Today one of my favorite families came for a visit. The kids were behind on their check-ups, but this wasn’t too surprising. Their young mom was recently diagnosed with stage 3 cancer and was working her way through surgeries and chemo. The length of time since our last visit made me worry that mom’s health kept the kids from their routine visits, but upon entering the room she looked well. We chatted for a bit and caught up on her health before moving to talk about the kids.
“Sorry we’re behind. Our insurance company sent a letter saying you were no longer a provider, so we had to transfer out. I couldn’t find a doctor soon enough, so we just went to the ER and Urgent Care for sick visits and the care wasn’t as good. When I called your office to get our records transferred, it turned out that letter was false. I’m glad they asked why we were transferring, we almost left you based on that letter.”
I sat in stunned silence and blinked back tears of frustration and anger as the full weight of her statement hit me. In the middle of cancer treatment, this family was forced to leave and seek care in the ER for one reason and one reason only: MOC.
I’ve hesitated to share the outcome of my failed MOC battle for many months now, but this visit today reminded me why we must fight against the monopoly of forced MOC. MOC doesn’t just harm doctors. It doesn’t just cost money. It harms our patients and it nearly cost me the right to care for one of my very favorite families in their most vulnerable time.
I’ve passed the American Board of Pediatrics board exam twice, I’ve completed countless hours of their proprietary online tests, I’ve completed three of their research projects on my patients. But when the ABP demanded another $1300 or they’d revoke my certification, I had enough. In protest of the shake down, I didn’t pay. The ABP and ABMS advertise their MOC product as “voluntary”, so I took them at their word.
It turns out MOC isn’t voluntary at all. Within weeks of not paying, I received a letter from BCBS of Michigan telling me to buy my board certification by December 31, 2016 or risk being decredentialed. I am board certified through National Board of Physicians and Surgeons, and asked if that was acceptable, and was rejected. Only ABMS boards allowed.
The date came and went, I didn’t pay, and I prepared to defend my case in front of their medical directors at the two appeal hearings guaranteed in my contract. Certainly the medical directors would understand this was a money grab by the boards, that I had passed every academic requirement due until 2023? Certainly the medical directors would see how discriminatory it is to require me to pay and jump hoops unceasingly, while exempting grandfathered doctors from MOC altogether? Certainly the medical directors would see I had fulfilled more board requirements than a grandfathered physician, resident, or medical student but was treated as less qualified?
The date for my hearing was set, and I felt confident the logic of my argument would prevail.
And then the phone calls from panicked patients started.
A full month before my hearing, BCBS started sending letters to my patients telling them I was already a non-participating doctor. Patients started to transfer out, my billers and partners started to panic. I called BCBS, and asked them to stop the letters until my hearings were completed. They refused. I contacted my state attorney general, he couldn’t help. I contacted the state insurance commission, they couldn’t help. I contacted the AMA, and they said to contact my state medical society. I contacted my state medical society and their lawyers for help. Their advice: just pay.
Tired, trapped, and under coercion, I paid $1300 plus a $200 late fee. Within seconds, I had my American Board of Pediatrics certificate in hand, within hours BCBS reinstated me, and never sent out another letter to my patients. It was clearly, all about the money.
I am a diplomate of the American Board of Pediatrics against my will. I find it morally reprehensible to financially support an organization that harms fellow physicians. I find it demoralizing to know my money supports their lobbying efforts against our state MOC legislation. Yet I paid in order to see my patients. I paid so I could still be a doctor. The American Board of Pediatrics could ask for another $1500 next year, and I’d have to pay again. There is no choice.
Is it possible I was targeted for being so outspoken on MOC? Possibly. My initial letter to the ABP has over 100,000 views. My medical society has used me on the cover of their magazine and their website dedicated to fighting forced MOC. The ABMS Senior Vice President knows me by sight, and has watched me testify against forced MOC in our state capitol on multiple occasions.
