Volume 74, no. 2 February 2018
Growing physician opposition to their Maintenance of Certification (MOC®) cash cow is apparently causing consternation at the American Board of Medical Specialties (ABMS) and its component boards. They need to persuade legislators that MOC® is actually improving the quality of care—and not just contributing to physician burnout, decreasing access, and increasing cost.
The latest evidence is trumpeted in a bold headline by the American Board of Internal Medicine (ABIM): “Women are more likely to get breast cancer screenings they need when they see internists who maintain board certification” (tinyurl.com/ybdufcqc). The authors, three employees of ABIM, write: “The results of this study also suggest that recent calls by state legislatures to restrict the use of MOC by hospitals in conferring privileges, and payers, in terms of reimbursement policies, might have the unintended consequence of impacting women’s health negatively by reducing participation in MOC” (tinyurl.com/yafvtllo).
The study compares billing claims data from fee-for-service beneficiaries who consulted internists certified in 1989, just before certificates were time-limited, with those from patients of internists certified in 1991. At baseline (1999-2000), annual screening mammography was done in 53.5% of women attributed to grandfathered physicians, and 53.2% of those attributed to MOC-limited physicians. In the period 2002-2004, the percentages were, respectively, 56.3% and 57.3%. The regression-adjusted percentage difference was 2.8% (p = .001!!).
In all the data-dredging details, the authors failed to disclose how many comparisons were made (as of time periods or quality measures)—a critical factor in determining statistical significance. If enough comparisons are made, at least one of them is highly likely, by chance, to reach the desired p value.
“Inappropriate fiddling” with p values is rampant, writes Barbara Duck (https://tinyurl.com/hewjumf), who links to a video by Charles Seife, author of Proofiness: the Dark Art of Mathematical Deception (discussion of statistical significance and the multiple comparisons fallacy starts at 29 min).
ABIM’s MOC® modules “focus on recent advances in medicine, such as changes in guidelines and the rationale for these changes,” according to the article referenced above. Mammography guidelines have changed frequently, sometimes by one vote after a contentious committee debate. Different groups issue guidelines that vary greatly. Some believe it astonishing that a screening test as poor as mammography has achieved widespread acceptance and insurance coverage. Would research dollars be better spent on seeking a more accurate test than on guideline compliance? But increasingly, quality is being taken to equal compliance (http://aapsonline.org/newsletters/nov98.htm).
Ironically, the ABIM Foundation initiated the Choosing Wisely® campaign to discourage “unnecessary” diagnostic tests.
“Teaching to the test,” rather than developing independent thinking, is becoming the method for “lifelong learning,” as well as for undergraduate medical education. To improve scores in the USA Medical Licensing Examination Step 1, completing >2,000 practice questions is recommended (tinyurl.com/ybb2kkmy).
Is Certification or MOC® Voluntary?
ABMS continues to assert that MOC® is voluntary despite its opposition to state laws that prevent hospitals or insurers from requiring it. Actually, it does appear to be voluntary—unless a physician wishes to prescribe a medication or get paid.
An AAPS member sent a prior authorization form from a Benecard pharmacy benefits manager (PBM) demanding to know whether the physician is board certified.
Medicare payment for interpreting sleep studies is now being tied to board certification. Sleep centers would lose their accreditation if their director failed the MOC® examination, employees would lose their jobs, and patients would lose access to testing for a potentially life-threatening condition. One specialist, who with an associate has interpreted 30,000 sleep studies, writes that his experience probably far surpasses that of most of the consultants writing the examination questions. He felt that many of the questions on the exam he took were intentionally confusing or had multiple defensible answers.
For “grandfathered” doctors with lifetime certification, MOC® might be voluntary, but 65% of boarded physicians had time-limited certificates in 2009. This is projected to reach 93% by 2020 (https://tinyurl.com/yda4fjo2).
“Everybody Can Row in the Same Direction”
The ABMS Portfolio Program, for which Part IV MOC credit is offered, “supports physicians’…competence in systems-based practice” by “establishing the professional standards used by its 24 Member Boards” (https://tinyurl.com/y8erv3lf).
