Legislation would prohibit health plans, hospitals, and/or state licensing agencies from requiring physicians to be board certified and/or participate in periodic maintenance of certification programs operated by specialty boards.
This article first appeared May 11, 2017 on Medpage Today.
by Cheryl Clark
Since her residency in 2003, Grand Rapids, Mich., pediatrician Megan Edison, MD, has done everything required to maintain her board certification.
She passed her tests, paid her fees, and completed required "continuous learning" projects even as their frequency and difficulty increased demands on her time.
In one particularly awkward exercise, she even distributed surveys to her patients' parents, asking them to score how well she washed her hands.
None of it improved her patient care, she said. Test questions were "pretty worthless," often showing old, discarded practices as the correct answer. Begrudgingly, she put up with it until December 2015.
That's when the American Board of Pediatrics threatened to yank her certification if she didn't pay another $1,300. "It was just down to money. If I didn't give them $1,300, I'd lose my certification," she said.
She angrily protested, refused to pay, and posted a scathing letter on Rebel.MD explaining why the board had gone too far. Certification had become "a monster" that put her in a "hamster wheel."
But resistance carried consequences. A major insurance plan told her that without certification, she was no longer considered a provider in that plan.
She appealed. But the plan sent letters to her patients "saying I was no longer a provider, and they were being reassigned to another doctor." Distraught parents called, disrupting office workflow and upsetting the staff, she said.
She had no choice. It was either pay the $1,300, plus a $200 late fee, or lose a lot of patients.
A few weeks ago, she relented and paid up. "Within seconds I was board certified again."
Action in 17 States
Stories like Edison's have prompted a legislative backlash with bills or laws in at least 17 states, most of them introduced this year by physician lawmakers. They would prohibit health plans, hospitals, and/or state licensing agencies from requiring physicians to be board certified and/or participate in periodic maintenance of certification (MOC) programs operated by specialty boards.
One bill would prevent a health plan from removing a non-board certified physician from a network, like what Edison said happened to her. A second would prohibit the state licensing agency from denying a doctor's license on the basis of board certification or MOC. A third, introduced in late 2015, would prevent a hospital from denying admitting privileges to a physician who is not board certified.
"We're not opposed to board certification," emphasized Martin Dubravec, MD, an allergy and immunology specialist in Cadillac, Mich. "We're opposed to mandatory board certification."
But doing what the specialty boards want comes with higher fees and more time studying and taking tests, "with no good science to say they're relevant," said Dubravec.
"These are not regulated by any state or federal agency, and therefore should not have undue influence on whether a physician should be able to practice medicine," he said.
Many states' proposed or enacted legislation on the topic seeks to prophylactically prevent state licensing agencies from using a doctor's lack of specialty certification or MOC to deny or revoke a physician's license, which no state licensing agencies now do. But many fear that's coming.
Under the Interstate Medical Licensure Compact, the 19 currently participating states may allow a physician who is board certified, and meets certain other requirements, to bypass some state vetting processes to become licensed to practice in that state. The compact began accepting applications in April.
There is fear that states may become more aggressive in requiring board certification as a condition of state licensure.
Oklahoma was the first state to pass a law prohibiting discrimination based on certification last year. The language sought to prevent a hospital from requiring a physician to participate in specialty board MOC programs as a condition for staff privileges, employment, reimbursement or licensure. But Rep. Mike Ritze, MD, a family medicine practitioner from Tulsa who co-authored the bill, said one Tulsa hospital found a loophole; the law inappropriately coded the statute.
Ritze introduced clarifying legislation but it failed. The American Board of Medical Specialties (ABMS), the umbrella organization for 24 specialty boards, "brought in four powerful lobbyists to kill the bill," he said. A third legislative try is in the works.
Kentucky and Arizona also passed laws last year. They limit the ability of state agencies to deny licensing based on MOC or board certification status.
In California, a bill introduced in February by Sen. Richard Pan, MD, says, "The award or maintenance of hospital or clinical privileges, or both, shall not be contingent on participation in a program for maintenance of certification."
If passed, such language would invalidate policies in many hospitals that require board certification and MOC.