But I’ve been contacted by countless quiet Michigan physicians threatened and de-credentialed for simply refusing to pay for MOC. It doesn’t matter who you are, an outspoken physician with a state medical society behind you…or a solo practitioner quietly trying to stay afloat…you must comply.
I don’t know the solution to this problem. It seems like every legal, logical, and ethical boundary that should prevent a certifying company from gaining such absolute unchecked power has been ignored, and every professional organization that should help us is impotent.
My state medical society has held clear policy opposing board certification, let alone MOC, for insurance plan participation for 20 years. They’ve been negotiating for 20 years, yet aggressive MOC discrimination continues. The AMA has strong policy opposing MOC abuse, but refuses to do anything. The FTC should see this monopoly as a clear anti-trust violation. They are waking up, but still not acting. I am baffled the IRS doesn’t question the million dollar salaries raked in by these “non-profit” organizations. It seems like this would be a slam-dunk class action lawsuit for some smart law firm, but no one is interested in the case. State legislation is likely our best bet, but the lobbying power of insurers, hospitals, the billion dollar ABMS certification industry and their codependent specialty societies is nearly impossible to fight.
If nothing is done, ABMS will win, because their entire coercive business model relies upon our professionalism. As physicians, we take an Oath to “Do No Harm”. We promise this to our patients.
My first emotion when I heard my patients were forced to receive care in the ER was not anger at ABMS. It was gut-wrenching guilt. I dared to speak. I dared to fight. I underestimated their power. I was stupid enough to think MOC was a physician issue. It never crossed my mind that my patients would be harmed. I know better now. The next time they ask for another check, I will comply, and they know that. I just hope something is done before then. Primum non nocere.
Lynn Ebaugh MD Nephrology says
I feel your pain. You are not alone. We, as physicians, are all being taken on a ride by MOC. I recently took my board recertification exam and it was no picnic. As I have been taught to think and ponder about my patients’ problems, I have difficulty doing 240 “consults” (questions) in 8 hours..even with 90 minutes of break time. The time required is phenomenal and my practice suffered. I went to the Harvard Board Review and completed > 600 practice test questions from 2 online services. Many dollars and much time lost, I suspect. No pass or fail mailed out yet, guess they are waiting to email us just before Christmas. I have logged more than 100 CEUs for this year, not counting the ones associated with the Board review course or the 2 online question and answer companies. I was considering not taking it again if I don’t pass (since I will soon be 65 and close to retirement) but your situation put the fear of MOC and ABIM into me.
Deborah Sutcliffe, MD says
I too feel your pain as a Family Physician, board certified since 1993. This year I said NO. NO to insurance companies. NO to MOC. NO to MIPS/MACRA/PQRS/forced EMR. I had already paid for my board exam so I took it–don’t give a crap now whether I pass as I am board certified now with NBPS too. #DPCSavesDocs
And in the long run, probably saves patients’ lives. You’re undoubtedly far less stressed and far more able to actually form a relationship with your patients, actually listen to them and prescribe for them as “people” instead of a number. As a patient who worked with her Orthopod father in the 60’s and 70’s, I wish I could find a DPC physician, sigh.
Whitney Huston says
Steve Karp MD says
Nearly all physicians are in the same boat. Even if you are lifetime certified, physicians found themselves listed as ‘out of compliance.’ Two points of mild criticism: Do you see what’s going on in this country? The former and current heads of the IRS should be in jail. Of course you became a target by your board. No need to cry over that or about the impact on your patients which is unfortunate but beyond your control. Also stating “The next time they ask for another check, I will comply, and they know that” just lets them smell blood in the water. That being said I don’t see where you or your group has hired a personal attorney for reputation harm, interference with your practice of medicine and business etc. The idea is to get all their internal documents into evidence. Funny though that the lawyers don’t retake their Bar exam, as if law remains stagnant. I also certified with NBPAS and sent them additional money to support the cause. We live in crappy times. Keep fighting though. If nothing else to serve as a positive example for your kids. It’s going to take generations to fix the mess this country’s in. Our guild lost more than 100 years ago. See my article on American Thinker http://www.americanthinker.com/articles/2017/04/breaking_up_the_legal_industrial_complex.html for a solution I proposed.
