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The Doctor Squared Movement: An Alternative to Regulatory Burden

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By NIRAN AL-AGBA, MD

The 4th amendment of the U.S. Constitution shields an individual (or business) from unreasonable government intrusion. It is inferred this right extends to ALL people, regardless of profession.  Advanced nurse practitioners are independently practicing medicine in 23 states yet are not subject to onerous Maintenance of Certification (MOC) requirements– physicians are not equally protected under the law.  Physicians must fight, as one group, against the burden of MOC.  We have two choices:  become a Doctor Squared (Dr. ²) or join an alternative certification organization such as the National Board of Physicians and Surgeons (NBPAS.)

A Doctor Squared (Dr. ²) denotes one who obtains both an MD and a DNP (Doctor of Nurse Practitioner) degree.  This allows independent practice and eliminates the power of MOC.  Reviewing a list of affordable DNP programs in the country shows a degree from the University of Massachusetts – Boston DNP program only costs $10,180.  Coursework is online, and will take only 3 years if attending part-time.  Renewal of an MD license in Washington State costs $697 biannually while DNP license costs $125, putting more money in my pocket.  Additionally, the continuing education requirement is different; advanced practice nurses must complete 15 hours annually while physicians need 50 hours annually even though both professions are independently practicing medicine.  According to Medscape, malpractice insurance rates are $12,000 yearly (2012) for a family physician, while a family nurse practitioner pays $1200, one-tenth as high.  Remember, the cost of MOC for internal medicine is $23,600 every 10 years. 

While the American Board of Medical Specialties (ABMS) argues MOC participation makes for better doctors, no credible proof supports this assertion; only initial board certification has been scientifically validated.  Seven states already eliminated MOC compliance to maintain licensure, physician hospital employment, or insurance contracting, however this same freedom must be extended to the other 43.

Until then, an alternative certification pathway through the National Board of Physicians and Surgeons exists.  In 2015, the Washington State Medical Association resolved to allow alternative certification, yet MOC remains a requirement for licensure, hospital employment, and insurance contracting.  Recently, HB 2257 was introduced, precluding MOC as a condition for state licensure, though overlooks the fact hospitals and insurance companies require physicians, but not nurse practitioners, to comply with MOC.

Why are hospitals and insurance companies enforcing MOC compliance?  Conflict of interest (COI) is defined as a person or organization experiencing multiple benefits, financial or otherwise, which can corrupt motivation or decision-making.  ABMS appears full of corruption.  If there is a risk one decision could be unduly influenced by a secondary interest, a COI is present.  Margaret O’Kane serves on the Board of Directors at ABMS, and her secondary interest is her role as Founder and President of the National Committee for Quality Assurance (NCQA), the organization certifying insurance companies.  She has each hand in a different MOC cookie jar. 

NCQA requires that insurers credential only physicians who comply with MOC programs.  It appears Ms. O’Kane is profiting from the NCQA requirement on one hand while forcing physicians to spend millions completing MOC on the other.  While the average internist earns $150,000 annually, Ms. O’Kane appears to be handsomely profiting from this “arrangement.”  Wikipedia defines collusion as “an agreement between two or more parties, sometimes illegal–but always secretive–to limit open competition by deceiving, misleading, or defrauding others” to gain leverage. It is an agreement between individuals or corporations to divide a market or limit choice and opportunity.  Through Ms. O’Kane, ABMS and NCQA have a connection while misrepresenting themselves as being independent. 

ABMS assumed physicians would never contest corruption, however numerous brave physicians are fighting:  Dr. Wes Fisher, Dr. Ron Benbassett, Dr. Meg Edison,  and Dr. Paul Tierstein, who created the National Board of Physicians and Surgeons, (NBPAS).  While NBPAS has made headway with hospitals, not one insurance company will credential physicians who refuse MOC.  Should insurance companies be in charge of our healthcare system?   

The Maintenance of Certification (MOC) program was initially voluntary; however when billions in potential revenue were realized, participation became mandatory.  My brave friend and colleague, Meg Edison, MD refused to re-certify for the third time, yet was forced to bend to the insurer demands.  We have two choices:  1) Become a Dr² –having all the knowledge and experience of a medical doctor without the regulatory capture or 2) Credential with NBPAS and leave ABMS and NCQA in the dust.  Regulations will not disappear until physicians realize there is no healthcare without our blood, sweat, and tears.  May we all find our way once more. 

If you are struggling under the weight of MOC requirements, please consider taking this survey developed by a Dr. Wes Fisher, who is leading a crusade against forced MOC compliance.  Choice.  Transparency.  Autonomy.  https://www.surveymonkey.com/r/PPA_MOCSurvey.

