In 1998, when I finished my residency in Dermatology, a necessary rite of passage was to acquire board certification. It meant that you were a fully trained and most decorated and venerated specialist in a medical field. It was a huge achievement. The test was administered nationally one weekend in the Chicago-O'Hare suburb of Schaumburg. We all had to fly there and stay for a long weekend to complete the 2 day exam. It was a high stakes and high pressure situation, like high school SAT's on steroids but this time, you're paying $2000 out of pocket just to take the test, and the trip isn't fun at all. Flying from California there was the jet lag, anxiety, and potential delays. Time off from work had already happened in spades with special intense weekend courses to buff up on the questions and answers. Slides were projected on a screen for what it seemed like hours, and you had to diagnose the disease and fill in the little round circle with your No. 2 pencil. Each person had a microscope and you were given pathology slides and in a timed fashion, view the slide, provide the diagnosis. It was a sizable investment and one had to ensure that the test would be passed. I passed, heaved a sigh of relief, and moved on with my life.
There were murmurings at the time that board certification was a time-limited certificate that would expire in 10 years, and to renew it one would have to take this test again. We were told that it would be an open book, at home exam, much less time intensive and much less expensive. The particulars had only been recently fleshed out, as the ABMS had issued a decree that all persons certified after 1990 would have time-delimited certification. By an accident of birth, my friends and I were sucked into the turbine of Maintenance of Certification©.
Well now here is the grand conclusion from this erratically administered certification process. Maintenance of Certification, the product sold by the American Board of Medical Specialties (ABMS) and for me in particular, American Board of Dermatology (ABD) is directly tied to the new MACRA Medicare pay schedule. So these private entities lobbied to have participation (and thereby purchase) of their product as a requirement for the acceptance of full Medicare payment. If you don't buy into this product line, you will be assessed a regulatory penalty. By the federal government.
My quick economic analysis suggests that money out, money in-- it will cancel each other out, and so the one thing you are losing is TIME. You will be spending hours completing hundreds of hours of advanced courses and quality improvement practice modules, performing patient safety courses, administering patient or peer surveys (now optional but who knows what will happen in the future), paying $150 annually in a non-negotiable fee which is a "pay to play" fee just to keep your board certificate registered. This can't be minimized. The time you could spend with your family, or planting a garden, or learning a new surgical skill, or learning a new language, forget it--you must spend this time in chains. I see this as a deliberate ploy to keep physicians so busy and so tied up in knots that they don't see the little man behind the curtain pulling the levers.
I naively completed some requirements in 2008-2013 because the draconian requirements at the time stipulated that these had to be completed once in each 5 year period. But like most regulations, they changed the rules mid-stream, and so whatever had been completed by 2014 would now be applied to the 10 year recertification cycle, and additional continuing medical education programs would now be added (which are conveniently sold to us by the American Academy of Dermatology). It was at this point that I started asking questions, mostly of myself. Do I really need this? Do I want to do this? Is this what my life will be forever, taking tests, preparing for them, running around doing all of this extra work, only to have it cease for a year and then start up again?
I said no more.
I reached the boiling point when the ABD stated we had to administer surveys to something like 90 patients (or 15 peers) in order to maintain board certification. So strangers would hold the bag of control over my certificate, my livelihood. To add to this, at the time there were 2 options to conduct these surveys. You couldn't do it yourself. You had a cost-free option administered by the ABD itself, a lengthy and cumbersome process by which you had to personally contact the people you trusted to take a survey on your character, then ask for their email address and phone number, then pray that they get it (check your spam folder!) then pray that they complete it in a nice fashion, then you're done. The other option was to purchase the survey services of DrScore.com, a company founded by a fellow dermatologist Dr. Steven Feldman. Hmmm, how did he get this contract and the siphoning of dermatologists flocking to his site, where $795 would get you the full service package? This was never answered in my letter to the ABD. I am a diplomate of this organization and no response was deemed necessary. Shut up and pay your fee and keep your head down.
The answer came last year, where suddenly links to Dr. Feldman's website and services were taken off the ABD requirement list, and the ABD themselves pulled back and called the surveys entirely optional. Hmmmmmm again.
The trust has been irretrievably broken. I decided to immediately end my relationship with this monopoly. I figured I'd just wing it. If insurance companies would require me to purchase a product to continue on their networks, I'd resign. I'd notify my patients as to why. As it is, I've been a good girl and was kicked off the United Health Care Medicare Advantage network for unknown reasons, but later they admitted it because I wasn't a cost effective doctor. Never mind that I'm in southwest Florida where skin cancer is an epidemic, and the right thing to do is biopsy and/or excise the lesions. "No, that makes us pay out too much". HELLO SKIN CANCER? ARE YOU GOING TO TAKE THE MEDICAL LIABILITY OF LETTING IT GO? I thought not. I wouldn't sign on to their EHR system nor their preauthorization system. In short, I wouldn't sign on to be their vassal. And I'm board certified and have jumped through every hoop, but it doesn't matter, "we can't control you and we're removing you from our network, and we can do this because it's stipulated on p. 15 line 35 of your contract". OK, good bye and good riddance!
There was no other alternative at the time, but since then Dr. Paul Tierstein, a cardiologist at Scripps Clinic San Diego, was angry enough to found an alternative board certifying body, the National Board of Physicians and Surgeons. Finally a sane alternative. Register for a flat fee, provide proof of previous board certification, continuing education credits, and state licensure in good standing, and you're set. This is how it should be. This is what I'm deciding on. I have the blessing of my staff, manager, patients...that's all I need.
