The Florida Medical Association is on their heels. They have been called out by the Florida AAPS for betraying Florida doctors on legislation to control MOC in the state. They are now working overtime to divert attention from their betrayal with a series of attacks on the Florida AAPS for telling the truth! The Truth is that their MOC Control replacement language makes matters worse for MOC in the state, addresses non-existent “problems” and enabled the Florida Hospital Association to support more MOC madness for Florida doctors!
A simple reading of their preferred MOC language shows that it does nothing – absolutely zilch – to stop mandated MOC in the state. In addition, the FMA complaints should be viewed as a cowardly political move by a once great medical organization that now trades on political influence peddling in Tallahassee, rather than effective advocacy for Florida’s doctors. It has never been more clear why Florida doctors should drop their FMA memberships and look for another organization that is unafraid to stand for them – the Florida Chapter of the AAPS.
Read more below about the key facts about the FMA language that gutted the MOC control bill. An MOC control bill that was successfully placed by Florida AAPS into the legislative process. Read how the Florida Hospital Association took advantage of the FMA’s massive legislative blunder and failure. (You can use the handy links above to navigate around the page).
See the line-by-line analysis of the FMA amendment that gutted and deleted the original, high quality, MOC control bill (below). The FMA wrote it and supported its passage. The Florida AAPS opposed it.
Key Facts about the FMA’s MOC replacement amendment, and the further FHA-supported amendment it allowed.
· FMA MOC language stops a problem that doesn’t exist: Board “required” MOC. No board requires MOC – it is all voluntary.
· FMA’s MOC language would only apply to THREE of 25 boards (ABIM, ABP and ABNM) – not the other 23 who are not 501(c)3’!
· FMA MOC language would NOT prohibit MOC required by hospitals, insurance companies and for state licensure. The original Florida AAPS supported bill did – the FMA gutted it.
· FMA language could allow targeting of the alternative Board certifying entity (NBPAS- National Board of Physicians and Surgeons) to exclude them from getting a certificate by the state.
· FMA ignores the fact that having a certificate is meaningless if it is not tied to prohibition of MOC by third parties.
· FMA ignored and did not oppose Florida Hospital Association supported language placed right on the on the FMA’s MOC “certificate” platform that requires each entity to have a Quality improvement program component for MOC. This will exclude the NBPAS and encourages more government-supported power to ABMS and their allied organizations!
· The FMA ignored and did not oppose FHA-supported language that states ONLY doctors undergoing MOC (as approved by state) can advertise themselves as “Board certified”!
|MOC TRUTH ALERT
The FMA claims that their proposed MOC replacement amendment will prohibit Boards from requiring Maintenance of Certification (if they want a certificate from the state department of health).
Is the FMA unaware that MOC is COMPLETELY VOLUNTARY and no Board certification organization can REQUIRE any doctor to do MOC?
The FMA offers a strawman solution to a real problem that completely avoids the true burden on doctors: Mandated MOC by hospitals, insurance companies and potentially for state licensure!
No one is complaining about Voluntary MOC by Boards- Only MANDATORY MOC by third parties (hospitals, insurance companies and state licensing boards)!
Key Political facts on MOC control legislation.
· Florida AAPS opposed all of these changes that gutted the original MOC control bill that would have banned mandatory MOC for physicians by hospitals, insurance companies and for licensure.
· Florida AAPS knows that if the FMA had used its “clout” to insist on a Senate hearing and vote on the original MOC control bill, it would have gotten through the first committee. The FMA most likely didn’t want to put some Senators in the position of opposing the insurance companies and the hospitals.
· Florida doctors deserve an organization that will use its clout to insist on support for their legislative agenda when it is a “top priority” as FMA claimed MOC control was.
· The FMA did not ask any legislator to propose an MOC control bill earlier this year. The Florida AAPS did ask for a sponsor and secured both a House and Senate Sponsor. The FMA came to the game late. This is poor advocacy by the FMA that claimed that MOC control legislation was a “top priority” for its members.
· The FMA complains that the Florida AAPs is working to raise funds to fight MOC in Florida – an odd complaint from an organization with millions in annual revenue and PAC fundraising!