Four other state legislatures have passed laws that now await their governor's signatures. Missouri, Maryland and North Carolina bills would limit MOC and board certification from being used to deny licensure; Georgia's, sent to the governor in April, precludes MOC from being used "as a condition of licensure to practice medicine, employment in certain facilities, reimbursement, or malpractice insurance coverage; to provide for definitions; to provide for related matters; to repeal conflicting laws; and for other purposes."
ABMS Pushes Back
The ABMS acknowledged it is working hard to defeat this flurry of legislation, which it believes "puts patients at risk," according to a statement from spokeswoman Susan Morris.
Board certification with its periodic testing and learning exercises through formalized MOC programs make sure physicians know the latest evidence to assure patients and insurers they give good patient care, the ABMS believes.
Otherwise, physicians can say they're board certified simply because they passed their exam decades ago, with no other proof of learning other than varying, self-selected continuing medical education (CME) course credits required in each state. Those don't usually come with quizzes that doctors pass or fail.
"Patients deserve to know that their physicians are up to date," Morris said. "Faced with a physician who was initially certified after residency but who has not kept the certificate current, patients will be in the dark. They will not know whether that physician chose not to participate, or failed to earn recertification, or was denied the certificate for unprofessional behavior."
With so much objection from physicians, many of the boards have modified their requirements. For example, the American Board of Internal Medicine, which certifies some 200,000 physicians, has softened its requirements, allowing physicians to complete learning programs in open book or "Knowledge Check-In" models, a bit more like how they typically practice.
Green emphasized that "a good body of literature" shows that certification and MOC make a difference in patient care. They encourage physicians' adherence to guidelines resulting in better outcomes. "Things like disciplinary actions and mortality have been linked with various measures of certification and MOC."
In response to what happened to Edison, current ABP president and CEO David Nichols, MD, said in a statement he understands "the time, effort and expense involved in maintaining certification." He added that the ABP is trying to improve the criteria.
"However, I stand with the vast majority of board-certified pediatricians who find value in continuous learning and improvement." He stressed that the ABP board opposes the legislation under discussion in various states, especially versions that would allow doctors to pass muster by only completing their CME.
R. Adams Dudley, MD, director of the University of California San Francisco Center for Healthcare Value who has studied whether MOC makes better doctors, disagrees. "If MOC were a drug, it would definitely not get FDA approval," he said. "There's no evidence at all."
Rather, he said, "let's not see whether doctors can pass a test which asks esoteric questions," which is not how doctors really practice anyway. Instead, he said, "doctors should be measured on their outcomes."
Continuous learning modules emerging in specialty boards are somewhat better, "but there's no evidence that improves patient outcomes either," he said.
In hearings on a Texas bill introduced in February to ban discrimination against doctors not participating in MOC, Houston neurologist Kim Monday, MD, testified that MOC can cost doctors $10,000 or more. She further charged that MOC "has become more of a money-making scheme versus a relevant tool to help physicians stay current on best practices."
Monday mentioned two issues that especially irk many of her colleagues. First, she said, older doctors have generally been granted "grandfather" status by their boards, and don't have to go through these re-certification hoops. "That dichotomy makes absolutely no sense," she said.
The second issue is the types of questions and activities that various boards require. Her neurology board wants her to know specifics in the genetics of pediatric neurology. "I practice adult neurology, so I don't need to know that. I'm not going to evaluate a newborn."
"It may sound scary to a lay person that doctors seem to want to know less information," she continued. But times have changed. Doctors faced with a puzzle "can look up anything you need on your phone anytime."
Florida Bill Killed
A Florida bill introduced earlier this year by Rep. Julio Gonzalez, MD, an orthopedic surgeon, would have prohibited use of MOC or recertification status to deny licensure, reimbursement or admitting privileges for physicians who were initially board certified.
The bill is dead for this year because, according to St. Petersburg neurosurgeon David McKalip, MD, "insurance companies and hospitals strongly opposed it."
Hospitals and insurance companies want to control doctors and how they practice medicine in the hospital, he said. "But MOC does not improve any quality of care whatsoever. The main motivation of MOC is to make money for the boards, tens of millions of dollars."
Many of the questions contain "esoterica, not applicable to the real practice of medicine," he said.
