The 2018 AMA House of Delegates kicks off this weekend. Despite being 100% open to the public, and free for any physician to attend regardless of their AMA membership status, very few regular physicians attend or know what goes on behind closed doors in Chicago. Most doctors have no idea who their state AMA delegates are, how they are elected, what resolutions their AMA delegates are presenting on behalf of their state, or how those state resolutions even got to the point of being voted on at the AMA.
The AMA House of Delegates is a baffling mix of state delegations, regional alliances, specialty societies, incredibly large and vocal swaths of students, special micro-delegations based on identity, age, or interest. Among the voting delegates, and milling about testifying and lobbying those delegates, are powerful entities within the hospitals, insurers, and of course…the ABMS and all their specialty boards. It’s a veritable who’s who of the healthcare ruling elite. Even still, the actual voting comes down to the delegates, not the elite. The elite can testify, they can try to sway committees, but the delegates can ignore all that and vote on behalf of their hurting colleagues back home.
Lately, the delegates have become quite unruly when it comes to MOC, taking the AMA to task for failing to protect physicians from certification harm. In 2016 they defied the committee, and voted to end the high stakes MOC exam. (Which quite honestly didn’t do anything, ABMS just rolled out “CertLink”. Now doctors are forced to do timed exams monthly, instead of once every 10 years).
Emboldened, at the 2016 interim meeting, the delegates wrote AMA MOC policy to clarify that the MOC program “should not be a mandated requirement for licensure, credentialing, recredentialing, privileging, reimbursement, network participation, or employment, or insurance panel participation”. They passed resolution 310, directing the AMA to increase efforts with insurance companies to ensure MOC not become required for network participation (too late, and harm continues to this day).
In 2016, they also voted to require the AMA to write model state legislation to prevent MOC from being tied to license, hospital privileges, and insurance participation and make that language available to state medical societies and any interested party. The AMA grudgingly complied, but certainly hasn’t made an effort to help states get legislation passed and have asked anyone who posts the model language publicly to remove it (oops, I did it again).
In 2017, they voted for ABMS board websites to make initial board certification data public, regardless if the physician opts out of MOC. (So far, the boards are ignoring this. They continue to erase names of physicians who stop paying MOC fees).
So what’s going to happen in 2018? For me, I’m watching three new MOC resolutions and the outcome of two 2017 resolutions that were “referred to committee for futher study” and will be voted on again this year. Here are the new resolutions:
1.) Resolution 316 “End Part 4 Improvement in Medical Practice” Requirement for ABMS MOC” introduced by the Michigan delegation asks:
“That our American Medical Association call for an end to the mandatory American Board of Medical Specialties “Part 4 Improvement in Medical Practice” maintenance of certification requirement”.
It’s worth reading the whole resolution and argument for why forced Part 4 needs to end. At its core, Part 4 is the most insidious and dangerous part of MOC. At best, it’s an annoyance. At worst, it’s research on physicians without consent, it’s research on patients without consent, it’s blatant misuse of research data to sell an educational product, and outright cronyism. Physicians are caught in a trap where they are forced to do proprietary Part 4 in order to work, the projects are designed so physicians HAVE to show improvement, and then that data is misused by ABMS boards to “prove” the value of MOC to hospitals and insurers…who turn around and force doctors to participate.
Anyone with a shred of scientific conscience reading the MOC research knows there is no proof that QI done for MOC credit is better than QI done independently, yet science goes out the window when ABMS uses the data for their own purposes. We’re better than that. Our professionalism demands integrity in our research and proper use of that data. The AMA has given “direction” that Resolution 316 be rejected, let’s hope the delegates can find the strength to approve it.
2.) Resolution 314 “Board Certification Changes Impact Access to Addiction Medicine Specialists” introduced by the Michigan delegation asks:
That our American Medical Association work with the American Board of Addiction Medicine (ABAM) and American Board of Medical Specialties (ABMS) to accept ABAM board certification as equivalent to any other ABMS recognized Member Board specialty as a requirement to enroll in the transitional maintenance of certification program and to qualify for ABMS Addiction Medicine board certification examination.
