I read with great interest your latest installment on Board Certification titled
“Board Certification Envy”. Of your three papers on the subject, I think this one
was the most up to date. The first installment, almost 10 years ago, was a satire
and the second one (“To Whom is Board Certification Important?”) missed the
point regarding Maintenance of Certification. You covered the recent move in
health care well with your third installment.
As I indicated in a prior letter I wrote to you following your paper “To Whom is
Board Certification Important?” I want to say thank you for the leadership and
service you have provided our wonderful profession. Your insight and forward
thinking single-handedly brought medical optometry onto the map and continues
to drive many young people into our profession because of it. We all owe you
our appreciation and gratitude and your work should be better understood by all
—especially younger optometrists!
Your paper couldn’t be more clear to the points you are making. Since you state
them over and over and over again I won’t need to rehash them here. But I do
want to cover a couple of topics that confused me in your paper. I am hopeful
you can clarify my confusion.
JOINT COMMISSION (JC)
The JC is the credentialing body for medical professionals. For all doctor level
professions credentialing requires BC except for optometry and dentistry. For
optometry and dentistry, as you point out, the state license is the credentialing
certificate.
That means any time an optometrist wants to get onto a hospital medical staff or
other healthcare organization she most likely gets credentialed via the JC. If the
JC credentials ODs only by state license then what is the point of the American
Board of Medical Optometry? It can’t be for credentialing if the JC only
recognizes state licensure for optometrists. Or will the JC have 2 sets of
standards to use for optometry: one for ABMO and one for all others? Or will JC
change their view of optometrists and decide that only ABMO doctors can be on
hospital staffs? Or will JC decide that optometrists are credentialed by state
license therefore the ABMO is not recognized?
I tried to get answers about the ABMO online but my Google must not be
working. I can’t find any information about the ABMO. Your paper indicates that
it was “recently formed” but since my residency wasn’t in the VAMC maybe I just
haven’t received the information yet.
So I am just left to wonder things like: was the ABMO created to set a new
standard in optometry credentialing and will every optometrist currently with
hospital staff privileges get kicked off without an ABMO certificate? I’ll have to
wait and see.
WHY DID MEDICINE CHANGE?
You indicate in your paper that optometry has been proactive and long had
mandatory MOC by virtue of annual continuing education. You indicated that
because medicine is now requiring MOC for recertification they (medicine) are
“just now catching up” with what optometry has long done—mandatory
continuing education or mandatory MOC tied to relicensure/recertification.
What I don’t understand is why did medicine make it so difficult on themselves?
Why didn’t they “catch up” to us and make it simple by only setting annual CE
criteria? Instead, they complicated the process by requiring self-assessments
and record reviews as well as written tests, communication improvement tasks
and quality improvement items. Didn’t they know that optometry and dentistry
already set the stage for mandatory MOC by only requiring CE? Man did they
miss the boat and complicate their lives!
Take the American Board of Ophthalmology (ABO) as an example. Now
remember, this was an organization that already had a BC program and a MOC
program that was recertifying their doctors on a regular basis. Why did
ophthalmology sign up for a program that increased their CE hour requirements,
closed the book for the written test, require a record review and quality
improvement task and now a communication improvement task. Didn’t they
know they had it easy with their old MOC system? I wonder what the
ophthalmologists were afraid of that made them scrap the idea of just using CE
as a model MOC system. After all, it has worked for dentists and optometrists for
years.
You only have to look as far as the American Board of Ophthalmology website
for the answer that states:
“MOC is a direct response to the rapidly changing environment of
medical practice, increased demand by patients for consistent
quality medical care from their doctors and formation of healthcare
industry and payer-based organizations aimed at measuring
physician competence. These organizations are reacting to a
perceived lack of quality care that may lead to the profession’s loss
of freedom to set its own professional standards while also
burdening already busy physicians by fragmenting the processes of
quality care measurement.”
medical practice, increased demand by patients for consistent
quality medical care from their doctors and formation of healthcare
industry and payer-based organizations aimed at measuring
physician competence. These organizations are reacting to a
perceived lack of quality care that may lead to the profession’s loss
of freedom to set its own professional standards while also
burdening already busy physicians by fragmenting the processes of
quality care measurement.”
1. The ophthalmologists already had a BC program and were already
using a recertification program. But THE OPHTHALMOLGISTS
were afraid to lose the freedom to set their own professional
standards and therefore created a standardized MOC program.
2. Next, when the ophthalmologists created their MOC program they
didn’t copy the optometrists. Instead of only requiring CE, they
require CE, a written test, a record review, communication
improvement and quality improvement.
