What one Grand Rapids-area physician considers a form of “extortion,” others see as a necessary way to gauge how well doctors keep up with modern medicine.
In a contentious issue that in some cases pits doctors against one another, state lawmakers are again considering legislation that proponents argue would ease one of the burdens of practicing medicine in Michigan.
Two bills before the House Health Policy Committee would prohibit the state from requiring a doctor to maintain board certification to obtain a state medical license. It would also bar health insurers and HMOs from requiring the certification for a physician to receive reimbursement payments.
The main sponsor of the legislation, Rep. Edward Canfield, a Republican from Caro and an osteopathic family physician, argues that earning recertification from some medical boards has become a burdensome and costly process over the years.
Prior to 1990, doctors received lifetime specialty board certifications, Canfield said. Since then, organizations that grant board certification and recertification have constantly raised requirements. That started with the American Board of Internal Medicine, which decided in the 1990s it “should have a shelf life” and started issuing limited certifications, according to Canfield. More than 20 other specialty medical boards followed suit and required doctors to retake their boards every seven to 10 years.
In testimony before the House Health Policy Committee, Canfield said studies “found no difference” in the quality of care delivered by doctors with an expiring board certification and those like him with a non-expiring certification.
“In medicine, we’re trained to follow the science,” Canfield said. “In this case, the science indicates that requiring doctors to take national board exams … has not been proven to improve patient care.”
According to Canfield, the recertification process promotes “extreme stress” and takes doctors out of their offices to study, where they’re away from patients who need care. He also criticized the cost of recertifying, which for primary care doctors can reach $20,000 over a decade or $40,000 for specialists.
Canfield worries that requiring doctors to maintain board certification for their state license or to receive reimbursement from insurers worsens the doctor shortage in Michigan that’s projected to hit 4,500 physicians by 2020. He notes that Michigan already requires physicians to undergo 50 hours of annual continuing medical education to keep up with medical advances.
“This isn’t about doctors,” Canfield said. “We in the Legislature need to keep good doctors working in Michigan. We need citizens seeing qualified physicians who are well trained and they do not need to take a national test to maintain a piece of paper that’s hanging on the wall.”
‘FLAWED’ BUT NECESSARY
Opponents of the bill contend the issue isn’t quite that simple.
At a recent hearing on the legislation, physicians affiliated with a variety of medical boards opposed the legislation. They argue that third-party certification boards help to ensure that physicians keep up their skills and knowledge.
“Medicine is changing so rapidly. We believe that it is crucial that surgeons demonstrate that they are up to date in their specialty,” said Dr. Ronald Hirschel, a pediatric surgeon at the University of Michigan who has served on the American Board of Surgery.
Surgeons serve voluntarily to determine requirements for certification, Hirschel said. He conceded that the process “is flawed,” but “we’re trying to change it.”
“As anything, it was an experiment that is being changed, it’s being re-evaluated, and is being improved,” said Hirschel, who opposed HB 4135, which applies to health insurers and HMOs.
Dr. Larissa Traill, a board-certified emergency physician at University of Michigan-MidMichigan Health, contends that the maintenance of certification (MOC) provides a periodic, third-party assessment of a physician’s ability. While Michigan’s annual 50-hour requirement for continuing medical education (CME) “serves as an important role in facilitating learning, it is not an externally validated assessment of a physician’s knowledge,” said Traill, who also serves as president of the Michigan College of Emergency Physicians.
“I have learned significantly more from my MOC than from many of my CME activities,” said Traill, noting that maintenance of certification with her particular board is neither onerous nor expensive. “Under this law, an important incentive for physicians to achieve excellence would be removed. Why would Michigan adopt a system that does not reward excellence?”
INSURERS VOICE CONCERNS
Opposition to the bills also came from Blue Cross Blue Shield of Michigan. Although sympathetic to the “genuine concerns” raised by doctors about the maintenance of certification process, the state’s largest health insurer believes HB 4135 would “virtually eliminate the ability of health plans to establish their own reasonable credentialing for physician network participation,” said Kristen Kraft, director of state relations for Blue Cross Blue Shield.
The insurer requires participating doctors to maintain board certifications in their areas of practice to receive reimbursement “to ensure the highest quality physician network for our members,” Kraft said.
Blue Cross Blue Shield believes, for example, that requirements from the American Board of Medical Specialties “are a reliable indicator of a physician’s training and competence to care for patients within a medical specialty,” she said.
The insurer pays physicians 10 percent to 20 percent more if they are board certified and meet certain standards, Kraft said.
‘EXTORTION’ BY ANOTHER NAME?
But according to Dr. Meg Edison, a pediatrician at Brookville Pediatric and Internal Medicine in Wyoming, Blue Cross Blue Shield goes too far in requiring the maintenance of certification.
Edison passed her boards on 2003 and positions herself as a “cautionary tale” of a process run amok. She earned recertification seven years later at a cost of $1,000. She was subsequently asked by her medical board three years later to take another test, do two more research projects involving her patients and submit data, and read “obscure” medical journals and answer questions.
Edison was later asked to pay $1,300 to maintain her certification. She refused. Her patients then received a letter from Blue Cross Blue Shield informing them she was no longer part of its care network and telling them they would be assigned to another care provider.
“This created absolute havoc with my patients and with my staff,” said Edison, who went online and paid the $1,300, plus a $200 late fee.
“Within seconds I had my board certification in hand, (and) within hours Blue Cross Blue Shield left me alone,” she told legislators. “If that’s not extortion, I don’t know what is. It was very, very stressful and it was about the money.”
Fourteen other states are presently considering legislation similar to what’s been introduced in Michigan, Edison said.
She also takes issue with how some physicians are grandfathered in and do not have to periodically earn recertification from a medical board. She considers that discriminatory against younger physicians.
“You can’t force a certain group of doctors to jump through hoops and you don’t require others to do it,” she said.
AN ISSUE OF OVERREACH
Edison and other backers of the bills say quality incentives paid by insurers and initiatives such as accountable care organizations provide them plenty of motivation to keep up with changes in medicine without going through maintenance of certification through a medical board.
Dr. Martin DeBravec, an allergist from Cadillac, said medical specialty boards operate without any state or federal statutory authority. Yet “they have inserted themselves to the point where fully-licensed physicians in the state of Michigan cannot practice unless they purchase thousands of dollars in products from them.”
“Board certification may be of benefit to some doctors, but they can and should make that decision,” DeBravec said. “It is as simple as this: Michigan deserves better than to have unregulated private companies determine who can practice medicine in our state. This is really a restriction of trade issue.”
DeBravec is also founder and CEO of the National Board of Clinical Medicine Inc., a certification board whose process is strictly voluntary, he said.
The two bills in the Health Policy Committee are similar to legislation considered a year ago but with one key exception: They do not include language banning hospitals from requiring board certification in order for doctors to receive admitting privileges.
Kraft at Blue Cross Blue Shield said it “makes little sense” to allow hospitals to have that requirement as a quality measure but not health plans.
The Health Policy Committee plans to hold additional hearings on the legislation.