Your EM colleague here supports you 100%! Thanks for fighting the good fight for all of us! Lost the battle, not the war. Please stay brave and keep us tuned!
Robert Sterling says
Creeping injustices everywhere
I’m very saddened to read of the trials and tribulations you and your patients were put through over your fight against the mafia-style protection racket known as MOC. You paid the pizzo, like in sicily, and you were granted the right to see your blue cross of Michigan patients. I believe the only way to win this war is to stop participation in all third party payer contracts, they are corrupt and neck deep in the mud with the kickbacks, payouts, all manner of dirty unknowable schemes. The population does not care and doesn’t know anything about MOC and it’s best that they don’t. I hate to be cynical but the ignorance of basic things out there such as the difference between a physician assistant and a physician tells me the public cannot be educated on this issue. The only way the ABMS will cease to exist is if it is starved of money. I’m sorry in pediatrics you’re so bound to take insurance. I think insurance plans as we know them will approach collapse in the next couple of years, Aetna was hurting, sold itself to CVS. The blues are different, a public/private cartel run differently in each state, but the flood of high deductible plan and non insured folks is coming. As doctors, we are like cats, we cannot be herded, we are busy and trying to survive by stomping on disease, one at a time. We would need an alternate behemoth like AMA 2.0 to fight this legal and political battle. I’m not very hopeful. I think they want to drive doctors out of business to siphon the sick to RNP’s through their wholly owned health system, hospital and pharmacy benefit plan. We were sold down the river. We’re gonna have to buy ourselves back.
Chris Foley says
I wholeheartedly agree with Dr. Shapiro above – stop all third-party arrangements including Medicare and Medicaid. Go direct pay which I did as one of the first internists in the Midwest to do so 20 years ago. I have never looked back. I slide my fee scale as appropriate. I do a fair amount of pro bono work. However, I charge $500 per hour for everyone who is in a reasonable situation to afford my fees. I tried to deliver more than I promise.
Fairly soon, only the real ignorant and incompetent physicians will be participating with the third-party payer cartel. Why? Because they have to in order to have anyone walk through their door seeking medical care.
You exhibited far more resilience and patience with this type of tyranny than I would have. When I left mainstream hospital-based internal medicine, I was 50 years old and fed up. I was on the Board of Directors of a major healthcare system and completely understood where it was all going. If it hadn’t been for my very devoted spouse – who became my office manager – we never would’ve made it. However, now, we have a very robust and very private practice with a long waiting list for new patients. Pediatrics particularly is vulnerable to this type of thing. A pediatrician with a slightly “broader set of bookends” in terms of what good medical care is – at least here in Minnesota – would do extraordinarily well in a direct pay situation. Interestingly, our very large immigrant community here literally shuns conventional pediatrics and large ACO -related clinics because they consider them to be untrustworthy. I had no idea that our new version of first generation Americans were so intelligent.
Christine Madlock CPPM CPC CRC says
I’m a Revenue Cycle Consultant for private practice physicians and my heart breaks for the frustrations they are faced with coming in all directions, but it powers my passion to continually find ways to help.
Former ER doc says
I work as a medical director for a large insurer. I agree completely that Moc is a shakedown. I felt that way 30 yrs ago when it started because mine was the first year to pay and all those before me were grandfathered. Initially the fees were not so heinous and the concept of having a standard minimum is not a bad one. But now it is a complete rip off and should be voluntary. I have written emails and letters of complaint like you. To no avail. I will lose my job if I am not board certified and I can’t be board crrtified without MOC. We need a class action suit for interference of commerce. Not sure why you have no lawyer take the case.