Though Edison gave in, she has not given up, becoming a poster child for physician resistance. She said she has a lot of company, especially when reports come out about million-dollar salaries paid to officers of non-profit specialty boards that hold her future in their hands.
"These boards are making millions and millions," she said, pointing to former ABP president James Stockman, MD, who she said was making $1.3 million in salary. "That's the kind of stuff that burns you when we're working so hard every day, only to see one more requirement from an unaccountable board, which if we don't comply, we can't practice medicine."
The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.
WASHINGTON -- The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.
The vote on a revised version of H.R. 1628, the American Health Care Act (AHCA), came just before House members headed out of town for a week-long recess. The measure now heads to the Senate, where many observers say it will have a tough time getting through.
Under the original version of the bill, the Congressional Budget Office (CBO) estimated that 24 million people would lose their health insurance as of 2026 if the bill were passed; it would also reduce the deficit by $337 billion over the same period, CBO said. However, the current bill -- which has several revisions -- was voted on too quickly for the CBO to develop a revised estimate.
Mandates Eliminated
The AHCA would eliminate the taxes and mandates that financed the ACA -- including the individual and employer mandate penalty -- allow insurers to charge older adults and young people less, and replace subsidies based on need with flat tax credits based primarily on an age. Over time, the plan would repeal the Medicaid expansion and put a ceiling on the entitlement program by shifting its structure to a per-capita block grant, which would increase as enrollee size increases. The bill would also freeze federal funding for Planned Parenthood.
The original AHCA bill was scheduled for a vote on March 24, but it was pulled at the last minute by House Speaker Paul Ryan (R-Wisc.) after he determined he did not have enough votes to pass it. Since then, Republicans made several changes to their bill in order to attract recalcitrant members of their party, both moderates and conservatives.
These included:
An amendment by Rep. Tom MacArthur (R-N.J.) that would allow states to opt out of requiring insurers to cover the ACA's list of "essential health benefits"; instead, states could develop their own lists of what benefits they considered essential. The amendment also would allow states to charge more for 1 year to patients with pre-existing conditions if they have been without insurance coverage for 63 days or more. This type of medical underwriting would be done in lieu of a 30% penalty called for under the law for patients who re-enroll in health insurance after such a lapse in coverage. States who opt to allow medical underwriting also would have to set up high-risk pools for patients with high costs due to pre-existing conditions.
An amendment by Reps. Fred Upton (R-Mich.) and Billy Long (R-Mo.) that would provide states with an extra $8 billion over 5 years to set up high-risk pools to cover patients with high costs due to pre-existing conditions, in addition to the $130 billion already in the bill that states could use for that purpose. Although no CBO estimate is available, an estimate from the Center for American Progress, a left-leaning think tank here, found that states would need an extra $200 billion for the high-risk pools to be adequately funded, assuming that 5% of patients in the individual and small-group markets end up in the pools.
An amendment by Rep. Martha McSally (R-Ariz.) to prevent members of Congress from being exempted from the AHCA. The AHCA originally exempted Congress members from being affected by state waivers.
Rep. Phil Roe, MD (R-Tenn.), an ob.gyn., said he was voting for the bill because the ACA cannot be fixed. "The whole [ACA] plan is so complicated it's impossible," he told MedPage Today in a phone interview. "There are people out there who got helped by [the ACA], no question, but they'll get helped by this bill also."
More than half of those who have coverage through the ACA "have out-of-pocket costs and copays so high that they don't go for healthcare," he said. "If you have a health insurance card but you can't use it, it's not of much value to you. So we have to try to get the costs down."
Medical Groups Pan the Measure
Medical organizations' comments on the bill were overwhelmingly negative. "None of the legislative tweaks under consideration changes the serious harm to patients and the healthcare delivery system if AHCA passes," American Medical Association president Andrew Gurman, MD, said in a statement. "Proposed changes to the bill tinker at the edges without remedying the fundamental failing of the bill – that millions of Americans will lose their health insurance as a direct result of this proposal."
