To: President Andy Biggs, Sen. Sylvia Allen, Sen. Gail Griffin, Sen. Steve Yarbrough, Sen. Nancy Barto:
Re: concerns about HB 2502, Interstate Medical Licensure Compact (IMLC)
The Health and Human Services Committee heard lengthy testimony on HB 2502. While it narrowly (4:3) approved a do-pass recommendation, testimony on both sides provides serious reasons to reject the Interstate Medical Licensure Compact (IMLC) being aggressively promoted by theFederation of State Medical Boards (FSMB).
The hearing showed a stark division in the medical community: big multistate healthcare systems, also represented by the Arizona Medical Association (note that ArMA and Mayo have a common lobbyist), and independent physicians, represented by the Association of American Physicians and Surgeons (AAPS).
We agree about the existence of problems. There is a shortage of physicians, and Arizona is a net exporter. Also, Arizona may lose prospective physicians because of the long delay in issuing an Arizona license. The Compact, however, would worsen them, rather than solve them.
We agree that Arizona patients deserve good medical care, and that we need technologic innovation, including telemedicine. The Compact is unnecessary and even harmful for quality and innovation.
The Legislature needs to investigate the cause of the licensure backlog. If it is bureaucratic inefficiency, counterproductive requirements, or lack of resources, these problems should be remedied for all licensees, not just Compact licensees (of which there are as yet none). Ohio has had good results in expediting licensure; New Mexico has expanded reciprocity. If the problem is specific requirements in Arizona, do we want to relax those? Its advocates claimed that the Compact would not do that, despite numerous clear provisions that its rules would supersede state law, and some ambiguous or contradictory language on this point.
Rather than reducing bureaucratic delays and costs, the Compact likely just adds another bureaucracy, this one a multistate private entity with no accountability to Arizona voters.
Testimony was confusing about whether the Compact requires licensees to meet all requirements of all states, or simply the requirements of one state, the least common denominator. Pro-Compact witnesses called concerns about overriding Arizona law a “bogeyman.” But if the Compact doesn’t override state authority, what is the function of the Compact Commission? And what is the meaning of repeated references to its superior authority?
Pro-Compact witnesses admit and even applaud the fact that the Compact will exclude some 20 percent to 25 percent of currently practicing physicians because they lack board certification. This percentage will likely increase as “grandfathered” physicians with life-long certification retire, and younger physicians choose not to participate in the “voluntary” Maintenance of Certification® process, which fills the coffers of the Federation of State Medical Boards and its web of private corporations, at the expense of physicians who must take time away from their practices and lives and pay thousands of dollars to satisfy the requirements. (Compact advocates argue that once “in,” Compact licensees won’t be booted out for later failure to meet MOC® requirements, but then why demand them in the first place?)
Compact advocates seem to see a brain drain as a solution to shortages: make other states (and nations) the net exporters of physicians. The Compact will not by itself make Arizona more attractive. Why are doctors leaving Arizona now? Could it be crushing workloads, compounded by excessive bureaucratic demands? An unfriendly tax and regulatory climate? Non-remunerative fees? Will still more leave if their patients are drained by in-network, low-cost foreign nationals, some working out of state by telemedicine, and by the increasing market dominance of multistate managed-care cartels?
Mayo in particular is a strong advocate of a brain drain from foreign countries. Does the Compact further enable big systems to import foreign citizens who are tied to and dependent on the system? Note that employment-based green card applicants must continue working for the same employer at the original job offered (http://www.immihelp.com/greencard/employmentbasedimmigration/sponsoring-employer.html). Physicians whose status is essentially like that of an indentured servant would put themselves at serious risk if they put the interests of a patient above that of their employer.
We must note the irony of excluding non-board-certified American physicians, while expanding the scope of practice of physician extenders and importing foreigners who, even if they pass an FSMB-prescribed examination, may have severe communication problems.
And is board-certified necessarily better? Some of our best physicians, preferred by other doctors to care for family members, are non-board certified. Many fine physicians are or were board-eligible, who successfully completed years of rigorous training but have not, for various good reasons, jumped the final expensive, time-consuming hurdles. Years of actual practice experience are likely far more valuable than still more years in a training program. And what is the logic of saying a physician is qualified one day, but suddenly disqualified the day a Board announces that he missed one question too many on its costly proprietary examination?
Compact advocates, including Rep. Carter, insist that the Compact is (and presumably will remain) “voluntary.” The FSMB’s Compact is likely, however, to remain “voluntary” in the same sense as MOC®. You may choose not to do it, but if you don’t you will be excluded from the hospital staff or insurance panels. And for patients, it may be “voluntary” in the sense that you may choose to see an out-of-network physician, but if you want your Plan to cover it, you may have to have a telemedicine consult with an in-network specialist.
Telemedicine can be and is being expedited in many states. The Compact is not necessary for this. Telemedicine may be inferior to hands-on medicine but still be the best available modality. States may, however, wish to forbid it for certain procedures, such as chemical abortions or assisted suicide. Can out-of-state Compact doctors circumvent the law? Apparently, pro-life legislators thought an amendment was necessary, but is it sufficient? And what about other circumstances not yet contemplated?
The Compact appears to be a step in the direction of control of medical practice by a private multistate Commission. By putting all the state licenses of Compact physicians at risk of automatic 90-day suspension, or worse, it could compel physicians to “choose” to perform or withhold treatments in violation of their conscience and the Oath of Hippocrates—or else lose their livelihood.
Contrary to the innuendo of the ArMA/Mayo lobbyist, we favor competition. We believe all patients should be able to choose an independent or an in-network physician. But if independent physicians are driven out of the market, as patients are pushed into narrow networks and non-Compact physicians become a legally disfavored underclass, this choice will be meaningless.
We urge you to reject HB2502, or to delay it until legal questions can be elucidated, after the Compact is actually implemented in other states.
Jane M. Orient, M.D.
Executive Director, AAPS