BTW, insurers can set limits like board certification so private practitioners are screwed there. The MOC has to be choked off at the ABMS level otherwise like a weed it will come back. PS I do not like insurers either even though I work for one but in our capitalist society single payer will not fly and fee for service separates the have and have nots. Insurance coverage now is only for those who can afford the monster premiums, deductibles, coinsurance and copays. I also dont understand why hospital, insurers and MOC senior staff make 100’s of thousands and millionsin the case of insurance CEO’s. I escaped out of clinical medicine because hospitals shake you down with metrics. I will stop my rant here. Can’t wait to be able to retire.
Foermer ER doc says
Clarification: minimum standard for a body of knowledge was what I meant by minimum.
When the medical societies and organizations should be thinking about physician burn out and decreasing our administrative burden, they support and promote the opposite. This is truly outrageous.
The only way to win this fight is for all physicians to stand together and rebel. Imagine if everyone chose to let go their certification. ABMS profits would decline, and lose its lobbying power. If payers stick with their requirements then they would loose adequacy of their network, and hospitals wouldn’t have a medical staff. We can win only if we stand together.
Let’s start a new oath, we will never let any coercive, non-evidenced based, and monopolizing efforts ever govern how we practice medicine and care for our patients.
Stephane Ngo, M.D. says
Thank you Dr. M. Edison for your words of inspiration.
I obtained my Initial ABMS certification in Psychiatry in 2008. I currently work as a contractor and been extremely busy. As a contractor, I had to take 2 weeks off to study before my re-certification which amounted to a loss of over 25K in lost wage. This is not counting the $1000 (Registration and test taking fees) I had to pay and the $1400 in study material and question banks I had to pay. My disgruntled comments/criticism with ABPN for MOC:
1) I don’t mind retaking the MOC if ALL boarded psychiatrists take it. That includes the doctors who were “grand-fathered.” It makes absolutely no sense that older docs don’t get tested and refreshed in their knowledge. You would think that the MOC would apply more to them. This makes no sense to make special rules and exemption. If the ABPN mandates that we participate in the MOC and take a close testing every 10 years, then “ALL” initial boarded physicians (including “grand-fathered”) should be subjected to the same expectations.
2) The ABPN keeps changing their rules every so often. For years, there was criticism that the oral was too subjective. I took my Initial certification in 2007-2008 and had to experience this, right or wrong. So why did ABPN changed their format and later testers were not submitted to the same exam?
3) The ABPN is again changing their rules/options for MOC starting in 2019 with a pilot where diplomates can choose a different pathway with journals/CME activities instead of taking an actual exam. They told me that I am not eligible for this because my certification expires on 12/31/2018. Again this makes no sense. If ABPN introduces some new regulations, it should apply to EVERYBODY, whether you passed you initial certification in 1990, 2007 or 2018.
5) My last argument against the MOC is does any State Medical Board makes us retake a close exam such as USLME 3, 2, or 1? The answer is of course “NO” because ALL of us already passed these medical tests and completed an approved residency program in order to obtain a physician and surgeon license.
I participate in the MOC and just retook my MOC closed examination last week (It will be another 10-12 weeks of agony to know if I passed or not) only because the ABMS requires it and I simply don’t want to lose my Initial Certification which I worked really hard to obtain. I am a contractor working primarily in forensic psychiatry for different State hospitals or prisons. As a contractor, there is absolutely no incentive (required, financial or else) for me to maintain my ABMS certification. I would even go as far as to say that more than half of the practicing physician in the State system don’t even hold an initial board certification.
No wonder there’s not broader application of psychiatric care. You’ve missed the entire point of the battle and your comment is the whole reason we’re in this mess right now.
Healthcare that is quality and affordable.
The inmates that you are caring for are someone’s uncle, brother, or relative.
