ORIENT: The medical ‘quality’ cartel

Board recertification is more about dollars than health

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Someday soon, you may find that the doctor you know and trust has been kicked off the hospital staff or off your insurance’s list of approved physicians for no other reason than that he has not been recertified by an approved specialty board.

Recertification is supposed to ensure “quality.” The burgeoning industry of certifiers and recertifiers is promoting its product with Congress, licensure boards, hospitals and insurers.

The quality cartel commissioned a Gallup poll, which purports to show that patients think it is very important for their doctor to be board-certified.

Respondents, however, were likely thinking about training and licensure — not about a lifelong, costly, time-devouring process of jumping through specialty-board hoops every few years. Lawyers don’t have to keep retaking the bar exam. Why should doctors have to keep doing the equivalent?

Patients rarely ask doctors about board certification, and do not volunteer this when asked how they choose a physician. They probably prefer to have their doctor available when they call instead of one periodically cramming for difficult board-exam questions that have little relevance to their practice.

Until recently, board certification was granted for life, after several years of additional specialty training and passing rigorous examinations. It is now generally time-limited, though older physicians are “grandfathered.”

Recertification is supposedly “voluntary.” The specialty boards, though, in collusion with hospitals and insurers, are making every effort to see that physicians who do not recertify will have great difficulty earning a living. They even would like to tie use of their lucrative product to renewal of a medical license.

Specialty boards admit on their own websites that failure to achieve certification or recertification does not mean that a person is not a competent physician. Some of the best physicians were never certified — and are often chosen by their colleagues as physicians for themselves or their family.

It makes sense that one does not become a better physician by reporting patient data to board bureaucrats, taking expensive courses focused on possible exam questions rather than problems one’s patients might have, or traveling to remote locations for a “secure” examination.

What does this process accomplish? It brings in millions of dollars in revenue to specialty boards and their highly paid CEOs, many of whom have declined to be recertified themselves. It may also increase profits for companies that sell items related to the “correct” answers on the exams.

Recently, CareFusion paid a $40 million fine to the U.S. Department of Justice to settle a charge that it paid a $12 million kickback to Dr. Charles Denham, who allegedly manipulated National Quality Forum standards to increase sales of an antiseptic that CareFusion makes.

The “Patient Safety” movement, which includes prominent members of specialty boards, is trying to distance itself from Dr. Denham. But outside sources of income for National Quality Forum’s new CEO, Dr. Christine Cassel, are now under scrutiny.

There are a lot of high-level connections between various boards and “nonprofits” that claim to be the authorities on “quality,” including revolving doors for the executive positions of medical-specialty societies and specialty boards.

Just who certifies these authorities? Why, they certify themselves — and each other. A more pertinent question might be: Who funds them?

The National Quality Forum is funded largely by contributions from Medicare and Medicaid and from the Robert Wood Johnson Foundation. Here we have a public-private partnership also involving big business and “private,” “nonprofit” organizations.

Business funds the “quality” movement, which gets products, devices and recertifications endorsed and mandated by the U.S. government, all in the name of improving “quality.”

The National Quality Forum provides an annual report to Congress and the secretary of health of human services. There is thus no need to lobby — the forum has ready access to legislators and the executive branch.

When you hear the word “quality,” think of dollar signs.

If you want a physician who has not memorized the quality cartel’s answers, or is not constrained to follow its rationing guidelines (as in the “Choosing Wisely” campaign of the American Board of Internal Medicine), you might wisely choose a non-recertified physician.

Dr. Jane M. Orient is executive director of the Association of American Physicians and Surgeons, which has filed an antitrust lawsuit against the American Board of Medical Specialties.

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