3. The whole change to MOC was not precipitated by their own
doctors. It was the “rapidly changing” medical environment, patient
demands for quality and the formation of industry and payer-based
organizations aimed at measuring competence. And this was in the
year 2000, before PQRI and Pay for Performance.
4. Last, MOC was created to prevent their profession from becoming
fragmented by the various quality organizations that were creating
their own quality standards. By adopting the standardized MOC
process, ophthalmology set the parameters for quality that others
would use to measure their physicians.
Referring to the change to MOC, the ABO also says:
“In response to the national urgency for improved care, the ABMS
Boards began developing Maintenance of Certification (MOC)
programs in 2000 in a continued effort to demonstrate the
profession’s commitment to quality measurement and performance
assessment”
Boards began developing Maintenance of Certification (MOC)
programs in 2000 in a continued effort to demonstrate the
profession’s commitment to quality measurement and performance
assessment”
keeping in mind they already had a recertification prior to this. That is
interesting they describe it as a national urgency since patients don’t come
into my office telling me about it. Where is the urgency coming from? In
the ABO’s words, it comes from: “the public, payers and government.”
LET’S SEE WHAT PEOPLE ARE SAYING
You state: “optometrists have no need for a BC process nor is there any
evidence any group or agency is considering requiring BC for optometry”. That
reminds me of Dr. Art Epstein’s editorial when he said: “There is not one iota of
credible supporting evidence that consumers, managed care organizations,
federal regulatory agencies, state legislatures, insurers, the government or other
third parties have any interest in optometry adopting board certification. That is
sort of true—but in a not so pleasant way.
The Spring 2008 American Board of Ophthalmology (ABO) newsletter
states:
“In 2007, the ABO joined with primary care boards and the
American Board of Surgery to pursue recognition of participation in
MOC for government incentive programs and will continue to work
toward this goal under the guidance of the American Board of
Medical Specialties.”
American Board of Surgery to pursue recognition of participation in
MOC for government incentive programs and will continue to work
toward this goal under the guidance of the American Board of
Medical Specialties.”
Specialties (ABMS) (which is the mother organization for the 24 medical specialty
boards including ophthalmology) for more clarification:
“Board of Ophthalmology has served as one of the standard bearer
ABMS boards working on behalf of ABMS toward the possibility of
working with CMS…[and] other quality organizations and boards to
streamline quality efforts and potentially have MOC approved as
one of the processes available to satisfy PQRI requirements.”
ABMS boards working on behalf of ABMS toward the possibility of
working with CMS…[and] other quality organizations and boards to
streamline quality efforts and potentially have MOC approved as
one of the processes available to satisfy PQRI requirements.”
tie BC to PQRI. I wonder why they are doing that? Do you think the
ophthalmologists realize we don’t have BC or a more stringent MOC
process?
So yes, you and Art must be correct. Insurance companies are not banging
down our doors asking for BC. Unfortunately, our adversaries know this and are
working to close that door.
But don’t worry, we’ve still got our continuing education leg to stand on. Do you
think that when ophthalmology is at the table with CMS they will flaunt our MOC
process? We are doing 1/5 the MOC that ophthalmology does!
US:
- CE
Them:
- CE
- Written Test
- Record Review
- Quality Improvement
- Communication Skills
Let’s not just look at what ophthalmologists and medical boards are saying, let’s
look at policy makers. You’ve heard of Senator Max Baucus. He is the
Chairman of the Senate Finance Committee. He breaches the topic in his White
Paper titled: “Call to Action: Health Reform 2009”.
Senator Baucus states (as
also previously pointed out by Russ Beach, OD in his paper “The Politics of
Proving Ongoing Optometric Competence”):
“Medical boards in particular are striving to meet the professional
needs of physicians while also fostering gains in quality of care.
Boards such as the American Board of Internal Medicine (ABIM)
are including some quality reporting in their maintenance of
certification process. In order to retain ABIM certification every ten
years, physicians must not only pass a traditional exam testing
their knowledge, judgment, and analytical skills, but they also must
participate in at least one quality reporting program. Going forward,
PQRI should work in conjunction with medical boards to encourage
more frequent and more aggressive recertification processes,
including those that go beyond quality reporting to focus on how
physicians actually perform.”
needs of physicians while also fostering gains in quality of care.