For those who haven’t followed the ABMS takeover of addiction medicine certification, it’s horrifying and couldn’t come at a worse time. Basically, ABMS is taking over addiction medicine certification from the independent American Board of Addiction Medicine, and making it a subspecialty of ABMS Preventive Medicine (complete with all the limited access to fellowships and additional fees that come with such a takeover). Addiction doctors certified through ABAM are having to transition to the ABMS system, and if a doctor has let her primary ABMS certification lapse as a diplomate of ABAM, they are hosed, there is no pathway. For addiction doctors who let their primary certification lapse, regaining ABMS certification requires incredible costs, stress, testing, time away from patient care, and in some cases… returning to residency.
Hospitals and insurance companies used to grant an exemption for ABAM diplomates, because an ABMS addiction medicine option was not available. Now that ABMS has taken over addiction medicine, doctors have to quit addiction medicine or transition to the ABMS system if they want to care for patients. With the opioid crisis upon us, and the critical need for addiction trained physicians, this access issue is a public health disaster manufactured 100% by ABMS. We should be doing everything we can to make training of and access to addiction physicians easier, not adding costs, unnecessary tests, and fellowships.
The AMA has given “direction” that this resolution be rejected, because the AMA already has policy that hospital privileges and insurance credentialing should not be tied to board certification. Ha. Super helpful there AMA. When will you fight for us on this?
3.) Resolution 207 “Quality Improvement Requirements”, introduced by the American Academy of Pediatrics asks:
“That our American Medical Association develop a quality improvement initiative so that if physicians complete quality improvement requirements of their specialty boards, that payers, hospitals, and licensing agencies will accept the specialty board certification evidence that physicians are practicing good medicine and will not require physicians to meet separate quality improvement requirements of payers, hospitals, and licensing agencies.”
I think this is a horrible resolution. I understand the problem, everyone wants a piece of us, but the solution is not to coordinate efforts between the gangs trying to get their pound of flesh. How about fight back against these third parties who have no business in the exam room? By asking that Part 4 MOC be accepted these third parties, this resolution violates current AMA policy on MOC that MOC have nothing to do with licensure, hospital privileges, and insurance credentialing.
Particularly insidious here is the AAP’s claim that maintaining board certification is “evidence that physicians are practicing good medicine”, when there is no evidence this is true. While I understand the problem, the solution offered by the AAP is not a solution at all, and given that the AAP makes money selling Part 4 MOC credit…the cronyism underlying this resolution cannot be ignored.
I hope the committee rejects this resolution as it violates current AMA policy, and that the delegates vote no as well.
Now on to the 2017 resolutions that were “referred to committee” for further study (ie: stall for a year) in hopes that they would just go away. Resolution 316 and Resolution 318 from 2017 are completely different MOC resolutions, but for purposes of making them go away in a puff of obfuscation, the committee report dealt with them together. If you want to read the 33 page report, which amounts to a glorified advertisement on how much the AMA cares, and how much ABMS is listening, go right ahead. Here is it. I recommend bourbon.
1.) Resolution 316 “Action Steps Regarding Maintenance of Certification”, introduced by Florida, Pennsylvania, Georgia, California, New York, Arizona, Texas, American College of Radiation Oncology, American Society of Interventional Pain Physicians had 5 resolved clauses:
That our American Medical Association affirm that lifelong learning is a fundamental obligation of our profession, and
That our AMA recognize that lifelong learning for a medical physician is best achieved by ongoing participation in a program of high quality continuing medical education(CME) course appropriate to that physician’s medical practice as determined by the relevant specialty society, and
That our AMA develop model state legislation that would bar hospitals, health care insurers, and the state medical licensing board from using non-participation in the ABMS sponsored MOC process using lifelong, interval, high stakes testing as an exclusionary criteria for credentialing, and
That our AMA join with state medical associations and specialty societies in directly lobbying state medical licensing boards, hospital associations, and health care insurers to adopt policy supporting the use of satisfactory demonstration of lifelong learning with high quality CME as specified by a physician’s specialty society for credentialing and bar these entities from using the ABMS sponsored MOC process using lifelong interval high stakes testing for credentialing, and
That our AMA partner with state medical associations and specialty societies to undertake a study with the goal of establishing a program that will certify physicians as satisfying the requirements for continuation of the specialty certification by successful demonstration of lifelong learning utilizing high quality CME appropriate for that physician’s medical practice as determined by their specialty society with a target start date of 2020 or before, with report back biannually to the HOD and AMA members.