· The FMA falsely claims an “individual doctor” is pointing out the FMA failures, when in fact the AAPS has many Florida members and supporters. Florida AAPS also has a board of ten physician leaders who have been working hard to pass the original MOC control bill – on a volunteer basis that does not reimburse them for their expenses! (AAPS-Florida President Dr. David McKalip has engaged in six volunteer lobby days in Tallahassee on MOC and Direct Primary Care, has lost practice time and paid his own travel expenses. Other Board members have done the same).
· Dozens of Florida AAPS members have emailed and called legislators to support the original MOC bill.
· The National AAPS organization sponsored a critical poll of 667 doctors on the damage done by MOC, resulting in hundreds of comments submitted to the legislature about the dangers of MOC.
· Hardly a “fringe” organization, the Florida AAPS is working tirelessly and effective for MOC control legislation, securing an 11-4 victory on the bill in the First House committee stop. The FMA short-circuited the Senate Health Policy Committee from supporting the original bill at all by caving to political pressure rather than insisting on a vote on the original bill as a “top priority” of the FMA.
“Politically Possible” Query for FMA
The FMA says:
· The FMA says that getting the Original MOC legislative language passed in one Senate Committee of Seven members is NOT “Politically possible”.
· The FMA complains that our Florida AAPS Chapter “has no clout in the legislative process.”
· The FMA says: “Without this amendment, SB 1354 would not have gotten a hearing, and MOC legislation would have been dead for the session”
Queries for FMA on Moc and its “political clout”:
· Why isn’t the FMA up to this task? Aren’t they the best medical advocacy group in Florida history?
· If this is a “top priority”, what does that say about FMA effectiveness and willingness to go to battle for their members?
· Why can’t the mighty FMA get even four votes? In one Committee? In the first committee stop in the Senate?
· Why does the FMA have millions in its budget and spend millions in PAC dollars if it can’t secure even a simple committee vote on a “top priority” issue for its members?
· This is supposed to be child’s play for a group with such “clout” that is not “politically naïve”.
How are the FMA’s Actions a betrayal of Florida Doctors on MOC?
· The FMA proposed an amendment that gutted the original MOC control bill.
· The FMA supported DELETING a bill that identically mirrored its own policy calling for legislation to ensure that “health care providers shall not be required, by any public or private entity to comply with maintenance of certification requirements after achieving initial board certification”.
· The FMA did not insist that just four senators vote in favor of the original bill and did not insist that the bill be heard in just the FIRST Senate Committee stop – without first caving on a “compromise” amendment to delete the original bill.
· The FMA was rolled by the hospitals and insurance companies and did not put up a fight against them. Instead, the FMA wrote legislation that further empowers the ABMS, other Boards, hospitals and insurance companies.
In a 4/6/17 FMA “MOC alert”, the describe MOC control as a “top priority” and claim their supported amendment (that gutted the good MOC bill) “focuses more directly on the root of the MOC problem”. They then erroneously claim “the ABMS will be prohibited from requiring its maintenance of certification”. They then falsely claim that the language “in no way empowers government to further push MOC on physicians.” They go on to offer excuses about how it was not “politically possible” to pass an outright ban on hospital, state license and insurance company mandates for MOC. They state they “would have loved being able to require” such a ban but don’t explain how the strongest physician political advocacy group with a “top priority” of MOC control is unable to push a simple bill through its first committee! They only needed four votes!
They then go on to attack the AAPS as a “fringe group” engaging in “inflammatory” and “hyperbolic rhetoric” solely for the purposes of making money! In an internal email to its leadership, they personally attack the FL AAPS President Dr. McKalip of engaging “to misinformation, fabrication, and outright lies in order to raise funds for the AAPS”. Of course, they don’t specify what “lies” or “fabrication” to which they refer.
The good news is that Florida’s doctors are smart enough to decide for themselves which organization is correctly representing reality in Tallahassee on MOC. Here are the facts for doctors to evaluate on their own.
Point by point analysis of the “Substitute all” amendment authored by the FMA and given to the Senate Health Policy Committee for their use.
This is what the FMA says will “prohibit onerous maintenance of certification requirements (MOC) on Florida physicians (SB 1354)”.