Boards such as the American Board of Internal Medicine (ABIM)
are including some quality reporting in their maintenance of
certification process. In order to retain ABIM certification every ten
years, physicians must not only pass a traditional exam testing
their knowledge, judgment, and analytical skills, but they also must
participate in at least one quality reporting program. Going forward,
PQRI should work in conjunction with medical boards to encourage
more frequent and more aggressive recertification processes,
including those that go beyond quality reporting to focus on how
physicians actually perform.”
of annual CE hours. No mention of state license requirements. Only that
PQRI should work in conjunction with medical boards to encourage more
frequent and more aggressive recertification processes including those
that go beyond quality reporting.
Again, you and Dr. Epstein are correct.
The man in charge of the committee that oversees CMS has not
mentioned board certification and optometry in the same sentence. But
he appears to have an understanding of PQRI and board certification.
CMS has a new White Paper titled “Roadmap for Implementing Value Driven
Healthcare in the Traditional Medicare Fee-for-Service Program.” Hereafter I will
refer to it as the “CMS Roadmap.” Medicare as we know it is undergoing a
change before our very eyes. This paper describes how CMS has begun to
transform itself from a passive payer of services into an active purchaser of
higher quality, affordable care. The plan has a 3 to 5 year time frame for
restructuring the major Medicare fee-for-service payment system. Medicare is
moving away from a direct fee-for-service—everybody gets paid the same—
mentality.
ODs say, “what’s the rush” for JBCPT? I guess JBCPT saw the 3 to 5 year time
horizon for CMS had already started. It has!
Here is a term I had never associated with CMS or any other insurance
company: “active purchaser.” I always viewed insurance companies as the
“payer.” But they are the “purchaser.” They are going to start to purchase
doctors that have the ability to show better quality. We are not all going to be
viewed in the same light. And organizations like CMS are going to flaunt that
information, in the name of transparency, to make the public aware of who
provides quality and who does not.
Take the CMS Roadmap paper which states:
“…in December 2008 CMS enhanced the existing Physician and
Other Healthcare Professionals Directory by making public a limited
amount of information related to the 2007 PQRI program. CMS
expects to continue to enhance this information with more
comprehensive physician performance information as that
information becomes available.”
Other Healthcare Professionals Directory by making public a limited
amount of information related to the 2007 PQRI program. CMS
expects to continue to enhance this information with more
comprehensive physician performance information as that
information becomes available.”
quality care and they will publish to their clients who the quality doctors are. But
what about doctors that do not provide quality? Are their names simply left off
the list or will they be tied to a post in the center of town and flogged?
Again, let’s look to the CMS Roadmap for the answer:
“In another key transparency initiative, in 2008, CMS posted the
names of 52 poor performing nursing homes on medicare.gov as
part of our “Special Focus Facility” initiative. These are nursing
homes that move in and out of compliance with standards by fixing
only the minimum number of safety and quality of care problems
that allow them to temporarily comply with requirements, only to
lapse back into unacceptable quality shortly afterwards.
Posting the poor performing nursing homes on the website was not
an isolated activity, but just one milestone in a year-long, special
effort to move nursing homes forward on quality.”
names of 52 poor performing nursing homes on medicare.gov as
part of our “Special Focus Facility” initiative. These are nursing
homes that move in and out of compliance with standards by fixing
only the minimum number of safety and quality of care problems
that allow them to temporarily comply with requirements, only to
lapse back into unacceptable quality shortly afterwards.
Posting the poor performing nursing homes on the website was not
an isolated activity, but just one milestone in a year-long, special
effort to move nursing homes forward on quality.”
better go check to see if Grandma’s new place is on that list.
Can you imagine? Medicare is going to change its entire way of doing business
over the next 3 to 5 years with 100% focus on value-based healthcare. You can
read that paper to see how PQRI, Pay for Performance and the many
Demonstration Projects are being laid out for use and expansion. One of those
Demonstration Projects is called Medicare Medical Home. By now you have
heard that only board certified physicians can participate.
Today that means nothing (and it means everything). The Medical Home is a 3
year project and as of today does not include coordinated eye care. That means
that patients with diabetic retinopathy, glaucoma, etc will not be part of the
project. Ophthalmology is not involved either. But remember, this is a
“Demonstration Project.” Since 1995 CMS has been doing Demonstration
Projects to “test and measure the effect of potential program changes.” CMS
uses Demonstration Projects to study a process prior to it opening up to the
whole Medicare program. Some of our colleagues are participating in the Low
Vision Rehabilitation Demonstration Project that is examining the impact of
standardized Medicare coverage for low vision rehabilitation services. The mere
fact that CMS has set the criteria for Medical Home to include only BC physicians
has got to be scary. Even worse, it was Congress that set the criteria. Congress
did not limit the Low Vision Demonstration Project to only BC physicians. Why
start now? What does Congress see in doing that?