Physicians will learn how to communicate with patients and “adapt their practices to community health needs.” For only $250 per learner (“one dinner for three at a nice Chicago restaurant”), they can enroll in a three-phase (“assess, improve and reflect”) quality improvement module on advance directives, with links to POLST (physician orders for life-sustaining treatment) forms in 12 languages and references to state laws (tinyurl.com/y7es5rlh).
There are detailed instructions for a PDSA (Plan, Do, Study, Act) cycle, e.g. identify 25 patients for an end-of-life conversation.
New frontiers in interactive indoctrination?
AAPS Testifies for Anti-MOC Bill in Indiana
The Judiciary Committee of the Indiana state senate voted 7 to 3 in favor of a recommendation to pass SB 208, which would prohibit hospitals from denying admitting privileges to a physician or podiatrist based solely on the decision not to participate in MOC. Also, certification or MOC could not be required for licensure. A sickness or accident insurer or HMO could not deny a physician or podiatrist the right to enter a reimbursement agreement, deny payment for a covered service, or set reimbursement at a lower level based solely on the decision not to participate in MOC. AAPS general counsel Andrew Schlafly, member Christopher Magiera, M.D., and Daniel W. Stock, M.D., testified in support. The entire hearing may be viewed at https://youtu.be/1leSPM0cHU8.
Medicare-HMO Revolving Door
Studies of Medicare outcomes published by JAMA and JAMA Internal Medicine are restricted to fee-for-service patients, observes Brant Mittler, M.D., J.D., not Medicare Advantage (MA) enrollees. Medicare HMOs and all insurance plans employ battalions of data miners to help avoid risk. And what happens when enrollees develop expensive problems? Government Accountability Office (GAO) data show that of 126 MA plans with a rate of disenrollment higher than the median of 10.6%, 35 had health-biased disenrollment: Beneficiaries in poor health were 47% more likely to disenroll than those in better health. Of those who disenrolled, more than 25% reported problems in getting needed care, and more than 40% reported that preferred providers were not in network. GAO states: “CMS does not use available data to examine data on disenrollment by health status as part of its ongoing oversight; thus CMS may fail to identify problems in MA contract performance.” Contracts are prohibited from limiting coverage based on health status (GAO-17-393, Apr 17, 2017).
In a 1997 article, “The Medicare-HMO Revolving Door—the Healthy Go In and the Sick Go Out,” Morgan et al. wrote: “The rate of use of inpatient services in the HMO-enrollment group during the year before enrollment was 66 percent of the rate in the fee-for-service group, whereas the rate in the HMO-disenrollment group after disenrollment was 180 percent of that in the fee-for-service group.” They concluded that a marked selection bias existed in enrollment and disenrollment, highlighting the need for longitudinal and population-based studies of the managed-care model (NEJM 1997;337:169-75, https://tinyurl.com/y8hkklgy).
“Nothing much has changed in 20 years—except that more taxpayer money subsidizes these entities and they have become a legally protected class,” writes Dr. Mittler.
“The scientific method is not a belief system, it is a practice…. Skepticism is the lifeblood of scientific progress…. It is not ‘antiscience’ to be skeptical—it’s definitively pro-science…. Over-confidence to the public, not skepticism, are characteristics of an anti-science attitude. But whereas skepticism and uncertainty have always been the heart and soul of science, confidence and certainty are the coin of the realm in much of today’s public discourse. Unquestioning confidence is deeply troubling for the scientific community…, and it has led people…to question scientific enterprise itself. We should all be troubled when science is treated as if it were an ideology rather than a discipline.”
Sue Desmond-Hellmann, M.D., https://tinyurl.com/yd8fbr67
“Revalidation” Spreads Internationally
The UK version of MOC, mandatory revalidation, was imposed on physicians in 2012, and on nurses and midwives in 2015. The process is described in the book Developing Reflective Practice: A Guide for Medical Students, Doctors, and Teachers by Andrew Grant, et al., reviewed by AAPS director Paul Martin Kempen, M.D., Ph.D. (https://tinyurl.com/y735zymv). Revalidation obliges the practitioner to self-document continuing education and “reflection” in what amounts to a diary. The apparent purpose of the book is “to provide the educational authority, framework, and scientific doublespeak necessary to establish foundations for this newly emerging and necessary lynchpin of UK medical professionalism.” The cost of revalidation was estimated to be nearly £100 million per year (about $733 per physician), with the greatest singular cost being lost physician work hours.
