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Physicians are taking their well-known disdain for maintenance of certification to state legislators. Has it made a difference?
With her 10-year maintenance of certification (MOC) clock ticking closer to zero, Kim Monday, MD faced a harsh reality.
Either pass the required MOC test or lose her right to practice medicine. It was - and for many physicians, is - that simple. Monday, a Pasadena, Texas-based on-staff neurologist in the Memorial Hermann health system, lays out the truth for many doctors when it comes to MOC, especially those in large metropolitan areas.
"If you're in a big metro area, and [this also applies to] smaller metro areas, you have to have hospital privileges in order to be on insurance panels. If you're not on insurance panels and you're not [doing] concierge medicine…you're out of business," says Monday. "That seemed wrong on many levels and that's why I initially got involved."
Monday's "involvement" in this case was working with the Texas Medical Association to pass a bill essentially removing MOC from being a mandatory requirement to be on staff at hospitals. It took her all the way to the Texas Legislature, where she testified against MOC on behalf of the medical association.
Monday's involvement represents a new trend in medicine, as physicians affected by board recertification have taken their fight against the required program to their state-level governments. They're trying to remove MOC credential requirements in hospitals, on state licensing boards, and on insurance panels within their states. Medical Economics reports 19 states,, have either proposed or passed some kind of MOC-related legislation in effort to curb the requirements. Most have popped up in the last year or two.
"The problem with MOC is we're forced to participate, so there is no incentive for these boards to change. Why would they? We're forced to participate to work and they can charge whatever they want. That's why we're focusing on state legislation, because if you take away the 'force' part of that equation…we might actually have a chance of getting the boards to listen and modify MOC [requirements]," says Meg Edison, MD, a private practice pediatrician in Grand Rapid, Mich.
Many like Edison are not against the idea of continuing medical education, but do not like that MOC is required in order for them to work. Monday echoes a familiar sentiment among physicians when she calls MOC a form of extortion. Westby G. Fisher, MD, an internist, cardiologist, and cardiac electrophysiologist at NorthShore University health system in Evanston, Ill., puts it more bluntly.
"[This issue] crosses the political divide in America. It doesn't matter if you are right leaning, left leaning, extreme right, or extreme left politically. Corruption is corruption. Extortion of physicians will unite…like nothing else," he says.
State-level efforts have popped up as physicians are rallying around what many say are outrageous fees the American Board of Medical Specialties (ABMS) and American Board of Internal Medicine (ABIM) charges physicians to take the test. A recent study in JAMA found that initial exams averaged $1,846 in cost for the written version and $1,694 for the oral component; MOC fees were, on average, $257 per year, or $2,570 for a 10-year period. The researchers also found that fees collected from certification exams accounted for 88 percent of revenue coming into those boards in 2013.
"It's clear the entire ABIM structure is colluding under this financial benefit they get from recertifying physicians," says Fisher, who is an active voice in the anti-MOC movement and has been tracking various state-level efforts on his blog.
In Michigan, Edison is also active in anti-MOC circles, as her open letter to the American Board of Pediatrics (part of ABMS) went viral last year. The letter, she said, made her realize she was in a position to tackle the issue head on. Last year, she worked on proposed legislation in her own state of Michigan that targeted MOC requirements in hospitals, on insurance panels, and through the state licensing boards. It hit a common roadblock.
"[The bill] went to a hearing and then it didn't go anywhere. There was a lot of pushback from insurance companies and hospitals," Edison says. "Those are very strong lobbies." This year, Edison, working with the Michigan State Medical Society, is reintroducing the bill and focusing on removing MOC requirements for insurance panels. She says this is because hospitals will be hesitant to change their bylaws if they aren't paid by insurance companies. Thus, physicians have to focus on changing insurance company bylaws first to eventually change hospital bylaws, she says. Otherwise hospitals will be pressured by insurance companies to keep MOC requirements intact.
Michigan's Legislature is currently in summer recess, Edison says, but when they return, there will be a hearing on the updated bill. She foresees this becoming a vital issue of physician recruitment as more states address MOC requirements. "This is exploding across the country….we need to get on board if we want to be a competitive state and attract physicians," she says.
One area of the country where this movement has made inroads, in particular, is in the southwest. In 2016, Oklahoma passed Senate Bill 1148, which said physicians were not required to recertify through a MOC program as a "condition of licensure, reimbursement, employment or admitting privileges at a hospital."