The prior Pay for Performance demonstration projects have shown unequivocally
that quality improves and cost declines which is the basis for Medical Home
starting. Once the eye care components are brought into Medical Home it will
take an act of Congress (literally) for optometry to get to the table. How likely is
that? This is not excluding optometry from all CMS eye care. We are only being
excluded from Medical Home.
The architect of the term Medical Home is the
American Academy of Pediatrics and they describe it this way:
“A medical home addresses how a primary health care professional
works in partnership with the family/patient to assure that all of the
medical and non-medical needs of the patient are met. A medical
home is defined as primary care that is accessible, continuous,
comprehensive, family centered, coordinated, compassionate, and
culturally effective.”
works in partnership with the family/patient to assure that all of the
medical and non-medical needs of the patient are met. A medical
home is defined as primary care that is accessible, continuous,
comprehensive, family centered, coordinated, compassionate, and
culturally effective.”
Medical Home and they describe it this way:
“…everyone should have a personal medical home that serves as
the focal point through which all individuals -- regardless of age,
sex, race or socioeconomic status -- receive acute, chronic and
preventive medical services. Through ongoing relationship with a
family physician in their medical home, patients can be assured of
care that is not only accessible but also accountable,
comprehensive, integrated, patient-centered, safe, scientifically
valid, and satisfying to both patients and their physicians."
the focal point through which all individuals -- regardless of age,
sex, race or socioeconomic status -- receive acute, chronic and
preventive medical services. Through ongoing relationship with a
family physician in their medical home, patients can be assured of
care that is not only accessible but also accountable,
comprehensive, integrated, patient-centered, safe, scientifically
valid, and satisfying to both patients and their physicians."
medical needs? Works with family and patient? Doesn’t that sound like
optometry should be at the table?
But again, you and Dr. Epstein are correct. CMS didn’t knock down our doors to
become BC so we could participate in Medical Home. CMS didn’t ask optometry
if it was OK to post optometrists names on their website that provide quality care.
Ophthalmology didn’t ask their friends, the optometrists, to make sure they got a
BC program because their working with CMS to make that a criteria for PQRI. In
fact, nobody has picked up the phone to specifically ask optometry to do
anything. They aren’t calling us to get ready! They aren’t calling us to give to
make plans! Nobody is asking optometry to do anything.
You and Dr. Epstein keep pointing out that nobody is asking us to become BC.
Isn’t that scary? Nobody is asking us to become BC!!
DEJA VU?
Your paper calls it “Deja View” when describing the JBCPT model by comparing
it to the American Board of Optometric Practice (ABOP). I think that is a
disservice to the past 18 months. You use the arguments that the JBCPT model
was created so we can “check the board certified box” or that ODs are being
excluded from panels. I have not seen in any JBCPT Powerpoint, White Paper,
presentation, discussion, phone call or email these arguments and I wonder if
you are still stuck on ABOP?
It’s a good thing that ABOP was rejected in 2000 because the gold-standard
Maintenance of Certification was being invented that same year by David
Nahrwold, MD. He is known as the architect of MOC and stated:
“…the public has a right to know their doctors are competent and
…one-time certification isn’t sufficient.”
Two years later each of the 24 Medical Specialty Boards from the ABMS adopted
MOC as their new gold-standard in recertification. Dr. Nahrwold went on to be
the President of your beloved Joint Commission (formally JCAHO) and later the
Chairman of the Board. Do you think he set the stage with JC policy makers to
include his love of MOC for all credentialing health professions?
I DON’T HAVE A SISTER
Your paper states that optometry and dentistry are sister professions based on
training, licensing and credentialing. You say this because our legal
requirements for practice are similar: professional degree and state license.
I think that is a stretch. How about step-sisters? In your paper “To Whom is
Board Certification Important” you said the American Board of General Dentistry
(ABGD) had 700 Fellows out of 135,000 dental graduates. In your most recent
paper that pool some how grew to 370,000 dental graduates. While I am not
sure how the planet inherited 2.5 times as many dentists in only 3 months, I do
recognize that the number 700 is very small compared to either.
Your paper states there is no evidence the JBCPT consulted dentistry as to why
they rejected BC of general practice dentists.
Isn’t it obvious? General practice dentists reject BC because they don’t want to
do a residency which is required for general practice BC. Not even my sister
would want to do a residency in general optometry to become board certified.
You advocate in your “Board Certification Envy” paper that a “creditable” MOC
program would be to establish a uniform national curriculum of CE and a
standardized written examination administered by each state licensing authority.