Virginia May Clawback Pay to New Doctors
Physicians who need another reason to decline contractual relations with insurers should look at proposed Virginia House Bill No. 139 (https://tinyurl.com/yalcymba). As Suja Amir of the Univ. of Virginia’s Sorensen Institute points out, this would require an insurer to clawback money from doctors who are denied credentialing by the insurer. And it would also prohibit attempts to collect fees from the patient who had received services while the doctor’s application was pending. [See Ms. Amir’s presentation on battling the MOC industry at our 2015 annual meeting in St. Louis (https://tinyurl.com/yahlexvq).]
According to senior neurology consultant Prof. Patrick Pullicino, the UK’s National Health Service is “killing 130,000 elderly hospital patients a year.” Of the 450,000 deaths in Britain each year of people who are in hospital or under NHS care, 130,000 are on the Liverpool Care Pathway (LCP). The LCP is said to be initiated when doctors believe that it is impossible for the patient to recover and death is imminent. However, little evidence (and apparently no advance directive) is required; factors include scarcity of beds and difficulty nursing confused or hard-to-manage patients (Canada Free Press 9/15/17, tinyurl.com/y9kcqkq6). Prof. Pullicino stated that many who could live substantially longer were likely being killed by the LCP. A Dept. of Health spokesman denied that the LCP was euthanasia and said it “is recommended by NICE and has overwhelming support from clinicians—at home and abroad” (https://tinyurl.com/d84valn).
Apr 6. Thrive Not Just Survive and board meeting, Atlanta, GA.
May 19. Texas state chapter meeting, San Antonio, TX.
Oct. 3-6. 75th annual meeting, Indianapolis, IN.
Gell-Mann Amnesia and the Law
Described by the great particle physicist Murray Gell-Mann, this disability “turns off the skeptical switch,” writes John Dale Dunn, M.D., J.D. It allows people to agree with what they read in sources they already knew were unreliable and deceptive in areas they know about. “It is why propagandists do so well.”
The late Michael Crichton wrote that newspapers are full of “wet streets cause rain” stories in which journalists get cause and effect backward. He stated that this amnesia doesn’t operate in all areas of life. In court, there is the legal doctrine of falsus in uno, falsus in omnibus, which means untruthful in one part, untruthful in all (https://tinyurl.com/ydz7dnlo).
Vaccine Exemptions: What Is Religion?
The federal Equal Employment Opportunity Commission (EEOC) has intervened in three instances in the past 2 years when health care workers challenged mandatory vaccination policies. One sticky issue concerns EEOC’s definition of religion: “moral or ethical beliefs as to what is right and wrong which are sincerely held with the strength of traditional religious views.” Its breadth has created practical uncertainty about whether there are any meaningful distinctions between religious and philosophical objections to vaccination. In Chenzira v. Cincinnati Children’s Hospital Medical Center, the court found it “plausible” that a vegan lifestyle constituted a religious belief. In Fallon v. Mercy Catholic Medical Center of Southeastern Pennsylvania, the court held that a conscientious objection that the risks of influenza vaccination outweighed the benefits was not religious, but “personal and social.” Opel et al. summarize pertinent cases, concluding that heavy-handed enforcement may fail, but “well-drafted and reasonably applied policies should avoid or withstand legal challenge, while also protecting patients” (NEJM 1/31/18, https://tinyurl.com/y9bnl83c).
Is “Medical Professionalism” a Religion?
