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.
You’re inspiring. Thank you
I’d love to understand your story. but there are too many TLAs (three letter acronyms, which, is also any idiom for any acronym) to look up to make it worth the effort.
I know! I’m sorry. This is such a crazy topic…docs dealing with it know what I’m talking about. Hopefully, we can fix it so all these corrupt TLAs are retired into the dustbin of history.
Don’t apologize for your (amazing) work and for sharing it with us. Rather, you should appreciate the feedback. Kristin
The FSMB Interstate Compact concession is unfortunate. It represents another cash cow that does almost nothing to benefit patients. Glad you got MOC done but the price was expensive.
Agreed. I have a feeling the Compact is going to be a bust anyway. Costs more, is barely marginally quicker, not many docs want multiple licenses, still have to maintain CME in every state, each state has different times for renewal…and it’s a risky process for docs to agree to from a civil liberty standpoint. It’s just a money grab in the end, and an attempt to force board certification for a medical license.
As of March, they’ve processed “3,314 applications resulting in 5,450 medical licenses”…which is hardly a success. From those numbers, compact applicants aren’t getting multi-state licenses. They’re getting 1, and maybe 2 states. Silly waste of money.
We just amended it to protect docs as much as possible: 1.) It must be voluntary, a hospital can’t force a doc to get a compact license, they can always use the traditional reciprocity route and 2.) Compact rules only apply to compact licenses, not standard state licenses.
Here’s a link to the Michigan Compact Language: http://www.legislature.mi.gov/documents/2017-2018/publicact/pdf/2018-PA-0524.pdf http://www.legislature.mi.gov/documents/2017-2018/publicact/pdf/2018-PA-0524.pdf
I’m EM. I hope the ABEM gets the pants sued off of them. God bless you for your persistence.
ABEM is pretty bad. They’re the only ones with the audacity to claim that their diplomates love “their” MOC. Their whole argument is “yes, everyone else’s MOC is really horrible, but ours is so awesome”. I’m like…fine…docs love continuing education. If your product provides better CME than any other EM product, docs will buy it. The fact that you have to ensure participation by force is a red flag.
The author of this prescient letter sent me a very nice handwritten note thanking me. This is the real matter at hand when ABEM is trying to force MOC, and makes all protests laughable when we see who is actually seeing patients in the ER. https://journals.lww.com/em-news/fulltext/2009/08000/MDs_without_EM_Training_Better_than_Nonphysicians.10.aspx
Amazing job! You are awesome! I have 6 years til next recert and still have to do MOC. You are an inspiration for change!
Congratulations Meg! It’s Pappy time. Cheers. Thank you for helping us in Ohio. So sad that our bill never made it out of committee but your story is inspiring. Holly Thacker
Meg, you have been an inspiration to me and so many others!! I’m here to help you do “whatever it takes” as is Practicing Physicians of America! ( well, I have a few things I will draw the line at)
Thank you! I have been following your story since and I am right there with you fighting this debacle. Another big fight is the compact state licensing requirement for MOC certification …
I have no idea why FSMB keeps lying about MOC being required for the Compact License. I watched them intentionally lie in committee, even though the compact clearly states a doctor must be ABMS board certified to get approved by the compact…but may drop certification after initial approval. It’s the weirdest thing. Our state actually tried to take them at their word, and simply add an amendment that says only initial certification and an active unrestricted state license is needed to get approved by the compact….ha ha. No dice. They REALLY want doctors to buy MOC to get the compact license.
Neilly, this whole issue with the FSMB Compact probably requires a whole post, but here’s the testimony by John Bremer of FSMB on the Compact. On Page 4, FSMB clearly states “The Compact does not require Maintenance of Certification (MOC) at any stage of the process. Physicians are only required to possess specialty certification, or a time-unlimited certification, as an entry point into the Compact process”. …So to translate this… MOC isn’t required at any point, but we require MOC as an entry point? It’s bizarre. https://megedison.com/wp-content/uploads/2019/05/JohnBremerFSMB.pdf
Please do not generalize ABEM leadership agendas with the average EM physician. We were all with YOU.
You’re correct. This reminds me so much of the Right to Work battle in Michigan. Michigan was a forced union state, where every worker in a union shop had to pay dues to work. The Right to Work fight was lead (and won) by rank and file union members who were tired of being forced to pay dues to an organization that no longer worked to represent them. The union workers refused to say “Union Leadership”, because they weren’t leading. They called them “Union Bosses”, which was more accurate to what they were doing over the workers. I think “ABEM bosses” is far more descriptive of how they are behaving.
Tireless. A physician’s physician. Walks the walk. A leader. A hero. Singleness of purpose on display. A can do attitude. Humility. A role model. That’s you Dr. Meg Edison! Thank you. Thank you. Thank you.
Meg: Well done! You stated it perfectly “every state has their own organized medicine and political culture” and medicine is a state-licensed art of healing. ATTENTION colleague: Join your state medical association through your county medical society, voice your opinion and recruit your colleagues to join, regardless of their employer or practice type. Our voice is vital to the health of our communities. Our involvement in important issues that affect direct patient care requires a “critical mass” of physicians to speak up. All of us practicing physicians understand hard work, diligence and perseverance as these traits drove us to become and drive us to remain physicians. Tests had meaning to be granted admission into and to graduate from medical school. Board exams during and after medical school and internship grants us our license to practice medicine. Specialty board exams should be a fraction of the present cost and should be required to graduate residency/fellowship (not after graduating and not as a profit for private boards). We don’t “have to purchase MOC.” Just don’t do it! Meg, Michigan will certainly be at risk for treating physicians differently regarding MOC based on their specialty. That doesn’t sound right. Are there any attorneys out there with an opinion?
Thank you, Dr Edison. You are well named, like Thomas Edison, a LIGHT and inspiration! After passing Opposition to MOC Mass Medical Society House Policy (12/4/2014) with splendid help from academia and delegates during a Saturday afternoon snowstorm, we are still working to pass appropriate state legislation. We drag through the slow laborious Massachusetts state legislative committees. I might phrase this as the Physicians Right to Work and Patient Access Act. We are due to testify Tuesday May 28 2019 in the Boston State House, on just a few business days notice as usual. May the physician profiteers and promoters of MOC who continue to “eat” and destroy our younger distinguished scholars and boarded diplomates with these costly, irrelevant, and onerous MOC requirements tied to initial Board certifications burn in Hades if there be an afterlife…Meanwhile, some of us have engaged in Class Action vs ABIM MOC, out of Philadelphia Federal Court. Might David bring down Goliath someday? Keep us in your prayers.
Thank you. I am glad the docs win sometimes and it should be more often. I stopped working in pain/addiction medicine 6 months ago (able to retire) and the MOC stuff is part of what keeps me sidelined rather than part time. Keeping up MOC in three fields was a expensive proposition when added to the other regulatory burdens. Miss the patients, colleagues, and craft but other projects keep me going so far.