I don’t know about other states, by Virginia is continually running into budget
shortfalls and does not have the money to administer additional tests. They find
it hard enough to audit the CE of 10% of the licenses, would this make it even
harder for the state?
How is your recommendation of uniform national curriculum of CE different from
the failed ABOP? ABOP was uniform CE with a test (Transcript Quality or
Continuing Education with Examination, whichever you prefer). Proposing
uniform CE is along the lines of ABOP. I’m not sure why we would want to revisit
ABOP and I’m not sure how to get 50 state governments to agree on absorbing
additional costs for ongoing optometric competence testing. They cannot even
agree on uniform CE requirements. That is best demonstrated by Connecticut
and New Hampshire. CT requires 8 hours of CE per year while NH requires 50
per year.
A ‘new paper’ that has circulated online (but not on Snopes.com) appears to be
written by the North Carolina State Board of Examiners in Optometry and
touches on this state disparity further. Previous “policy” statements by the North
Carolina Board have made it on their website including a 2004 policy on the use
of the words “board certified” by their optometrists. Somehow this ‘new paper’
never made it to the website so either it is not an official policy or it is something
else. Parts of the ‘new paper’ can be found in the Executive Director’s report
from their July 31-August 4, 2008 minutes.
The ‘new paper’ reads in part:
“…you don’t have to look far to realize that therapeutic drug
privileges granted optometrists by their respective licensing
statutes vary greatly, and therefore their scopes of practice vary.
Simply stated, an optometrist may be “fully” licensed in one state,
yet may not be either qualified by education, training, or experience
or permitted under his state’s licensing act to perform procedures
or prescribe or administer pharmaceutical to the same extent as
optometrist in other states.”
privileges granted optometrists by their respective licensing
statutes vary greatly, and therefore their scopes of practice vary.
Simply stated, an optometrist may be “fully” licensed in one state,
yet may not be either qualified by education, training, or experience
or permitted under his state’s licensing act to perform procedures
or prescribe or administer pharmaceutical to the same extent as
optometrist in other states.”
“to convey or imply to the general public that “board certification” in
optometry therefore signifies the same level of practice authority
and competency in treating diseases and condition of the human
eye exists in all jurisdictions would be incorrect.”
optometry therefore signifies the same level of practice authority
and competency in treating diseases and condition of the human
eye exists in all jurisdictions would be incorrect.”
certification protocol create a scenario that all optometrist were on the
same playing field? We may not have to demonstrate equal competence
to our states since we all have different therapeutic privileges but we all
should be able to demonstrate equal competence regardless of our
geography.
The North Carolina Board tries to tie levels of practice authority to
competence. That is their mistake. Let’s take Massachusetts as an
example. For years, the ODs in Massachusetts have not been able to
prescribe glaucoma drugs. Were they less competent? I would think not.
They were prisoners of the state legislators. Board certification is a tool of
uniform ongoing competence. It is not trying to usurp the abilities of state
boards. State boards are necessary for their intended goals which include
protecting citizens and licensing optometrists. Our first run at competence
is the National Board of Examiners in Optometry (NBEO). Did the NBEO
(Parts, I, II, III) ever supersede state laws? No. States get to pick and
choose what they want to define optometric competence with. If that is
Part III for initial licensure then so be it. If that is their own test, then so be
it. If a state wants to use the American Board of Optometry as a measure
of ongoing competence, then so be it. If they do not, then so be it.
The ‘new paper’ in North Carolina states that any national organization
created to confer “board certification” upon its doctors is infringing upon
the authority of the North Carolina Board. How is that possible? The
proposed board certification does not change anything that a state is
doing. North Carolina and every other state still get to decide what is the
ultimate gauge of evaluating competence for their doctors. If a doctor
were to become a Diplomate in the American Academy of Optometry and
also reside in North Carolina, would that infringe on the “authority” of the
Board? I would think not.
WHAT IS IN A NAME? THAT WHICH WE CALL A ROSE BY ANY
OTHER NAME WOULD SMELL AS SWEET
Adversaries to the term “board certification” in optometry are quick to point
out that we are not specialists. The second paragraph in your “Board
Certification Envy” paper provides a definition of board certification. It
states:
“The initial process to ensure specialist competence that
requires residency training, passage of a written
examination and meeting other criteria set by each specialty
board.”
requires residency training, passage of a written
examination and meeting other criteria set by each specialty
board.”
according to every commercial medical insurance company, we are
specialists. Just ask a patient that comes to see me with Anthem or Cigna
or United Health Care. Each time they pay their co-pay they pay the
specialist co-pay. That is because I am not their primary care provider.
But let’s not use that as the only indication that I am a specialist.
