As Ohio Goes, So May Go the Nation:  The Patient Access Expansion Act

According to recent Ohio statistics, 1.3 million people have limited or no access to primary care physicians. Based on the 2015 Ohio Primary Care Assessment, 60 of 88 Ohio counties have medically-underserved populations.  The Patient Access Expansion Act (HB 273), co-sponsored by Representative Theresa Gavarone (3rd District) and Representative Terry Johnson (90th District), specifically addresses healthcare access by prohibiting physicians from being required to comply with maintenance of certification (MOC) as a condition to obtain licensure, reimbursement for work, employment, or admitting privileges at a hospital or other facility. 

Recently, I spoke with Representative Gavarone on the critical importance of this legislation for Ohio.  Physician family members have grumbled about the expense of MOC compliance however, a practicing cardiologist better clarified the connection between MOC regulations and the growing physician shortage.  “He shared his frustrations at the time and money involved participating in a program that has absolutely no scientifically-proven benefit for patient outcomes,” said Representative Gavarone.  The cardiologist discussed numerous hours wasted preparing for an exam with little to no bearing on his day-to-day work serving his patients.

While the public may not be familiar with the harm of MOC regulations, many have experience searching for a new physician when their doctor retires earlier than anticipated.  “Patients are waiting months for appointments,” said Representative Gavarone.  “As physicians leave their practices through cutting back or early retirement, this translates to reduced access to care for everyday Ohio citizens,” she said.   Gavarone is touching on a vital issue facing practicing physicians across the country:  there are fewer incentives for compassionate, brilliant minds to enter the field of medicine.    

Oklahoma was the first state to enact Anti-MOC legislation and six more states (Georgia, Maryland, Missouri, North Carolina, Oklahoma, Tennessee and Texas) have passed laws prohibiting the use of MOC as a condition for obtaining medical licensure and hospital admitting privileges.  Doctors are being “boarded to death”.  To become licensed to practice medicine in the U.S., we must pass 4 exams, each lasting 16 hours in duration over 2 days.  The US Medical Licensing Exam (USMLE) has three parts:  USMLE Step 1 and 2 are taken during our second year and fourth years of medical school, and Step 3 is taken over a two-day “vacation” during internship year. 

After a 3-5 year residency program, we must pass a specialty-specific board exam, such as internal medicine, pediatrics, or surgery to become licensed.  While drowning in more than $100,000 in educational debt, the $1500 exam fee seemed exorbitant, yet passing the pediatric certification exam was only a one-time requirement. States already mandated completion of Continuing Medical Education (CME) hours annually for physician licensure, so why were additional requirements necessary?

The American Board of Medical Specialties (ABMS) eliminated “lifetime” certification to shore up their financial outlook; a modification having little to do with quality and much to do with rate of return.  Between 2003 and 2013, the ABMS member boards’ assets ballooned from $237 million to a staggering $635 million, an annual growth rate of 10.4%.  MOC is outrageously lucrative.  Almost 88% of their revenue came from certification fees. 

The testing environments to which physicians are subjected are abominable; those who are disabled, ill, pregnant, or nursing find their requests for accommodations in accordance with federal ADA guidelines denied, having no recourse for blatant discrimination.  MOC requirements violate our basic right-to-work, an intrusion deemed intolerable in other professions.

Groups lobbying heavily against anti-MOC legislation will likely be hospitals, insurance companies, and specialty groups, such as the American Society of Plastic Surgeons (ASPS) and Ohio Valley Society of Plastic Surgeons (OVSPS), who are out of touch with front line physicians.   Both organizations vehemently opposed a tax on elective (read: unnecessary) procedures projected to add $25 million to the state budget, calling it “discriminatory, economically damaging, and fiscally unsound.” They oppose HB 273 on the grounds that allowing board certification to “lapse” will prevent patients from receiving the “highest quality of care;” a statement that is altogether unproven, misleading, and deceitful. 

If you like your doctor, support HB273 –the Patient Access Expansion Act so you can keep them. The MOC program forces physicians to spend time away from our patients, clinics, and families for no demonstrable benefit.  Financial corruption touches every facet of MOC; the American Board of Medical Specialties has $701 million reasons to oppose this bill.  Representatives Gavarone and Johnson are David bravely battling Goliath.  Physicians and patients must help them fight for high-quality, affordable healthcare to be delivered by physicians free of futile testing regulations.   

Niran Al-Agba, MD is a pediatrician in Washington State.

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11 replies »

  1. And thank you for your follow-up. I came to the conclusion a few years ago there is little I can do as a laymen to influence discussions among professionals so I have mostly lost interest. I was an avid commenter a few years ago, and still recognize some of the names that still appear.

    From a distance the two challenges I see clearly are
    * turf-fighting when professional competence is more important and
    * charges that are almost certainly calculated to sweeten corporate profits over and above what is really required to insure competence.
    It became clear to me long ago that most medical professionals make no distinction between professional compensation and corporate profits. The fee-for-service model ensures that the only source of revenue for individual practices large and small, as well as hospitals and other specialty providers is “fees” for anything that can be called “medical.” The only time that paradigm changes (and not much even then) is when Medicare-covered “skilled nursing” care drops custodial charges after 99 days — after which private pay, long-term insurance or Medicaid picks up the difference.

