Arizona Senate Committee on Health and Human Services, Feb 11, 2015
Senator Barto, Members of Committee:
The Association of American Physicians and Surgeons and its Arizona State Chapter thank you for the opportunity to testify in support of SB 1257 and SCR 1003. We urge Arizona to protect its sovereignty and to reject the influence of out-of-state private corporations seeking to control the practice of medicine.
AAPS is a national organization of physicians in all specialties founded in 1943 to protect private medicine and the patient-physician relationship. I am Jane Orient, M.D., executive director of AAPS. I was certified by the American Board of Internal Medicine (ABIM) in 1977.
SB 1257 and SCR 1003 are important because of a national campaign by the Federation of State Medical Boards (FSMB) to persuade legislatures to require current specialty certification by a board approved by the American Board of Medical Specialties (ABMS) for a basic medical license (Maintenance of Licensure or MOL).
About one-quarter of American physicians never attain specialty board certification. This was formerly considered to be a high honor, not a requirement for basic competence. Many “board eligible” physicians, who successfully completed many years of rigorous training in their specialty, never got around to taking or passing the final examination. Some specialties required an oral examination with highly subjective criteria for passing. Non-certified physicians may restrict their practice to the specialty of their choice and provide highly competent care. Board-certified physicians may choose a non-board-certified physician for their own or their family’s care, knowing that the physician is excellent.
Before 1990, board certification, like passing the bar exam, was for life. After 1990, boards started issuing time-limited certificates. A “grandfathered” doctor, who certified in 1989, was certified for life. A slightly younger colleague, who had the same training experience completed in 1990, “expired” in ten years. There is no evidence to justify this two-class system.
Boards established proprietary Maintenance of Certification® (MOC) programs. Finding that most “grandfathered” physicians did not choose to enroll (or to continue enrollment) in these expensive, time-consuming programs, preferring other means for continuing education more suitable for their practice, the Boards are trying to make it mandatory for licensure. ABMS constantly asserts that MOC® is (still) “voluntary” although hospitals and insurers increasingly require it. Many patients have found that their personal physician can no longer care for them in the hospital or under their health plan because of summarily being kicked off the staff or the panel despite an unblemished record of excellent care. Enacting MOL would make such physicians unavailable to patients altogether, and greatly exacerbate the looming physician shortage.
FSMB uses the need to assure “quality” as the rationale for these requirements. But FSMB, ABMS, and member Boards have no special abilities to discern or define quality. Tellingly, many board executives have declined to participate in their own MOC programs, at least until they were forced to do so to keep their lucrative jobs.
In fact, quality may mean use of a proprietary product in which a board executive has a financial interest. It also means conformity to Board-determined protocols of treatment. These may be outdated by the time they are promulgated. Worse, Boards may require physicians to act contrary to conscience. Efforts to exclude physicians who decline to perform abortions may eventually succeed. Pro-life medical students are already avoiding OB/GYN programs. Boards could eventually demand participation in assisted suicide, withdrawal of food and water, sex-change surgery, mandated sterilizations, and so on.
FSMB is a private, wealthy, tax-exempt corporation, funded in part by state medical boards. ABMS and its member boards are also private corporations. Though tax-exempt, they have multi-million dollar revenue streams from their MOC® programs, used to pay lavish executive salaries. They are self-credentialed and not accountable to elected officials or voters. They are subject to no constitutional limitations on their quasi-governmental powers over the practice of medicine.
Physician backlash against MOC® has thwarted the drive to require it for Maintenance of Licensure (MOL). The ABIM has even issued an apology, and backed off, probably temporarily, on some requirements.
The Interstate Medical Licensure Compact, rapidly materializing and being pushed in many states, appears to be a back-door effort to gain a foothold for MOC®, starting with physicians seeking multistate licensure under the Compact. FSMB denials are not persuasive; the preprint of an article to appear in the Journal of American Physicians and Surgeons contrasts the FSMB denials with the actual wording of the Compact.
The ostensible rationale is to “streamline” applications to further “advanced health care delivery systems,” which are thought to be mainly about telehealth. FSMB specifically opposes legislation at the federal level to accomplish this. While AAPS also opposes a federal licensure system, the imposition of a quasi-governmental private system that supersedes federalism is even worse. FSMB assertions that it would not impair state sovereignty are not credible.
Telehealth may be very helpful, as in bringing physician consultation to rural areas, and Arizona already is making provisions for that. Telehealth also has dangers. There are interest groups that could try to use the Compact to circumvent restrictions that states may impose, as on chemical abortion by remote providers who have no personal contact with patients and no ability to manage complications. The huge lobbying effort required for pushing for the Compact simultaneously in many states suggests special-interest involvement, and any state considering the Compact should investigate funding sources for lobbyists.
AAPS urges the enactment of SB 1257 and SCR 1003. Arizona should maintain state control over medical licensure and reject the influence of out-of-state private corporations.
Respectfully submitted, Jane M. Orient, M.D