Let’s look at primary care physicians. They don’t do a refraction. They
don’t do applanation tonometry. They don’t fit a toric contact lens, rigid
gas permeable or bandage contact lens. They don’t perform gonioscopy
or a Park’s Three Step. They don’t measure vergences, accommodative
insufficiency or facility deficits. They don’t prescribe prism or slab off. Nor
does a cardiologist, family practice physician, dentist, or any other
provider except an ophthalmologist. An ophthalmologist does all those
things. An ophthalmologist is a specialist. In fact, we do every thing that a
specialist does except intraocular surgery. The surgery doesn’t make the
only definition of their specialty. So if I can do everything a specialist can
do, then what does that make me? If it looks like a duck and quacks like a
duck…
The ophthalmologist bills 92004 and I bill 92004. The ophthalmologist bills
92020 and I bill 92020. The ophthalmologist bills 92083 and I bill 92083.
Why would Medicare or any other insurance company allow me to bill the
same codes as a specialist if I wasn’t a specialist? More important, why
would a malpractice company allow me to do the same things as a
specialist—one that spent 3 years in residency?
Let’s look at specialties in eye care. There is a retina specialist. There is
a glaucoma specialist. There is a cornea specialist. Each one a
specialist and yet not one is board certified in their specialty. So what
makes them so special?
Ask any optometrist in the country whether or not they specialize in the
eye and its adnexa and they would be ignorant to say no.
And then there is my favorite quote referencing optometry in the 1970’s. It
is:
“I had been trained at NECO to view optometry as
comparable to medicine. This new model…made eminently
good sense to me.”
comparable to medicine. This new model…made eminently
good sense to me.”
So which is it Dr. Myers? Are we comparable to medicine or were you
taught the incorrect paradigm at New England College of Optometry?
How can we be viewed as comparable to medicine if we don’t look
ourselves in the face and call ourselves specialists of the eye and its
adnexa? This makes ‘eminently good sense’ to me too.
You are quick to indicate the JBCPT model is “pseudo board certification”.
The multitude of references indicates that any BC model brought forth by
the JBCPT would not be recognized by other health professionals. That
may be the case and let’s take a closer look. You undoubtedly have
heard of the American Medical Association (AMA). Take a look at their
Scope of Practice (SOP) Data Series. The first of 10 in the Series was
released in December 2007 detailing the practice of podiatry. Other
professions expected to be covered in the SOP Data Series include:
chiropractors, optometrists, nurse anesthetists, advanced practice nurses,
psychologists and midwives as well as a few more. The goal of these
white papers by the AMA is to feed propaganda to state and federal-based
health organizations and legislatures or as the AMA states:
“where the health and safety of patients may be threatened
as a result of unwarranted scope of practice expansions
sought by limited licensure providers.”
as a result of unwarranted scope of practice expansions
sought by limited licensure providers.”
papers. As you point out in your papers, Podiatry has a history of
residency training and board certification which are recognized by all
credentialing bodies. However, the AMA has a different take.
Paraphrasing, the AMA doesn’t give any credit to the board certification
programs offered to podiatrists. Their words are: “lack of assurance” and
“difficult for the public” to understand. So while you hold the podiatry
board certification right up there with the MD’s in your papers—the AMA
puts them down, way down. Your papers indicates that optometry’s
attempt at BC will not be recognized by the medical community. News
flash—they won’t support anybody’s BC—with or without a residency.
They won’t support any BC program of a limited license profession. Why?
You only have to look as far as AMA Resolution 814 (2006) which states
in part:
“the above healthcare professions are in economic
competition with physicians.”
competition with physicians.”
cover up for what Resolution 814 and the SOP are all about—money!
NEED A NEW ORGANIZATION?
Your paper admits that an “additional MOC program may be needed” if the
current system of 50 different CE requirements by the 50 states is not
adequate.
We didn’t wake up this morning to find ourselves incompetent. Our scope
of practice expansion, in spite of medicine’s efforts to squash us, has been
rather successful. Malpractice premiums and legal cases against
optometry are far and few between. Those are excellent indicators that
optometrists are competent. The reality is that cases against
ophthalmologists are not very many either. Yet somehow they felt
compelled to enhance their public transparency and standards of ongoing
competence testing. Again, I wonder why they were so afraid? Were they
showing signs of incompetence? Were they showing signs of increased
malpractice claims? Were they trying to take a proactive approach to the
changes in healthcare paradigms and accountability? I don’t know the
answer.