Niran Al-Agba (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State who blogs at peds-mommydoc.blogspot.com.

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14 replies »

  1. Points that we could use to bring MOC down.
    from Anthony Downs, Rand Corp, in “Inside Bureaucracy”, 1967 and 1994:

    Chapter 6, point 14: “Leaders of all large organizations are opposed to detailed investigations of the behavior of their organizations by outsiders.”
    Ibid, point 13: “Every leader of a large organization undertakes acts in his official capacity that he does not want made public.”
    Chapter 5, point 23: “Bureaus threatened with drastic shrinkage or extinction because of the curtailment of their original social functions will energetically seek to develop new functions that will enable them to survive with as little shrinkage as possible. ”
    Ibid, point 16: “The expansion of any organization normally provides its leaders with increased power, income, and prestige; hence they encourage its growth.”

  2. About the only reason I keep up with my certification is so I can do IMEs for my state Industrial Commision. I’d like to do it when I retire, but that means I’ll have to retest again. Since I do Occupational Medicine, most of the test except for Urgent Care and Musculoskeletal really doesn’t apply to me. I had to retake last year after spending a week and lots of money for a review course. I don’t relish doing that again at age 68.
    If lawsuits don’t work (and they are long, costly and unwieldy) about the only thing that would work is total boycott. But I don’t see that happening.

  3. Brad, I’m glad to hear your experience was not as trying as mine. I am not alone as many young physicians were nursing infants and forced to comply with no testing accommodations. I believe our profession should help one another, however whether or not you jump in to this fight is completely up to you.

  5. I did the focused pathway in hospital medicine two years ago. I didn’t mind the experience and thought the review I did a few months leading into the test was helpful.

    Pricey? Yes, but not a dealbreaker. Humiliaiating? No. Am I open to different formats? Of course.

  6. I think they are laughing about the fact they do not have the same regulatory burden we do and thanking their lucky stars they are managed by the State Nursing Boards and not State Medical Commissions….

  7. In Washington State, there is no restricted status, no supervisory requirement, and a newly minted FNP with 3 years of schooling can hang a shingle, call themselves a pediatrician, and misdiagnose a child with a congenital heart defect as described here: https://thehealthcareblog.com/blog/2017/05/29/md-vs-dnp-why-20000-hours-of-training-and-experience-matters/. My proposition is keep our MD degree we earned, ignore the MOC garbage, and do a quick DNP (like everyone else in the country), and call ourselves Doctors Squared (since it is technically correct.) Then, yes, life goes on. I am very open to other suggestions, however, how did you like your recertification test? Mine was awful as described here: http://peds-mommydoc.blogspot.com/2016/05/an-open-letter-of-complaint-to-american.html, It was humiliating, expensive, time-consuming, required office closure, and had NO value for patients. Why the heck are physicians putting up with this when a practitioner with less training does not have to?

  8. This was a GREAT interview!!! It got the word out that MOC is a scourge on the face of medicine for physicians.

  9. It is a “restraint of trade” issue or “right to work” issue, but no one seems to be able to get various lawsuits to move through the court system. When they do, the big guys ABMS win. Meanwhile, costs will keep climbing and people will keep dying.

  10. I have always wondered whether or not a “Restraint of Trade” anti-trust issue existed for the ABMS, especially since there is no valid research to verify its value. Remember especially that our nation’s excessive level of health spending per citizen as compared to all of the other 34 OECD nations was @ $3,200.00 per citizen in 2016. Among the OECD nations, we are the only nation with a declining level of longevity and a worsening maternal mortality incidence.
    .
    Twenty-five years ago, Peter Drucker wrote a book “Post-industrialist Society” about the institutions that define their productivity through the analysis of information. His analysis led to a proposition that information institutions will eventually survive based on their investment in the career development of their professional assets. No where in the health care industry does this occur, especially its medical schools. The current use of “Post Residency Graduate Medical Education” is an unfocused waste. The real issue of course is the lack of vigor within our nation’s physician assets and no means to re-energize it.

  11. Editor’s Note: An earlier version of this post misidentified the author of this post as Westby Fisher. THCB regrets the error.

  12. I want to understand your proposition…

    I as a physician will certify as a DNP. As a result, I practice, albeit under a more restricted status, with lower med mal and certifying costs. And life goes on?

    Thanks
    Brad

  13. If you can’t beat ’em, join’ em …

    For some reason, I feel like this is going to seriously piss off nurse practitioners