Well, I won. Six years after I started down the very slow process to end forced MOC (Maintenance of Certification) in my state, it happened. On December 27, 2018 Michigan governor Rick Snyder signed HB 4134 and 4135 into law. The harm Blue Cross Blue Shield (BCBS) caused me and my patients will never happen to another pediatrician in Michigan.
I know. Crazy. I’m still in shock. It’s taken a while to process it enough to write about it.
So what happened? How did we go from “My MOC Failure” to victory in one year? From an outsider’s view, this signing was an abrupt end to MOC discrimination in Michigan, a nice neat Thanos Infinity War finger snap.
The inside reality was more Endgame: old and new friendships from all walks of medicine and politics coming together, devising a plan, racing against time to beat a powerful adversary, but sacrificing some good people along the way.
The Michigan legislation started six years ago in the Michigan State Medical Society (MSMS) House of Delegates, with some very simple resolutions opposing forced MOC. As physician awareness of MOC and its harm escalated over the years, so did the strength of the resolutions passed by the delegates, eventually culminating in a resolution to pursue legislative action. MSMS stepped up to the challenge, found sponsors, and legislation was introduced in 2015 to prevent hospitals and insurers from discriminating against doctors for not purchasing MOC.
The first committee hearing in 2016 was eye opening. The hospitals freaked out. The insurance companies freaked out. The American Board of Emergency Medicine, located in Michigan’s capitol, freaked out. Clearly, these organizations allow grandfathered doctors to practice without concern, yet went into full doomsday mode at the idea of younger doctors practicing without buying MOC.
And that was it. The bills died in committee.
So next legislative session, in 2017, the bills were re-written and we started again. This time, instead of trying to fight insurance companies and hospitals, we focused only on the insurance companies. The rationale being that hospital bylaws can theoretically be changed by doctors, but discriminatory insurer bylaws cannot.
So off we went to committee again, thinking we’d have smoother sailing.
But now the opposition was even more organized and vocal. As anticipated, BCBS opposed. But American Board of Medical Specialties sent in their big guns, the American Board of Emergency Medicine stacked the room with their board members to oppose, the American Board of Ob-Gyn and American Board of Orthopedic Surgery did the same.
The kick to the gut was a mother of a chronically ill child, who gave tear-jerking testimony in opposition to the bills “on behalf of parents”, but never disclosed she was with the American Board of Pediatrics Parent Advisory Council. It was madness.
And so the bills sat in committee again. In the committee’s eyes, physicians were divided: some wanted the bills and some didn’t. They didn’t see the clear conflict of interest with all opposition coming from those profiting from the monopoly.
The bills sat for over a year, and were set to expire at the end of 2018.
The 2018 midterm elections in Michigan divided our state government into a Republican legislature and Democrat governor, and our bill sponsor Dr. Ned Canfield decided to retire. The prospect of finding a new sponsor, re-educating a new legislature, and convincing a divided government to pass MOC reform…ugh…it was over.
But what about lame duck? With just a few weeks left in the legislative session, the impending leadership change had bills flying left and right. Could we squeak in under the wire, and more importantly, under the radar of the powerful ABMS friends?
One physician lawmaker said, “No way. Not possible. You’re too late. Try again next year”. The medical society didn’t have a lame duck strategy for the bills, and were skeptical. But to their credit, they got to work and quietly moved them forward.
The insurance bill was amended to appease BCBS, a big amendment: it would only apply to “primary care”, so pediatricians, internists, and family medicine. And to appease the hospitals, the package included joining the FSMB Interstate Licensure Compact, with some minor amendments to assure the compact pathway would be voluntary.
It was a crummy deal, but with days left before the legislative session’s end and the possibility of years before we had another shot, it was better than nothing. We took the deal.
Freed of opposition by BCBS and the hospitals, the amended bills sailed out of the house, passed unanimously through the Senate Health Policy Committee and then the full Senate. It happened so fast, ABMS and team were caught flat-footed. They couldn’t scramble their “A” team to testify in time, and their “B” team was eaten alive in committee. All the usual opposition by the Emergency Medicine Board fell flat, as the bill didn’t apply to them. It was beautiful.