Another good demonstration of competence is Parts I, II and III of the
NBEO. With some state exceptions, we all pass Parts I, II and III before
we start practice. Passing NBEO I, II and III means that on Day #1 we all
exhibit the same competence. What happens after Day #1 becomes 50
different scenarios. Without uniform competence tests including a
cognitive test, there is no way to demonstrate the ongoing uniform
competence of optometrists across the country. Why is that important?
Besides everything above, let’s look at what research tells us about
physician competence.
A 2002 article in Journal of the American Medical Association admits
whereas physician satisfaction with traditional form of CE (face to face) is
often high, research has repeatedly demonstrated these more “passive”
learning activities are ineffective in helping physicians change their clinical
practice activities.
A 2005 article in the Annals of Internal Medicine reported that on average,
physicians’ knowledge and skill declines over time.
A 2006 article in Journal of the American Medical Association reported
that physicians are not accurate in self-assessment of their knowledge
and skills. Furthermore, it states that their inability to accurately self
assess creates substantial challenges for physicians to determine what
their true learning needs are.
So traditional CE by itself doesn’t change practice patterns. Physician
knowledge and skill declines over time. And physicians are not accurate
in their self-assessment of their knowledge and skills. All interesting. And
all contrary to most ODs evaluation of the need for a uniform MOC testing
protocol for optometry. But that is not surprising since our own inability to
judge our learning needs has been proven and cited in the JAMA.
In your second paper “To Whom is Board Certification Important?” you
advocate that Fellowship in the American Academy of Optometry (AAO) is
one way to recognize general practitioners who are up-to-date in their
skills (demonstrate competence). This thought process is shared by other
optometrists as well. For those that have achieved the F.A.A.O. (I wish
them congratulations on hard earned and deserving recognition) they are
fully aware that there is no uniform system of demonstrating competence
decade after decade once the initial F.A.A.O. is received. Newer Fellows
may soon find a different story since the Board of Trustees for the AAO is
looking at a program called Maintenance of Fellowship. Pretty soon, all
new Fellows may find themselves in a maintenance of competence
program in order to keep the F.A.A.O. behind their name.
Today, achieving F.A.A.O. is a one-time occurrence and therefore as a
measure of ongoing competence it does no more than passing Part III of
the national board. It indicates you were competent at one time in your
life. That in no way is intended to indicate that you all the sudden lost your
competence, but to use it as a standard marker in optometry competence
is difficult to do.
Writing 10 case reports in 1979 (5 case reports in 2009)
does not demonstrate ongoing competence decade after decade. It is a
great feat when it is achieved but it is not a demonstration of ongoing
competence. (P.S., if Maintenance of Fellowship is adopted as a new
policy by the AAO, I hope they get rid of the requirement that you have to
attend their meetings to collect points toward Maintenance of Fellowship).
THE SMOKING GUN
If the rest of this paper wasn’t enough, the long anticipated White Paper
by the Senate Finance Committee describing options for CMS policy
change were released on April 29, 2009. The title of the paper is:
“Transforming the Health Care Delivery System: Proposals to Improve
Patient Care and Reduce Health Care Costs.” The proposals in the paper
“set forth ideas on ways to revise payment systems and policies in the
Medicare program to promote higher-quality and more cost-effective care.”
Direct your attention to pages 5-7 of the report which indicates that the
Senate Finance Committee is proposing that a new level of PQRI
(Physician Quality Reporting Initiative) be added and will reimburse
physicians that use a MOC process. The MOC here is defined as
Maintenance of Certification—not Maintenance of Competence.
The paper goes on to describe two options for MOC. One that uses the
ABMS MOC for those that qualify (MD/DO) and another called MOC
equivalent programs. It describes equivalent MOC programs that include
the following components:
• Valid, unrestricted license
• CE and self-assessments
• Cognitive knowledge demonstration
• Practice performance assessments using best practices
• Audit process
Interesting, the JBCPT proposal contains the components outlined by the
Senate Finance Committee:
Senate Finance JBCPT
•Unrestricted License Active state license and
•Clearance by National Practitioner Data Bank & Health Integrity and Protection Data Bank
•CE & Self Assessments CE & Self-assessment modules
(SAMs)
•Cognitive knowledge demonstration Written cognitive test
•Practice performance assessments using best practice Performance in Practice Modules (PPMs)
•Audit Process Not yet defined
Finally, the paper outlines the fate of the PQRI bonus payments beyond
2010. The options essentially eliminate the bonus payments between
2011 and 2013 and replace them with a 2-5% penalty on all allowable
charges for physicians that do not use PQRI—an expected consequence
of non-participation.