According to the ABMS Definition of Medical Professionalism adopted by its board of directors in 2012, “medical professionalism is a belief system in which group members (‘professionals’) declare (‘profess’) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals” (Kempen, op. cit.). This belief system rests on a set of assumptions without scientific validation, and with no outcome-based study to date to validate its claims to help achieve the “Triple Aim”: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
!Tip of the Month: Momentum is growing in state legislatures against maintenance of certification (MOC®). Hospitals should not be requiring it, but many increasingly are slipping a change into their medical staff bylaws, or adopting it as part of their rules or regulations. You might ask for an up-to-date version of the bylaws at your hospital, and be vigilant in blocking insertion of a requirement for MOC®. Check our list (http://bit.ly/mocbills) to see whether there’s a bill in your state, and let us know if you are aware of one we are missing.
A Gnostic State Religion?
An Oct 17, 2017, JAMA Clinical Guidelines Synopsis contains “strong recommendations” based on “low evidence” or “very low evidence” for hormone treatment and surgery in adolescents with gender dysphoria (https://tinyurl.com/y9vwuj8m). Although their use is increasingly common, the impact of GnRH (gonadotrophin releasing hormone) analogues—puberty blocking drugs—administered to transgender youth in early puberty and <12 years of age has not been published. And UK’s Bath Spa University recently refused to allow a researcher to investigate people regretting their gender reassignment surgery who “detransitioned” to their birth sex. Nevertheless, disagreement with pro-LGBT policies can get one branded as “anti-science.”
Transgender ideology has been called Gnostic in its denial of physical reality in favor of an allegedly overruling knowledge plus feelings. The ancient philosophy (belief system) of Gnosticism is being enforced by the state. California’s 2016 Healthy Youth Act requires pro-LGBT instruction in state junior high and high schools—with no opt-out. Illinois is ridding itself of foster families and social workers who will not “facilitate” transgenderism. The First Amendment is believed not to apply because denying the assertions of an identity politics zealot is portrayed as an assault on personhood or human rights (https://tinyurl.com/y9btuvw9), writes Andre Van Mol, M.D., of the American College of Pediatrician’s Committee on Adolescent Sexuality. Outside the U.S., change is even more rapid. In Canada, Ontario’s Bill 89 allows for state seizure of children whose parents disagree with LGBTQI policies and ideology. In Andalucía, Spain, LGBT indoctrination is imposed on physicians, Catholic schoolchildren, and others, with fines up to $148,000 (tinyurl.com/y7g3fplw).
ABMS emphasizes communication. It doesn’t yet require use of the six genders taught to Ontario schoolchildren, but will MOC® eventually require modules on implementing POLST, or “voluntary euthanasia” called “assisted dying,” or the “choice” to abort, if these become the “standard of care”?
Medical Board Members Ordered to Pay Damages
In a stunning rebuke, a Judge has ordered 14 Maryland medical board appointees, the board’s lead attorney, and the person who conducted the investigation against Mark and David Geier to pay half of the [$2.5 million] damages out of their own pockets, between $10,000 and $200,000 apiece, depending on their net worth (Washington Post 2/4/18). The Geiers were initially attacked for research on the association of thimerosal-containing vaccines and neurodevelopment disorders (see jpands.org). Dr. Mark Geier lost his medical license for treating some autistic boys who manifested precocious puberty with Lupron (a GnRH agonist that is FDA-approved for precocious puberty). Damages were awarded by Judge Ronald Rubin because the board allegedly publicized private medical information about the Geiers in an effort to humiliate them, and failed to preserve emails related to the case.
Regarding the testimony of those representing the medical board, the judge wrote: “If their testimony were to be believed, which the court does not, it is the worst case of collective amnesia in the history of Maryland government and on par with the collective memory failure on display at the Watergate hearings.”
The board is expected to appeal.
Burnout. Neurologists recently received a large postcard from the American Academy of Neurology stating that on a 2015 AAN survey, 61% of neurologists reported symptoms of burnout. It cited “issues related to reimbursement, staffing concerns, insurance hurdles, and EHR frustrations.” You can bet the percentage is even higher now. The scope of this “burnout crisis” likely eclipses the “opioid crisis.” Physicians who are labeled “burned out” will now also be eligible for sham peer review as burned-out status will be equated with being an “impaired physician.”