    Imagine how different hospital and doctor bills would look if NON-MEDICAL costs were listed — laundry, landscaping, legal fees, advertising production and air time, employee benefits, equipment maintenance, utilities, etc. And that’s before sales bonuses, incentive pay, executive compensation and golden parachutes are considered. (Shift differentials don’t count. That’s part of professional compensation.)

    As long as the public continues to imagine that insurance and healthcare are the same thing, I don’t expect to see much progress curbing costs. All this jabbering about competence and outcomes is interesting I know (and genuinely important — don’t get me wrong) but insurance and providers have two different objectives. Both manage risks, but not the same risks.

    Medical professionals manage medical risks.
    Insurance professionals manage financial risks.
    When these two easy to grasp differences are conflated, all discussions, including MOC arguments, become moot.

    /end screed/

  2. Hootsbudy, thank you for really digging in on the MOC issue. I know it is something the public knows little about and that is one of the reasons I wrote this piece. I can meet you part way on the being paid to maintain certification. I would add that insurance should pay for a locum tenens person to work in my office while I am out studying and traveling to and from the test site. For some of us who are independent physicians, the one or two weeks out of my office means I might not be able to take a salary that month. So basically, I have to pay to take a test which does not help me be a better physician and I lose one month of income completing the requirements. Can you imagine why the best and brightest do not want to be physicians anymore?

  3. I cannot disagree with using maternal mortality ratios as an indicator of access and quality for a state, county or region. Your point is salient in that you are utilizing “clinical” outcomes. Researchers should have evaluated “clinical” outcomes prior to mandating EHR implementation, mid-level providers being granted independence without clinical apprenticeship, and calling pain “the fifth vital sign.” All of those decisions have not improved “clinical outcomes”. We are scientists after all. Why aren’t we using the scientific method to properly test theories?

  4. Thank you, Dr. Nelson. The credit for the action in many of those states goes to independent and employed physicians who are fed up losing days in their office (aka income/productivity) to take tests without proven value. I hope physicians in Ohio working in these underserved areas stand up to support this bill and ensure passage to the best of their ability….

  5. Exactly, most of these large non-clinical organizations are protecting compensation for themselves at the expense of competence. Thank you.

  6. After thinking about it for a few days I have decided I like the idea of periodic maintenance of certifications, but with a couple of reservations, beginning with a serious look at costs in both time and money for those being “maintained.”

    A scale would be appropriate for highly-compensated specialties that can afford it should pay more, or better yet, the institutions, networks (as well as insurers who might otherwise blackball any who refuse to participate) should pay either part or all of the expenses. After all, the time invested by the professional (preparation & keeping up to date) is worth a lot, so that part of his or her professionalism is already on the table.

    More patient information and explanation for MOC is also way overdue. As a layman I had no idea what the hell this debate is all about, and I have been an avid spectator and lay investigator for the last fifteen years in my post-retirement life. I bet the average person on the street knows nothing — zero — about the existence, need or expense involved with MOC. This argument may be too abstruse for ordinary people, but I have sense enough to know that it has a serious impact on both my healthcare and my wallet.

    FWIW these are my thoughts as a layman.

    Incidentally, I found the Medscape link too darned hard to follow because it doesn’t allow single-page format (which is important for word searches) so I reformatted the whole thing at my blog if anyone is still interested.

  7. P.S.: I just thought I would check on how Ohio fared on the recently published state by state maternal mortality ratio, data set. (see OB & GYN, October 2016) The data covered 2005-2014: the best 5 states, (Massachusetts, Alaska, Colorado, Maine and California) had an average MMR of 7.22 annual maternal deaths per 100,000 live births. The worst 6 states (Mississippi, South Carolina, Oklahoma, Georgia, Arkansas, and New Jersey) had an average MMR of 27.58 . Ohio ranked 32 among the 50 states with an MMR of 18.4 . I continue to believe that a State’s maternal mortality ratio is the best over-all measurement of the availability and accessibility of the healthcare offered within the State over time.
    By comparison, the best 10 of the 35 OECD developed nations of the world have an MMR that averages 4-5 deaths per 100,000 live births. Currently, at least 500 citizens die annually in the USA just because they lived in the wrong, world-wide Nation during their pregnancy. For reference purposes we average about 4 million live births a year, and our national MMR was 23.8 in 2014. There is no current, nationally focused strategy to improve maternal healthcare, community by community, to solve this problem that has worsened 25 years in a row.

  8. Is it possible that the ABMS folks and their MOC commitment represents a leadership variant of the institutional co-dependency that exists between the academic medical centers and the payers of the reimbursement for the their healthcare? It also seems not unlike Big Pharma and all the odd variations in the strategy they use to maintain their business model: 40% of cash income is allocated to profit and promotion.
    In the meantime, Niran continues to produce insightful essays. This time a potent example of the unrecognized and widely ignored problems associated the equitable availability of Primary Healthcare in Ohio. I am somewhat surprised by the number of States that have already abolished any institutional recognition of MOC status.

  9. Agree with Hootsbudy, the ABMS is about protecting specialist turf, not the public. Primary Care could be learning how to expand their services and expertice instead of the idiocy proposed by the ABMS. Extremely crooked organization. Will take the force of law to reign them in, just as it would any criminal.

  10. Backstory here describes anti-MOC politics.
    (Six screens, unfortunately — I couldn’t find a way around it.)
    Readers need to keep acronym notes…NBPAS, ABMS and more.
    Why do I get the impression that ABMS resembles a union protecting compensation more than (or at least as much as) competence?