Anonymous but Fed-Up Specialist Physician says
I’m not re-certifying my credentials with the American Board of Psychiatry and Neurology (ABPN). The ABPN reported over $100 million in net assets on their 2016 IRS Form 990. They actually haul in millions more than is spent on examinations!
My situation is one where I can continue to see patients without board certification. By not sending money to the ABPN, their preferred CME ‘partners,’ and giving up scarce spare time away from patients and family, I am calling for a system that is not a plain, naked, money grab.
Quite a few people have asked why you didn’t get a lawyer. They should know better. If you hire a lawyer he will tell you that you are in the right. He will tell you that your legal rights have been trampled on. He will tell you that a good legal team could take on such a case from various angles including defamation, restriction of commerce, monoply issues, etc. He will tell you that you would probably win, especially if it reach class action status. To tell you all that he will charge you far more than you can afford and to win such a process in a meaningful way would cost more than your net worth with no guarantee of recompense even if you do win.
Dario Grisales says
You are my hero Dr. Meg Edison!. Board Certification should not exist at all. Let’s talk history. George Washington was killed by the 3 physicians that treated him. They bled him to death because the standard of care at that time was blood letting thinking toxins inside the body needed to be expelled by bleeding the patient’s toxins out. The last one to see him was the army surgeon, he who knew that bleeding killed, was pressured by the other two and had to agree. That kind of treatment (Sangria in Spanish) is still done but with clear indications. Medicine, our profession, is constantly evolving. Every day there are new concepts and changes in protocols and new consensus. We all have to get a number of CMEs to renew our licenses. That should be enough. From the new concepts, techniques, protocols, consensus, etc., as an intelligent physician/clinician (administrators probably were never successful as real physicians or got tired of being told what to do), I will take the best of that and implement what I think is best for the patients that I, and only I, have known for years, or the new ones in which I will have to put my best to diagnose correctly, first and foremost, with my devoted time, clinical knowledge and physical examination. Laboratory, MRIs, etc. are just to confirm my diagnosis, not to diagnose. I laugh with a grin in my face when new patients come to my office, spend 1-2 hours with me in their first visit and at the end they tell me: doctor, I feel like the other doctors that I have seen before and that did not help me were not real doctors. Then, I ask them: why? Their answer is almost invariably that they spent two minutes and did not talk or explain any thing to them. The worst of it, all of them Board Certified. I attend numerous societies annual conferences. (All of which I am a Member in my specialty). Every year I exceed and get more CMEs than what we are required to renew the license. Board Certification in what. The lies that you can be telling the patient about cholesterol and that today is a new concept? To use a new antibiotic from the start in a patient when you know you can use PCN and then switch if C&S if it reveals resistance? It is all clinical decision and observation of the patient. In medicine one size does not fit all. There are genetic, race and ethnicity, as well as pharmacogenetic, idiosyncratic and cultural differences that we have to deal with, and that, can only be achieved when you know your patients, when you talk to them, when you also educate them. I am a pain physician and do interventional procedures, implant SCS, do IT pumps and prescribe some opioids when necessary. During the so-called “opioid crisis” many of these BC physicians abandoned their patients (Fear of losing their certification status? Fear of being pointed at? Or perhaps knew the process was painful and required a lot of their time and effort and they really did not care about the patient but about their $time$ and reputation? Or may be they did not go to the conference on how to do it). I helped a lot of those to walk through their process of weaning off the opiates that had been at high doses because years before we were forced by agencies like the Joint Commission to treat pain adequately to the point there were law suits in California for undertreatment of pain. I have never advertised and receive very little referrals from my colleagues in town. My practice has always thrived, slowly and has been more word of mouth. These are the best patients because they trust you even if you disclose that you are not board certified. They come out of my office with a big satisfaction of the service they have received. It is a shame that the health insurance industry uses board certification to negotiate (what am I saying, impose) the fee. That is discrimination. Good job Dr. Edison!