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
No Physician Shortage? The great grim reaper death curve guru speaks again in a MedScape interview (tinyurl.com/y9y5q67y). Ezekiel Emanuel, M.D., Ph.D., architect of ObamaCare, states that despite dire warnings, there is no physician shortage. The population may be aging, and access to certain types of physicians may be problematic in some areas, but he insists that “more doctors” is not the solution. Who needs them when we will soon have mega data in interoperable electronic health records (EHRs), along with nurse practitioners, physician assistants, and telemedicine?
Jane Hughes, M.D., San Antonio, TX
Restored Professionalism? Before we get giddy about an AMA “professional resurrection,” consider the recent NEJM article “Beyond Burnout—Redesigning Care to Restore Meaning and Sanity for Physicians” (https://tinyurl.com/yd7a3pr2). It quotes Dr. Christine Sinsky, AMA vice president for professional satisfaction, who has done great work in documenting time spent in data entry clerking. It reports significantly lessened burnout in a hospital system that increased the ratio of medical assistants to clinicians from 1:1 to 2.5:1.
A big hospital system can afford the team—but such systems conform to the data entry EHR practice model and reporting demands. The Colorado hospital in the article is probably the typical mini-merged insurance corporation, a.k.a. Accountable Care Organization (ACO), which is often of necessity merged with a mega-HMO. The long-term result: the “team” and its physician leader will be at increasing underwriting risk, with “negative payment adjustments” (fedspeak for “Value Pay”) if too much of the hospital corporation’s capitation pay is spent (i.e. if there is “bad productivity”). Before the U.S. crony cartel system goes broke, gatekeeper clinicians will be practicing corporate population medicine with predictable lower pay for more and more work—and burnout will be back.
Robert W. Geist, M.D., North Oaks, MN
Life Expectancy Down. After rising for 26 years, U.S. life expectancy has decreased for the second straight year. News reports attribute this in part to the opioid overdose epidemic. Other contributing factors include: placing medical decision-making in the hands of hospital, insurance, and pharmaceutical administrators; denial of specialist care, testing, surgery, and medication; seniors placed on hospice prematurely; blocking hospital admission until the patient is extremely ill; patients delaying care because of increased financial burden; discharging patients from hospital too soon; hospital computer mistakes; doctor bonuses or contracts dangled by hospitals and insurance companies to minimize care; and Medicaid forcing patients into HMOs providing inferior care.
Gene Uzawa Dorio, M.D., Santa Clarita, CA, tinyurl.com/yd2e2xpv
Mergers and Buy-outs. The pending CVS/Aetna merger and UnitedHealthcare’s purchase of DaVita Group, adding 300 sites to Optum’s 1,100 sites of care of various sorts, are part of the corporate takeover of medicine, a trend that is growing daily. Medical care is becoming a commodity, and the patient-physician relationship destroyed. Corporate medicine was once outlawed, for good reason, in many states.
Stanley Feld, M.D., Dallas, TX
Stein’s Suit of the Month. North Carolina Attorney General Josh Stein is suing a drug company over marketing opioids to physicians. He has previously sued the Trump Administration several times. One suit failed when the U.S. Supreme Court allowed Trump to bar migrants from terrorism-prone countries. He clearly opposes strengthening border security, while illegal opioids flow unimpeded into our country.
Joseph Guarino, M.D., Reidsville, NC
Ignorant of History. In a recent poll, 40% of Americans said they prefer communism to capitalism. They remind me of journalist Eugene Lyons, who wrote Assignment in Utopia in 1937. Lyons was full of inspiration and idealism. But after 6 years in Moscow he wrote: “I was ready to liquidate classes, purge millions, sacrifice freedoms and elementary decencies, arm self-appointed dictators with a flaming sword—all for the cause. It was a species of revenge rationalized as social engineering. Then I saw these things in full swing and discovered that the revenge was being wreaked on the very masses that were to be saved by that cause.” Cultural purges by the BLM and Antifa show today’s youth have learned nothing. They are deaf to the words of Heinrich Heine who said, “Communism possesses a language which every people can understand—its elements are hunger, envy, and death.”
Ileana Johnson Paugh, https://tinyurl.com/ybtm2mhg