But we compromised a lot for this little slice of freedom: we went from a bill to prevent MOC discrimination by hospitals and insurers for all specialties, to a bill that prevents MOC discrimination by insurers but only applies to pediatricians, internists, and family doctors. As BCBS was the only insurance company engaged in MOC discrimination, we did all that work to prevent one insurance company from requiring MOC for three specialty boards. And we joined the FSMB Interstate Licensure Compact (which requires MOC to get the initial license). Like I said, it was Endgame. We won, but we lost a lot.
Was it worth it? Well, for me, yeah. Pediatricians were chosen as “winners” in this bill. In Endgame vernacular, I wasn’t sacrificed over the cliff on Vormir. Was this by design, to get me to finally be quiet? Maybe. If so, it kinda worked.
I took care of my peeps. I feel bad for physicians in the remaining 21 specialty boards excluded from this legislation (well, not the ER docs, you get all the MOC you deserve as your colleagues nearly derailed the whole thing). But certainly not bad enough to turn down the deal when lawmakers offered it.
And winning after six years of late nights, early mornings, travel, flights, testimony, meetings, phone calls, blog posts, media interviews, lawmaker roundtables, inbox full of encouraging emails, and some threatening emails has left me a little tired out. When I started down this path, my son was in kindergarten. He’s a middle schooler now. This has been a long haul. I’m not going to be leading the charge for the surgeons, but more than happy to teach them how to do it.
We have a saying in medicine: See one, do one, teach one. What can I teach? There is a general recipe for success that applies everywhere: get your state medical society on board with a policy resolution, find a sponsor (most likely a physician lawmaker), write a bill, get it passed. There are some cautionary lessons that carry through in every state battle, and these truths were reinforced in Michigan.
I learned about the power and impotence of organized medicine. Straight up, the AMA is worthless in this fight. ABMS found their way from Chicago to Lansing to oppose the bills multiple times over many years. But the AMA, located just a block away from ABMS in Chicago? Not a peep. No support. Not even a letter. Your state medical society remains your single greatest ally to effect change.
I learned how much harm physicians in power can cause practicing physicians, and the shameful tactics they will use. At every hearing, physicians came to oppose MOC freedom. Without fail, a simple Google search showed these physicians were benefiting from the MOC industry.
You have to be prepared for heartbreak, intimidation, dirty tricks, and last minute ambush efforts. I watched this play out in Texas and Oklahoma, but I was still shocked in my own state. The mother used by the American Board of Pediatrics to mislead lawmakers was just appalling. (Not surprisingly, she was rewarded for her loyalty by a prime seat on the ABMS Stakeholder Council). In our final senate committee, the president of the Michigan College of Emergency Medicine showed up at the last minute, yelled at me, threatened to derail the legislation, even though it didn’t even apply to ER physicians. With so much money and power at stake, these behaviors are not surprising, but still hard to watch up close.
The part I can’t teach is the art of this process, as every state has their own organized medicine and political culture. You don’t know how it works until you jump in. I’ve had many people tell me there were certain “lucky breaks” I had in Michigan to make this easier: I’m a medical society delegate, I’m on my county medical society board, I had the Rebel.MD blog, my medical society cares, I understand the legislative process, I know politicians and their staff… as if those “lucky breaks” weren’t 100% by design and hard work.
It wasn’t by accident that I gave up my weekends every spring to be a medical society delegate, or evenings every month to be on my county medical society board, or countless hours building and maintaining Rebel.MD to get the message out. It wasn’t by accident that I met dozens of lawmakers in their offices and out in the community to discuss many issues, including MOC. This was pure hard work, not luck, not privilege. This is the stuff you can’t be taught and you can’t outsource. You just have to do it.
I’m a private practice pediatrician. I’m a serious nobody. I don’t have family or friends in high places. I didn’t know anything about organized medicine, politics, or website building until I did it. All the docs who helped in Michigan were new to this. The fact that we did this in Michigan with such an inexperienced rabble of docs without any resources, should be inspiration that this can happen in any state.
It takes time, but this can happen anywhere. Who knows, maybe even Illinois.
Whatever it takes, docs, whatever it takes.
Oh, and here’s a photo of me and my hero, Dr. Ned Canfield, after the final senate hearing where his bills passed unanimously. I keep this on my desk in the office. He was a rock, the unsung soft-spoken hero of the MOC battle in Michigan. MOC freedom is his legacy, I am forever grateful.
See how your state is doing with MOC legislation at www.stateofmoc.com.