public interest value documented by any “outcome-based medicine” study.

Specifically, there is no verification that current CME-based licensure requirements do not provide for ongoing education and competency. Significant numbers of physicians in practice are not board certified: only 200,000 of the practicing 759,000 U.S. physicians are enrolled in Maintenance of Certification (MOC) and many have not recertified in the past decade. [1] Women and underrepresented minority students were found to display significantly lower levels of board certification. Nine years after medical school graduation in 2000, only 34.9% of female OB/GYNs were certified in 2009. [2] Only 73% of all practicing anesthesiologists are board certified in 2011. [3] Also, roughly 50% of practicing anesthesiologists currently possess lifelong certification obtained prior to 2000. There is no convincing evidence that board certification improves delivered care, needs to be renewed at 5-10 year intervals, or is demanded by modern patients seeking care. Board certification may actually increase legal liability in malpractice events.

MOL has resulted in significant controversy. [4] State medical boards do not consistently tabulate rates of certified versus non-certified physicians, while non-specialist (certified) numbers appear to run around 37% in Ohio as found in available State Medical Board of Ohio (SMBO) data. The SMBO publishes all “actions” online at http://www.med.ohio.gov/professionals-mfal.htm. A review of the first 3 months of 2011, with 69 physician “actions” and 35,562 physicians in active practice in the state (0.8% of all physicians a year were subjected to “actions” of any kind), makes clear that physician competence is an unusual causative factor, and this is recognized by the state board members: only four individuals were subject to actions for related reasons (mental health/retirement, wrong-site surgery, history of substandard care on license application)—yielding a rate of 0.04% per year, based on this quarter’s analysis. Roughly 80% of all actions deal, however, with physician drug and prescription abuse, alcoholism, and moral turpitude/financial fraud.

With more than 150 specialty certifications existing in the U.S., significant variability in medical and political importance of any individual board certification is certain. Periodic testing during “continual” MOC is, however, being actively mandated primarily by the multiple private organizations (FSMB and ABMS) destined to profit as MOL is legislated or otherwise secured. An increase in gross receipts (as well as ancillary expenditures), currently totaling more than $350 million per year and more than $400 million in accrued assets as a “board certification industry” (as accrued numbers of all composite boards and tabulated from the most recent and official IRS 990 forms on file, all available for review at http://www.changeboardrecert.com/ ). While physicians have and continue to keep pace with the individual practice of medicine and MOL (which has existed for decades in all states) via continuing medical education mechanisms at great cost, the imposition of repeated certification will certainly increase healthcare costs without proven benefits to quality, detection of cause for board actions, or any demand by the general public.

If Maintenance of Certification (MOC) becomes a requirement to sustain a medical license to practice (MOL), as is currently being advocated by FSMB, Inc. (a non-profit organization without legal mandate) and is being actively evaluated in 11 states (Ohio, California, Colorado, Delaware, Iowa, Massachusetts, Mississippi, Oklahoma, Oregon, Virginia, and Wisconsin), all physicians (and all patients and insurers indirectly) will be increasingly required to support the certification industry’s ever increasing bureaucratic costs. Reductions in bureaucracy and medical costs are, however, urgently needed and actively debated as essential at this time.

Please give this matter your serious consideration, as MOC/MOL threatens the availability of affordable physician care in Ohio. I am happy to speak with you and answer any questions.

Respectfully,

Jane M. Orient, M.D., Executive Director
1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716
(520) 323-3110


References:
1. Kirkner RM. Physician board certification isn’t what it used to be. Managed Care Magazine, May 2010. Available at: http://www.managedcaremag.com/archives/1005/1005.boardcertification.html. Accessed Feb 26, 2012.

2. Jeffe DB, Andriole DA. Factors associated with American Board of Medical Specialties member board certification among U.S. medical school graduates. JAMA. 2011;306:961-970.

3. Dutton RP. So what have we learned? An update from the AQI. American Society of Anesthesiologists Newsletter 2011;75(Dec): 40-42. Available at: http://viewer.zmags.com/publication/260e90a8#/260e90a8/42. Accessed Mar 21, 2012.

4. Orient JM: White paper in opposition to Federation of State Medical Boards (FSMB) proposal on maintenance of licensure. J Am Phys Surg 2008;13:23-16. Available at: http://www.jpands.org/vol13no1/orient.pdf. Accessed Mar 19, 2012.

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