Because the AMA is lame, the committee only approved the first 3 clauses and referred the last 2 “for study”, effectively shutting down debate. This was a pathetic move, as the first 3 statements do nothing. The model legislation was already written, per the vote from the 2016 interim meeting. The AMA was clearly irritated they were forced to write the model legislation to begin with, and CERTAINLY didn’t want to actually lobby to get the legislation passed.
As expected, the committee reviewed the last two statements as documented in that horrid 33 page report and has advised the 2018 delegates to reject the last two statements of this resolution…mostly because the last two statements actually matter and require the AMA to act. The last thing the AMA wants to do is actually act on MOC. I hope the delegates from Florida, Pennsylvania, Georgia, California, New York, Arizona, & Texas fight back and get their full resolution passed this year.
2.) Resolution 318 “Oppose Direct to Consumer Advertising of the ABMS MOC Product”, introduced by Michigan was written in opposition to the ABMS websites that target patients and parents with misleading information about what certification means. The American Board of Pediatrics website “MyCertifiedPediatrician.org” is designed to target parents with heart-tugging videos to check if their pediatrician is board certified, using mislead statements on quality, the ABMS website “CertificationMatters.Org” does the same. The resolution had two clauses:
That our American Medical Association oppose direct-to-consumer marketing of the American Board of Medical Specialties Maintenance of Certification (MOC) product in the form of print media, social media, apps, and websites that specifically target patients and their families including but not limited to the promotion of false or misleading claims linking MOC participation with improved patient health outcomes and experiences where limited evidence exists
That our AMA amend existing AMA Policy D-275.954, “Maintenance of Certification and Osteopathic Continuous Certification” by addition as follows: “Direct the ABMS to ensure that any publicly accessible information pertaining to maintenance of certification (MOC) available on ABMS and ABMS Member Boards’ websites or via promotional materials includes only statistically validated, evidence based, data linking MOC to patient health outcomes.”
In truly bizarre fashion, in their year long “research” the AMA completely ignored ABMS and physician testimony on this resolution and somehow decided the resolution didn’t have anything to do with ABMS and their deceptive direct-to-consumer advertising campaign….but somehow applies to physicians advertising themselves at board certified. They recommend disapproval of the resolution because AMA already has policy on how physicians and healthcare providers can advertise themselves?!? Their rationale can be found on page 16 of the 33 page bourbon-inducing AMA MOC report:
Although the AMA opposes direct-to-consumer marketing of drugs and devices, Resolution 318- 36 A-17 focuses on a different aspect of marketing. Health professionals, both physicians and non physicians alike, are generally allowed to advertise to the public their training, education, experience, and expertise. Twenty states have enacted legislation prohibiting deceptive or misleading advertising, communication, or other deceptive or misleading conduct concerning health professionals’ skills, education, training, professional competence, or licensure. Some physicians may advertise that they are board certified or board eligible. The AMA opposes any action, regardless of intent, that appears likely to confuse the public about the unique credentials of ABMS- or AOA-BOS-board certified physicians in any medical specialty, or takes advantage of the prestige of any medical specialty for purposes contrary to the public good and safety.
Truly the weirdest thing ever. I’m not sure if this degree of misreading a resolution is pure incompetence or intentional gaslighting. We’ll see if the delegates can actually read Resolution 318 from 2017 and see through the bizarre rationale for disapproval given by the board. Bizarre.
But that’s the AMA HOD for you. I’ll be there on Sunday to hear testimony, maybe I’ll tweet a bit. Maybe I’ll get a selfie with the new ABMS president. I hope to meet some of you there.
Photo by Miradortigre 
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