A new law in Oklahoma-and proposals in other states-looks to limit the power of maintenance of certification
Physicians who decide not to continue with maintenance of certification (MOC) can face consequences such as loss of hospital privileges and payer contracts.
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But that’s about to change in one state, where a law passed unanimously by both houses of the legislature and signed by the governor essentially makes MOC optional for doctors who would otherwise be concerned about hospital and insurance consequences. The Oklahoma bill, which takes effect November 1, allows MOC to be used as one possible path to retaining hospital privileges or insurance coverage, but it cannot be the only one.
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And given the rising frustration among physicians over MOC, it could become the spark for a national movement. Kentucky, Missouri and Michigan are considering or have passed similar legislation, not all of which goes quite as far. Michigan’s law would be identical to Oklahoma’s, but legislation in Kentucky and Missouri only prohibits MOC from being a requirement for state licensure.
“MOC is essentially a CME program, and it should not be used as a requirement for staff privileges, payment, licensure, or membership on an insurance panel,” says David Siegler, MD a pediatric neurologist and board member of the Tulsa County Medical Society and author of the Oklahoma State Medical Association resolution that helped lead to the law. “Why are we jumping through other people’s hoops? It’s not a government requirement. This is a private corporation.”
Kentucky State Sen. Ralph Alvarado, MD, an internist and sponsor of his state’s legislation, hopes the momentum is building to empower physicians. “It’s fun for me to see [this for] our colleagues in the private sector, who have been feeling pretty down and feeling like they’re not able to make an impact on things that are important for their practice,” he says. “I hope that becomes a contagious thing, that doctors feel in control.”
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Grant Greenberg, MD, MHSA, associate medical director of quality in the faculty group practice at University of Michigan Health System, believes such legislation will spread to other states. He understands the emotions involved, although he supports maintenance of certification.
Greenberg cites electronic health records and Meaningful Use as just two of numerous burdens facing physicians as part of their daily work. “When people are at a tipping point, no matter what the pressures are, one new thing, no matter what it is, people will respond negatively,” he says.
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He sees board certification as a mechanism to ensure physicians are up to date on the latest knowledge and in reassuring patients and their families that they are getting the best quality care. Nonetheless, other states will likely follow along.
“Once one state does it, other states are going to follow,” he says. “I think it’s unfortunate. … You can make legislation to say board certification is not going to be required, but I don’t think that’s good legislation, and I don’t think that’s beneficial to the patient, or the community or even the physician.”
Many doctors have grown frustrated with MOC as it’s been defined and redefined by the American Board of Medical Specialties (ABMS) and its 24 specialty affiliates, believing that the benefits to their practices and patients do not justify the cost and time commitment involved.
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That frustration has led to the creation of the National Board of Physicians and Surgeons (NBPAS), an alternative group to ABMS organized around less stringent MOC requirements. And the controversy has caused ABMS and its member boards to reexamine their policies and procedures with an eye toward achieving greater relevance for physicians and minimizing their anger."
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Figures provided by the Oklahoma Board of Medical Licensure and Supervision show that slightly more than two-thirds (68.3%) of physicians practicing in the state have maintained up-to-date ABMS certification. Oklahoma State Rep. Mike Ritze, DO, an internist, says many of those who have pursued MOC see requiring it for hospital privileges or insurance coverage as overreach.
In addition, he says, physicians’ own boards already have “much higher” standards than those of the American Board of Internal Medicine and other ABMS boards.
“Physicians are doing a very good job through state and national professional associations to put in place guidelines for their certification and continuing medical education,” Ritze says, adding that MOC “is costing physicians large amounts of money and time.”
Those sentiments have driven the current crop of state legislators introducing similar legislation and another half dozen who are “following this issue closely,” Ritze adds.
Oklahoma State Sen. Brian Crain says the Oklahoma State Medical Association approached him with the idea, based on concern that continuing to require MOC for hospital privileges and insurance could reduce the number of doctors in the state, especially in already thinly-served rural areas. The state ranks 48th in doctors per capita.
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“We’ve got a real challenge as far as our rural areas, in providing family practice and general practice physicians to small-town Oklahoma,” he says. “That’s one of the things we’re going to be able to insure with this, that we’re not putting up other obstacles to being a physician in a rural community.”
Doctors are already contending with additional costs and mandates under the Affordable Care Act, lower reimbursement under Medicare and Medicaid, tussles with private insurance companies, and growing student loan debt, Crain says.
“We’re not going to require everybody in the state be board-certified if it doesn’t positively impact patient care,” he says. “If you’re going to be the family practice physician in a rural area, you don’t necessarily need to be board-certified, you just need to be a good doctor who takes care of his patients.
