A Major Award and a Major Headache

Last night, my husband won Specialty Physician of Distinction for The Nebraska Medical Center. He poses with his plaque and Beth Pfeffer, the nurse manager of the Diabetes Center and Service Line who nominated him.

One bonus of the evening was the keynote address by J. D. Kleinke, medical economist extradordinaire. His views on healthcare reform provided further support for my own, and one of his books sounds like a must-read: Oxymorons: The Myth of U.S. Health Care System (2001).

I hoped to post this morning so my husband’s achievement could be easily shared with friends and family; unfortunately, my patients did not allow it. When I finally got to a computer, I skimmed one of my regular reads, White Coat Underground. The post today raised an interesting question: would health care reform cause physicians to leave medical practice?

I will let you read the original post, because the question (and supposed answer) are not, well, real.

I do know something that will make physicians consider leaving medical practice, though: Maintenance of Certification (MOC).

In the old days (before 1985), a medical student graduated and took one of two courses of action. After 1 or 2 years of rotating internship, most states would license an MD for general practice. Alternatively, one could pursue residency training for a number of years and then sit for board certification examinations in specialties. These specialties included primary care (Internal Medicine, Pediatrics) and more specialized fields (Endocrinology and Pediatric Nephrology for my household). Once you passed the test, you were board certified forever.

A few years back, someone decided that certification should not be forever. Boards should have processes to certify that a physician’s knowledge and skills remained current. I was in the first group in pediatrics that could not get permanent certification (we became board eligible in 1988).

It sounds reasonable to require continuing medical education (CME), and state licensing boards have required documentation of such coursework for years. Sitting through a lecture did not insure learning, though. This new process would assure specialty-specific CME, along with the examination to document the accomplishment. So far, so good.

But then the powers that be decided that knowledge alone does not a physician make. Practicing medicine requires skills not tested by traditional multiple choice exams. Thus, MOC was born.

MOC includes (1)maintaining unrestricted medical licensure; (2)completing qualified education modules; (3)practice improvement projects and patient surveys; and (4)secure examination.

My husband is currently performing a practice improvement module. A quality measure has to be first defined, and then measured via a chart audit. Once measurements are made, an improvement project can then be implemented. This takes time and person-power to accomplish. In academia, he has time to pursue this, along with support staff to help carry it out. Those in private practice will have to clear patient schedules to perform these tasks (loss of revenue), and/or hire personnel to perform them (increased costs). Either way, these requirements have negative economic impact on a practice.

Will physicians continue to practice after a couple of rounds of MOC? I believe most will; after all, taking care of patients drives most doctors to “doctor.” Will doctors maintain certification? A number of insurers require MOC for reimbursement of specialty services, so I suspect many will. I guess a fair number will not, especially in primary care. Once your patient base is set, they are unlikely to ask if you have maintained certification. Many doctors may find that patients prefer to have them more available, rather than working on MOC.

I recertified in general pediatrics once. At the time recertification was an open-book exam via personal computer. I learned a lot of things that I had missed while devoting myself strictly to my subspecialty. It was a great experience, and I had no ill will about doing it (not even the cost). I will no longer be maintaining this certification for a number of reasons, especially the fact that I have no general pediatric patients for the required survey. I am enrolled in the Pediatric Nephrology MOC program.

MOC looks good on paper, but it will not be easy to complete, especially in a clinical practice environment. Only time will tell if physicians maintain certification and if MOC makes any difference in physician performance or patient satisfaction.

Lack of data never stopped anyone from enforcing a course of action.

That “Special” Time of Year

‘Tis the season when a doctor’s fancy turns toward… re-credentialing. Not roasted turkey with family and football. Not jingle bells and candles. Just packet after packet from insurers and hospitals wanting to know all about you.

They all want the same information in different order:

• Are you still licensed?
• Are you still board certified?
• Has anyone sued you?
• Are you impaired in your ability to practice?
• Have you kept up your skills?
• Are you insured for malpractice?

Copies of your CV, your license, your DEA certificate, and your continuing medical education coursework accompany each form. You must also supply 3 to 5 peer references who are familiar with your practice. Also, your original signature (NO STAMPS) in 3 to 7 places.

Perhaps they would like a note from my kindergarten teacher? I believe she died, but a séance wouldn’t be much more work…

Repeat this process for each hospital or clinic at which you see patients. Fill out similar forms for every insurer. Then have your secretary make and keep copies (because at least one application will be lost).

As I struggle through this quagmire of paperwork, I wonder why this cumbersome process still exists. All of these parties request the same information; perhaps they could get together and come up with a single universal form. Even better, we could put that universal process form online. The amount of paper I am required to submit boggles the mind. The requirements can be interesting as well; some parties want only black ink while others specify only blue pens be used. (One year I used purple just to, perhaps, cause a bit of trouble.)

When you add up the cost in paper, time, and postage, we could put together a national online web-based process. Collecting these sorts of data is not rocket science. Of course, it would require some cooperation among competitors, but it is within reach. A bit of government guidance could make this reality! It would reduce administrative costs and reduce the hassle factor with a learning-curve less-steep than the electronic medical records funded by the stimulus plan!

Imagine filling out this stuff once… That would leave a lot more time for myself and my staff to enjoy family and football and bells and candles, not to mention actually taking care of patients and performing the rest of our academic duties.