It appears the JBCPT was listening to the Senate Finance Committee
Chairman Senator Baucus all along. They have essentially developed a
program that conforms to the new proposal as outlined by the Senate
Finance Committee on April 29, 2009.
THE FINALE
I am convinced that health care paradigms are changing before our very
eyes. They have changed from 5 years ago. They have changed from 10
years ago. And they have definitely changed from the 1970’s. Optometry
has come a long way over the past several decades to bring each state
therapeutic and surgical privileges. CMS has proven through their Value
Driven Healthcare and move out of a straight Fee-For-Service that this is
not the health care system we grew up with.
The Senate Finance Committee has outlined their plans to have doctors using a MOC process
with PQRI to drive physician quality. CMS has indicated that their time
frame for overhauling the Medicare Fee-For-Service mentality will occur in
a short 3-5 year window and the clock has already started. Now is not the
time to conform to the status quo. The JBCPT has put forth a workable
package. I don’t think it should be the final package. To accomplish a
more acceptable MOC program will take some discussion.
For example, the face to face requirements set forth by the JBCPT are out of whack with
today’s standard of passive education. Even the Accreditation Council for
Continuing Medical Education (ACCME), the crediting body for medicine
continuing education, has changed their Category I criteria. Historically,
Category I education was “face to face” education. Today, with the advent
of the information superhighway, that is not the case. Category I for all
medical physicians can now be face to face or journal/online with a test.
Why the JBCPT would require face to face CE when all other medical
professions are not limiting to face to face is beyond me. The states can
still require face to face (if they want to) but the model used by all the
ABMS boards is no longer face to face. Should we follow ACCME just
because medicine is doing it? NEVER!! But here is one time that it would
benefit us all.
The framework by JBCPT is in place but it has changed several times in
the past 4 months. The goal of every change has been to put more focus
on the MOC portion of this process instead of the initial certification
process. These changes are making the process more accessible and
more obtainable by “rank and file” ODs. Changes have included:
• Changing the make up of the Directors on the American Board of
Optometry so that “rank and file” ODs are more represented
• Reducing the number of CE hours needed for initial certification by
crediting points for years in practice (three points for every year as
an optometrist up to 75 points (25 years in practice))..
• Eliminated the 10-year window for doing an accredited residency or
AAO Fellowship. Therefore, regardless of the date of your F.A.A.O.
or accredited residency, ODs will get the 50 points for these
accomplishments.
States are justifiably concerned that there is a short time frame between
when this information was released and when the vote in the AOA House
of Delegates will be. Five months is not a long time to disseminate
information.
I used to be in that party—until I read the CMS Roadmap
outlining their 3-5 year window and the Senate Finance Committee (April
29, 2009) detailing PQRI and MOC. Twelve months ago I put together a
Powerpoint presentation about BC/MOC and the ABMS with the intent of
informing doctors in Virginia about BC and MOC in other professions and
its applications to PQRI and Medicare. I made predictions about PQRI
and CMS and reimbursements that are now a reality and are detailed in
the April 29, 2009 Senate Finance Committee White Paper. My point in
telling you this is that I never sat in the room with the JBCPT to discuss
these issues—I simply used the internet as my research tool. It doesn’t
take a rocket scientist to figure out where healthcare is going if you open
your eyes and read what CMS, Senators, AQA and other quality groups,
medicine and others are doing.
Ultimately the choice for optometrists comes down to this:
• You either believe that annual CE in your state will be the only
accountability required of you over the next 20 years;
• Or you believe that healthcare systems will require you and every
other profession to prove your value, quality and accountability
more thoroughly than annual CE requirements and the framework
the Senate Finance Committee is using is similar to that of
Medicine and will be expected of all Medicare physicans.
A doctor does not need 12 more months to make that decision.
The debate goes on. We have less than 60 days until the AOA House of
Delegates takes on the issue. I look forward to your cordial debate.
Finally, just as optometry students learn about famous optometrists like
Drs. Irving Borish, Jimmy Bartlett or William Feinbloom they should learn
to appreciate the foundation of medical optometry in the Veteran’s
Administration, Public Law 94-851 and Dr. Ken Myers.
Your work is commended and appreciated!
With Kindest Regards,
Jeff Michaels, OD, FAAO
About the Author:
Jeff Michaels, OD, FAAO practices in a group OD setting in Richmond, Virginia. He went to the Michigan College of Optometry and completed a low vision residency at Johns Hopkins Wilmer Eye Institute. Part of his optometric internships in Michigan were in the Veteran's Hospital system where some of the time was spent with Dr. Ken Myers in Grand Rounds. Dr. Michaels is the President-Elect of the Virginia Optometric Association.
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