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Physicians in Oklahoma had been concerned about losing their certifications even though they didn’t see it as essential, Siegler says. “If you’re certified and then you become uncertified because you fail a test, you will get kicked off insurance programs; and if you’re an employed physician you could get fired,” he says. “We would like to choose our own way of learning.”
Wes Glinsmann, director of state legislative affairs for the Oklahoma State Medical Association, has heard the new law referred to as “right-to-work for doctors,” a reference to laws that prohibit requiring union membership as a condition for employment in other fields. “Nobody is saying MOC is bad,” he says. “Nobody is saying hospitals and insurers shouldn’t use it as a tool. It just can’t be the only way in.”
Glinsmann has several concerns about the new law’s implementation, including what form the alternative methods for maintaining hospital privileges or insurance coverage will take. Secondly, he says, some hospitals think they have found a loophole because technically their physicians are not employees, which could open an end run around the law’s prohibitions against requiring MOC. “We may end up having to tweak this down the line. But we see this as a step in the right direction,” he says.
The ABMS did not attempt to influence the legislation but sees it as a significant step in the wrong direction for physicians and patients alike, says Lois Nora, MD, JD, president and CEO of ABMS. “It’s terrible public policy,” she says. “It’s bad for patients, it’s bad for physicians, and it’s bad for healthcare in this country. Board certification has been recognized as a quality credential … for decades.”
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The law takes away from hospital physician leaders the ability to make credentialing decisions as they see fit, Nora says. “For legislatures to tell hospital staff that they cannot use one of the best quality credentials to determine who’s going to take care of you and me and our children and our parents is just appalling.”
Paul Teirstein, MD, president of NBPAS, applauded passage of the Oklahoma law. “I’d like to see that same kind of law passed in the 49 other states,” says Teirstein, a cardiologist at the Scripps Clinic in LaJolla, California. “That [state action] highlights the grassroots nature of this anti-MOC movement. There’s no central, organized body, just a lot of doctors moving this along as they can.”
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Kentucky legislators considered copying Oklahoma but decided not to go quite as far. Instead, the state passed a law that says its medical licensure board cannot require MOC but does not limit what hospitals and insurance companies can require.
The early drafts of the Kentucky bill included language similar to Oklahoma’s, but hospitals and some insurers pushed back, expressing concerns similar to those of ABMS, says Cory Meadows, director of advocacy for the Kentucky Medical Association.
The bill’s sponsor decided to remove the language limiting hospitals’ and insurers’ options as a “good-faith gesture of compromise,” he says. “I don’t want to give the impression that the hospitals were jumping up and down and made it a priority to defeat, but the indications were that they didn’t like it. To preserve some physician input, they said, ‘Let’s not tie our hands.’ ”
Meadows says the state might eventually move toward the Oklahoma model. “At some point, it may be necessary to explore that route,” he says. “We thought [the new law] was a good, positive step in the right direction. Did it go as far as we originally wanted it to? No.”
Alvarado says he did not want to divide the medical community by passing a controversial bill, even if he believed the bill would be beneficial to the state’s physicians overall.
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“I did get some blowback from clinicians, doctors on hospital governing boards,” he says of the bill’s original iteration. “Their concern was that it would be almost a mandate on private industry-telling the hospital or insurance company that you have to furnish this or that.” So they decided to limit legislative action to what everyone could agree upon.
Some of that same resistance has greeted bills making their way through the Michigan state legislature, says Meg Edison, MD, a pediatrician in the Grand Rapids area and vocal skeptic of MOC. But she hopes that resistance will be overcome thanks to hearings in the state House of Representatives policy committee, which have produced “compelling stories, especially from physicians in rural areas, about how [requiring MOC] can be an access issue for patients.”
Edison says rural hospitals have more to lose than their metropolitan counterparts if MOC is required because their specialty ranks are thinner to begin with and could be decimated if physicians decide to retire rather than recertify. “If they lose one OB/GYN, that’s huge,” she says of rural hospitals. “In the larger towns, it’s not as big of a deal.”
The Michigan State Medical Society has been active in opposing MOC and “its burdensome process,” says Kevin McFatridge, director of marketing, communications and public relations. The society’s position is “pretty heavily shared” among physicians around the state, he says.
Missouri has legislation awaiting the signature of Gov. Jay Nixon that would follow Kentucky’s lead in impacting only physician licensure says Jeff Howell, director of government relations and general counsel for the Missouri State Medical Association. The state did not encounter opposition to going further than that, but Howell says advocates decided to take one step at a time.
“There’s probably going to be an appetite at some point to expand it,” he says.