"This bill ... will severely limit access to services for the more than 70 million people who rely on Medicaid for effective health coverage – and locks states' funding to what they spent on Medicaid in 2016," Margaret Murray, CEO of the Association for Community Affiliated Plans, said in a statement. "If history is any guide, at some point states will be faced with a choice between denying care to people who need it, or blowing a hole in their budget ... Should this bill move to the Senate, we encourage senators to start the debate around health reform where it should begin: with a clean sheet of paper."
"We are very disappointed that the most recent version of the legislation does not guarantee insurance coverage for emergency medical care," Rebecca Parker, MD, president of the American College of Emergency Physicians, said in a statement. "This latest version of the new healthcare legislation does little to improve the health of the nation and will lead to more Americans not having any form of healthcare coverage."
Heated Floor Debate
Debate on the House floor was heated. "How did we get to this point?" asked Rep. Michael Burgess, MD (R-Texas), an ob/gyn. "The ACA is simply not working for the American people; it is limiting choices, it is raising costs, it is leaving millions without access to care. The ACA has left the individual market in shambles and is driving insurers away from offering coverage."
"Pathetic -- that is the word to describe this process and this bill," said Rep. Jim McGovern (D-Mass.). "If the American people could sue Congress for malpractice, my Republican friends would be in deep trouble. How could you do this to the people you represent? You're allowing insurance companies to discriminate against people with preexisting conditions? What is wrong with you guys?"
Taking cannabidiol may reduce seizures among children and adults with a severe form of epilepsy called Lennox-Gastaut syndrome, researchers reported from a manufacturer-sponsored trial.
The industry 'is so screwed up and it's ripe to be disrupted,' says David Feinberg, MD, the CEO and president of Pennlyvania-based Geisinger Health System.
WASHINGTON – The U.S. healthcare industry could use a good shaking up, a healthcare executive said here Tuesday.
"I think our industry is so screwed up and it's ripe to be disrupted," David Feinberg, MD, MBA, president and CEO of Geisinger Health System in Danville, Pa., said at a conference sponsored by the Duke Margolis Center for Health Policy and the consulting firm McKinsey & Co. "Either we do it or some Stanford dropout in a black turtleneck is going to."
"Can we take care of people in a way that's dignified, that's culturally sensitive?" he asked. "Can they afford it? Is it easy to get? Is it something you want for your own family? Let's focus on high value, great experience, and low costs."
On the other hand, many of the problems with the healthcare system today are really public health problems and aren't something that private insurers can readily fix, said J. Mario Molina, MD, president and CEO of Molina Healthcare, a managed healthcare company based in Long Beach, Calif. "Obesity is not something you're going to cure; it's a public health issue. ... We really can't expect health plans to [take care of] that."
"We try to do something about obesity, but it's really difficult from a health plan, medical model," he continued. "We're really good at covering acute illnesses or managing chronic ones [but for conditions like obesity] it doesn't work well. We need to invest more in public health; if we did that, we wouldn't invest as much in healthcare per se."
But Feinberg disagreed: For example, "We take diabetics who are food insecure and say, 'Here's food for the whole week for you and your family' -- every week. We've seen decreases in hemoglobin A1c in every single patient, decreases in weight, decreases in blood pressure ... if this was a pill it would be a miraculous pill. We've had patients we had spent $220,000 in 4 years before we started giving them food; in the year they've been in the program, our medical cost is $1,200. Hippocrates talked about food as medicine a long time ago; I think we've lost our way."
Sometimes solving healthcare problems calls for breaking the rules, he continued. "When I got to Geisinger a couple of years ago, there were providers we were spending $500,000 a year on for visits, and the only thing they did was prescribe opiates. They weren't even in our network." But when Feinberg wanted to stop using them as providers, he was told he couldn't cut them off without going through a laborious process to do so.
But "they were [essentially] giving bullets to our patients," he continued. "I said, 'Cut them off and send the regulators to me.' The regulators came to me and I said, 'Put me in jail. I got rid of five doctors who only prescribe opioids to patients' ... We say, 'Let's do the right thing and let the chips fall where they fall.'"
The Affordable Care Act's health insurance exchanges also came up at the meeting. "The vast majority of [state health insurance exchanges] are stable and working well," said Peter Lee, executive director of Covered California, that state's health insurance exchange. "For 30% that's not the case, and those markets are at risk of destabilization. It's very important [to understand] that we're not talking about a ship that's sinking."
