Featured Post

Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Thursday, January 15, 2015

Is Maintenance of Certification (MOC) part of ACA and who put it there?

The short answer is :

Yes, MOC  has been implanted into the legislative structure of ACA and for many (most?) practicing physicians this is really breaking news and for those of us who oppose the ABIM's MOC program, may mean  bad news.

 Dr. Wes explicates how the Maintenance of Certification has been made part of Obamacare in his recent blog entry in which he questions the viability of an alternative "Board" to challenge and hopefully replace the ABIM's widely criticized MOC program.Does the letter of the law with its establishment of MOC in some aspects of Medicare preclude the replacement of ABIM's MOC with some less onerous process by a rival organization?  

"The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.  Section (k) is the section that defines how a "Quality Reporting System" is to be set up (with subsection (4) requiring the "Use of Registry-based Reporting") and Section (m) defining physician incentive payments physicians might receive if quality reporting occurs properly. (Sadly, those CMS incentive payments do not cover the cost of participating in MOC for most of us.)

Section (k) was modified by the ACA to include the ABMS MOC program as a "physician registry."  The registry was "defined" as requiring all four parts of the MOC program created by the ABMS, including the much-maligned "practice improvement modules" that have been described by the physician community as overly time-consuming, irrelevant ...."

After re-reading of the relevant sections, it is not clear to me exactly what penalty a physician would incur by forgoing MOC. I welcome any input regarding that.

ABMS's MOC program is part of the law and what ever alternative organization set up to do some version of less onerous MOC is not part of the law and IMO the political clout of the rank and file real physicians is likely not up to the task of changing the law.

Dr. Wes, see here, raises interesting questions about possible collusion between principals in certain organizations  and CMS, those certain organizations being some of the ones which would  benefit financially  from the statutory establishment of MOC in ACA.

 Medical certification boards would obviously profit from the MOC process being quasi mandatory  or tied in in real ways to a physician's compensation.  Dr. Wes focuses on two physicians with ties to ABIM and ABIMF and CMS and the National Quality Forum which incidentally receives significant funding from CMS.

[An interesting aside is that a member of NQF's Board is Liz Fowler, currently a VP at Johnson and Johnson and someone who  played a major role in the drafting of ACA. See my earlier commentary entitled  "Who Wrote Obamacare and where is she now?") Ms. Fowler has been described , accurately in my opinion, as the poster girl for the revolving door in regard to government and major health care players.It seems that some of the prominent medical elite know how to open the doors as well.}

Quoting Dr. Wes:

"Troubling concerns of collusion of ABIM board members with the Center for Medicare and Medicaid Services (CMS) and the National Quality Forum (which receives the bulk of its revenues from grants supplied by CMS) exist. Christine Cassel, MD, who is the current President and CEO of the National Quality Forum, was President and CEO of the ABIM from 2003 to 2013 and ultimately responsible for the $2.3 million dollar luxury condominium purchase by the ABIM Foundation in December, 2007....."

Dr. Wes then chronicles the job history of the current ABIM CEO, Dr. Richard Baron who was associated with ABIM and then left to be a full time employee of CMS from 2011 -2013 and came home to his current ABIM's six figure salary.

Again quoting Dr. Wes:

"Which leads to the question: how much influence did the ABIM leadership have in establishing a continuous money stream for itself and its Foundation during the writing and mark-up of the Affordable Care Act? (see pages 247 and 844-845 of this large pdf). Clearly, there should be public record available to this effect and physicians should inspect this record before creating an alternate MOC pathway"

The fact that the term "professionalism" is found in ACA may be significant.. ABIMF has been promoting their particular version of professionalism for several years such promotion being the major stated goal of that organization. Unlike traditional medical  ethics the ABIMF professionalism embeds the obligation of social justice and an obligation for physicians  to act not only for the individual patient but for some collective,which operationally could be a given ACO or HMO. Has or will ACA make the ABIMF's sea change professionalism "the law of the land"?

Statutory language does not appear by a random process.Public choice theory tells us to look at who might profit from a given law or regulation and often you will find who was responsible for it.  Cui bono.


DrWes said...

"After re-reading of the relevant sections, it is not clear to me exactly what penalty a physician would incur by forgoing MOC. I welcome any input regarding that."

In 2014, failure to participate in MOC disqualifies the physician for the 0.5% Medicare payment incentive. While this amount typically than what it costs a physician to participate in MOC, it neatly skirts federal kick-back laws that prohibits entities from receiving funds directly from the governemnt for self-referral to their program. Instead, the payment is made to physicians in hopes they will pay this amount back to the ABMS/ABIM for continued mandnatory participation in the MOC program.

Clever, huh?

james gaulte said...

Dr Wes,

Thanks for your input.


Anonymous said...

Even if it did require a legal challenge why not.

I think we have to be careful of blaming the ACA. All that happened is that smooth operators have manipulated it to their advantage.