When the legislation passed into law after facing little resistance, many anti-MOC observers celebrated it as a major milestone. But Jack Beller, MD, Oklahoma Medical Society past president and an orthopedic surgeon in Oklahoma City, said the bill has yet to make a huge difference. "We found out later the reason [we faced no] resistance from hospitals and insurance companies is that they felt it exempted them, even though they were specifically [named in the bill]," Beller says.
The reason, he says, is medical licensure, hospital regulations, and insurance regulations are in three separate titles of law in Oklahoma. The bill was written in the licensure title of law, but specifically named hospitals and insurance companies. However, the hospitals and insurance companies didn't think the law was applicable to them.
Rather than go through a legal battle with hospitals and insurance companies, the Oklahoma Medical Society, and the bill's sponsor, Rep. Mike Ritzke, MD, rewrote it to prevent any loopholes. As such, the two entities drew out the hospital and insurance lobbies against the bill and Beller says it hit a brick wall. Currently, the Oklahoma Legislature is working on a budget shortfall that has to get squared away before other issues - such as MOC - get worked out.
Beller says he doesn't have a problem with physicians on staff at a hospital deciding whether or not MOC should be required for re-certification, just administrators. Yet this stance, in Oklahoma and in many other communities, has pitted the physicians against the hospital, in an odd battle of provider interests.
A prominent example of this contrast between physicians and hospitals is in Oklahoma's neighbor to the south, Texas. The Texas Medical Association and the Texas Hospital Association were active voices on different sides of the debate over Texas Senate Bill 1148. The bill would prevent hospitals and healthcare facilities from requiring MOC as a way to credential, hire or fire physicians, with the exception of academic medical centers and comprehensive cancer centers.
In the proverbial battle between hospitals and physicians, there was a definitive winner. The bill was passed and signed into law by Texas Governor Greg Abbott in June, and will go into effect at the beginning of next year. Like in Oklahoma, Texas' bill was sponsored by two physicians, Sen. Dawn Buckingham, MD, an ophthalmologist in Austin, and Rep. Greg Bonnen, MD, a neurosurgeon in Friendswood, Texas. Carlos Cardenas, MD, president of the Texas Medical Association, says the law will empower medical staffs at the affected healthcare providers.
"It stops the discrimination against physicians who elect to skip the process and it more specifically prohibits the state from using [MOC] as a requirement for licensing or renewal. It brings back autonomy for medical staffs to make a decision about whether or not to use [MOC]," he says.
Those who have been following the various state-wide efforts, such as Fisher, say it's the strongest law passed against MOC thus far. In Michigan, Edison says the results in Texas are exciting and inspiring for other states trying to get legislation passed. Kim Monday, the outspoken advocate who testified on behalf of the bill in front of the Texas Legislature, offers advice to others looking to follow in their path.
"[Other state medical associations] should encourage their members, physicians on the ground to get involved with the legislative process. Let their legislators know [MOC programs] are onerous. And encourage their specialty board to make this a better process," says Monday.
Like many others that have been active voices against board re-certification, she notes she is not opposed to the idea of continuing medical education, but doesn't see this as being helpful to her specialty. "I don't think anyone would care about [MOC tests] if it was relevant, cheap and didn't take us away from our patients," she notes. For her part, Monday says she will still take her MOC test in November, as she doesn't want to risk exclusion from an insurance panel if something with the law changes
Leaders in Michigan, Texas, and Oklahoma say the efforts to thwart mandatory MOC regulations began when a groundswell of physicians presented these problems to the state medical associations. As the resistance to these requirements started to grow, many physician leaders such as Beller in Oklahoma, said its medical association was prompted to take action. Cardenas in Texas said the anti-MOC law began as a grassroots movement when members of the organization continued to bring it up as a problem.
Experts say this is the way to enact change, by bringing these issues forth to state medical associations. "Right now that's our most effective action," says Fisher. On the national level, Fisher has doubts about the American Medical Association's dedication to the cause, even after the AMA's House of Delegates passed two resolutions, one of which called for the end of mandatory MOC exams and the other that had the AMA create model state legislation to deal with this issue.
Edison too implores physicians to go to their state medical associations to get the ball rolling. She says these associations are the voice of the physician. Once the state medical society has an official policy on board re-certification, they are instrumental in getting bills introduced, she says. Another tip she offers is to get to know legislators who are also physicians.
"In almost every state that's done this, it's been physician lawmakers. It is finding your physician lawmakers, contacting your state medical society and [asking them], 'what can we do in our state to protect physicians and patients?' That's the absolute first step and stay on it. Don't stop calling after one try. Keep calling," she says.