One thing that could destabilize the exchanges, however, is if the Trump administration takes away the cost-sharing reduction subsidies that the federal government is giving to states to help low-income enrollees pay their out-of-pocket costs. "If you don't [keep the subsidies] ... it's going to cause massive disruption," Lee said.
But the bigger danger for stability is non-enforcement of the penalty for not buying health insurance if you can afford it, he continued. "Until there's an effective replacement, non-enforcement of the penalty would lead to mammoth increases in premiums and huge reductions in coverage."
In addition, money must be invested in marketing the exchanges, Lee said. "Health insurance has to be sold. Covered California spent $130 million this year to promote enrollment and outreach. ... If you're not investing in marketing, you're going to get a bad risk [pool]" because only the sicker patients will be incentivized to sign up for coverage.
Dennis Matheis, president of the Central Region and Exchange at Anthem, a for-profit health insurer based in Indianapolis, Ind., listed several ideas proposed by Republicans which he said would encourage insurers to stay in the exchanges. Allowing insurers to charge older people up to five times more than younger people -- rather than three times higher, as is the case under current law -- "will help improve affordability for younger people in the marketplace," he said. And re-establishing a mechanism for re-insuring the health insurance companies for high-cost patients "will help stabilize the market."
But Lee said he wasn't sure if changing the rating bands would really make a difference. "It's unclear if that will help, because it dissuades, older, healthier people from signing up." And getting more younger people to sign up for health insurance even though they typically buy cheaper, less comprehensive plans "is not lowering costs -- it's changing who pays the costs and saying that more should be paid directly by consumers. That's a formula for more bankruptcy and not necessarily better care."
When it comes to improving public healthcare programs, such as Medicaid, "block grants are a lousy idea," said Sen. Bill Cassidy, MD (R-La.). "If you just [make block grants] based on what the state has [already] received, then those states that have gamed the system are rewarded and those who have not gamed it so much are penalized." Per-capita caps, which take into account a state's changing demographics, are a better way to go, he said.
One-quarter of medical doctors spent less than two hours per day with patients, one of the first studies to use EHR access logs to study physician schedules shows. From MedPage Today.
Doctors have beenslow to embrace electronic health records. Even so, the systems now account for about half of the average doctor's day -- demonstrated most recently in astudy in the latest issue of Health Affairs.
In one of the first studies to use EHR access logs to study physician schedules, Ming Tai-Seale, associate director of the Palo Alto Medical Foundation Research Institute in California, and colleagues examined time spent on face-to-face medicine versus computer-related activities from 2011 to 2014. They found doctors spent an average of 3.08 hours on direct patient care and 3.17 hours on desktop during this period.
Moreover, computer time inched up over time, from 3.06 hours per day in 2011 to 3.37 in 2014. In-person time stayed about the same.
Progress notes accounted for the largest chunk of digital time, roughly a third of the day, on average. Telephone encounters and secure messages were the next highest activities, together accounting for 15% of the average day.
While the averages tell one story, there was -- perhaps unsurprisingly -- wide variation. The middle two quartiles spent between 2 and 4 hours a day in face-to-face time with patients. The same was true for time spent on the computer.
What that also means is that a quarter of physicians spent less than 2 hours per day with patients; and only a quarter spent more than 4 hours on direct patient care.
The results suggest that fee-for-service plans may need to come up with a new approach, the researchers said. Many of the desktop activities are not reimbursable, which can shortchange patients as well as the doctor.
"Many of those activities -- such as care coordination and responding to patients' e-mail -- are of high value to the delivery system and to patients, so the staffing, scheduling, and design of primary care practices should reflect this value," Tai-Seale and colleagues wrote.
WASHINGTON -- The Medicare Payment Advisory Commission (MedPAC) voted unanimously Thursday to recommend a competitive pricing program and make other changes to reimbursement for drugs under Part B of the Medicare program.
"Medicare, as a large third-party payer, always needs to take steps to make sure it's paying the right amount," said commission member Paul Ginsburg, PhD, of the Brookings Institution, a left-leaning think tank here. "I'm particularly excited [about the pricing program] -- it's not often we have the opportunity to foster competition in areas important to Medicare."
Under the Drug Value Program (DVP) -- which would be voluntary for physicians -- a small number of vendors would negotiate prices being paid for the drugs, but those vendors would not be the ones shipping the product. Providers would then buy the drugs at the vendor-negotiated rate, and Medicare would pay providers that rate plus an administration fee based on either the physician fee schedule or the outpatient prospective payment system. Providers also would have a chance to share in any cost savings generated by the DVP program.
The recommendation also includes several other changes to the reimbursement model for drugs paid for under Part B, which are those administered in the physician's office:
Improving average sales price (ASP) data reporting. Currently, only drugmakers who have rebate arrangements with Medicaid are required to report ASP data. Under the proposal, all manufacturers of drugs covered under Part B would have to report the data, and penalties for not reporting would be increased.
Modifying the payment rate for drugs that are paid for based on wholesale acquisition cost (WAC). Currently, some drugs are paid for at WAC plus 6%; the proposal would reduce the rate to WAC plus 3%.
Limiting payment rate increases for drug payments based on ASP. Currently, physicians are paid for administering certain drugs at a rate of ASP plus 6%, but there is no limit on how much those payments can increase over time; staff members noted at a commission meeting in March that between January 2010 and January 2017, nine of the top 20 highest-expenditure drugs had annual ASP growth of 5% or more. Under the proposal, manufacturers would have to pay a rebate if their products' ASP exceeded a particular inflation benchmark, such as the consumer price index.
Instituting consolidated billing codes for biosimilar drugs. Currently, brand-name drugs and their generic counterparts are paid under a single billing code; the proposed policy would require reference biologics and their biosimilars also to be paid under a single code. The Health and Human Services Secretary also might consider use of a consolidated billing code for groups of products with similar health effects, commission staff member Nancy Ray said at the March meeting.
To make it more attractive for physicians to transfer to the DVP, the ASP add-on percentage would be cut. If implemented, the recommendation would decrease spending by an estimated $250-$750 million in the first year and $1 billion to $5 billion over 5 years, according to commission staff.
One concern with the DVP is how sensitive providers might be to changes in the drug formulary, manufacturer, or price that might come as a result, said commission member Alice Coombs, MD, a critical care specialist at Milton Hospital in Weymouth, Mass. However, she added, "the golden nugget [of this] is the inflation rebate."
"I've got some parts I'm more optimistic about than others," said commission member Jack Hoadley, PhD, of Georgetown University here. "I'm skeptical about some aspects of the DVP, [although] it's grown on me a bit over the discussions -- it's definitely something worth trying."
The commission also heard a presentation on possible responses in case Congress and the Trump administration decide to institute a Medicare premium support program, in which Medicare beneficiaries would receive a set amount of money from the federal government to purchase one of several health insurance plans offered to them. Commission staff member Eric Rollins outlined several ideas:
The Medicare fee-for-service program should remain available and be treated like a competing plan
The use of a standard benefit package or another form of standardization would make it easier for beneficiaries to understand their options
Plans offered should have flexibility to include alternate forms of cost-sharing and to offer extra benefits
Beneficiaries would need good decision support tools to make informed choices
Competitive bidding should be used to set benchmarks
The base premium should be similar to the Part B premium
The effects of a premium support plan are "highly uncertain," according to Rollins, who added that the effects would vary across areas. Some beneficiaries would switch to lower-cost plans, but it's not clear how many, he said.
Commissioners expressed concern about the idea. "I worry about Medicare becoming too much of an income-related program, which undermines the whole point of social insurance," said commissioner Kathy Buto, MPA, a health policy expert from Arlington, Va. If low-income beneficiaries can only go to certain providers because they are in a lower-cost plan, "we are creating a two-tiered system of care."
Commission chair Francis Crosson, MD, a retired physician from Los Altos, Calif., emphasized that although MedPAC was looking at what to do if premium support were implemented, it was not endorsing the idea. "Going in that direction is not the position of the commission," he said. "We simply attempted to say... that based on the fact that others are thinking about this and it's our responsibility to provide facts and advice if we can, that we would do that service. But we have not taken a position about moving from traditional Medicare to this model."