Not so much.
|FMA authored MOC amendment –
(gutted entire MOC bill)
|456.0291 Recognizing agency certificate.— (1) The department shall issue a certificate authorizing a recognizing agency to grant physicians licensed under chapters 458 and 459 formal recognition as specialists in a particular area within the practice of medicine, if the recognizing agency submits a complete registration application containing the recognizing agency’s legal name, mailing address, telephone number, and business location; the particular area within the practice of medicine in which the agency will recognize a physician as a specialist; the requirements the agency will impose for a physician to be eligible to receive formal recognition as a specialist; and the amount of any fee charged to a physician to apply for, receive, and maintain formal recognition as a specialist from the agency.
|FMA “…in no way empowers government to further push MOC on physicians.”||This places the power to determining what is a legitimate and “certified” Board certifying organization (“recognizing agency”) directly under the purview of the Florida State Government through its Department of Health.
The Department could then be lobbied heavily by the Boards and ABMS. The DOH’s Board of Medicine could have doctors who are also members of Board certifying organizations.
This is a clear empowerment of government and it will allow the state to “further push MOC on doctors” if they set the standards to the ABMS liking.
Rather than advocate for a simple ban on MOC mandates by third parties, the FMA advocates a big government approach through bureaucracy!
|(2) The department shall approve an application for a recognizing agency certificate within 60 business days after receipt of the completed application if the recognizing agency meets all of the following requirements:
(a) It is an independent body that certifies members as having advanced qualifications in a particular allopathic or osteopathic medical specialty through peer-reviewed demonstrations of competence in the specialty being recognized.
|FMA: “ABMS and any other recognizing agency in Florida will have to obtain a certificate from the Department of Health to be able to bestow board certification on Florida physicians.”||This is no burden for the ABMS or any other board who make millions each year on MOC.
This does not limit the Ability of the ABMS and others boards to push MOC on doctors.
|(b) It requires successful completion of a comprehensive examination administered by the recognizing agency pursuant to written procedures that ensure adequate security and appropriate grading standards.
|No problems for any board – administering required tests is what the Boards do.
No change to MOC Problems for Florida Doctors.
|(c) It has been determined by the Internal Revenue Service of the United States to be a legitimate nonprofit entity pursuant to s. 501(c)(3) of the Internal Revenue Code.||FMA claims this Moc bill will “prohibit onerous maintenance of certification requirements (MOC) on Florida physicians (SB 1354)”.||MOST boards are NOT 501 c3’s, they are 501c6’s and will NOT BE EFFECTED BY THE MOC LEGISLATION!
Of 25 Board certifying entities, only 3 are 501(c)(3)’s! (*list below).
The FMA can’t even write language that applies to 88% of boards!
| (d) It has full-time administrative staff housed in dedicated office space that is appropriate for the agency’s program and sufficient for responding to consumer or regulatory inquiries.
|Does this exclude the National Board of Physicians and Surgeons (NBPAS), an alternative board certifying group that does not require MOC?
Will the DOH Deem NBPAS as having an “appropriate” amount of space that is “sufficient” for responding to “consumer or regulatory inquiries”.
There is great room for DOH abuse of NBPAS here – under the influence of ABMS and their allies.
|(e) It has written by-laws, a code of ethics to guide the practice of its members, and an internal review and control process, including budgetary practices, to ensure effective use of resources.
|This is meaningless as most organizations meet these requirements.
Possible that DOH could target NBPAS by saying there is not “effective use of resources”?
| (f) It does not mandate that physicians who receive initial certification from the recognizing agency undergo a maintenance of certification process that involves a periodic testing regimen, proprietary self-assessment, or peer evaluation in order to retain certification, other than the continuing medical education hours required for recertification under paragraph(h).
|The FMA says: “In order to get the certificate, ABMS will be prohibited from requiring its maintenance of certification process for board recertification. The Department may only grant a certificate to a recognizing agency that does not require a periodic testing regimen, proprietary self-assessment, or peer review.||No Board currently “mandates” that physicians undergo MOC!
ALL MOC Participation IS VOLUNTARY! Doctors can choose to do it.
The MANDATE is on the hospital and insurance company side to participate in MOC!
This is a Meaningless requirement that is EASILY OBTAINED by all Board certifying entities – it is all voluntary!
|(g) It does not charge more than $500 every 2 years for recertification.
|A nice touch, but it is possible this price will be amended up this cycle or over the years.
In addition, several entities can lower their annual fees to this level – and raise their testing and other fees.
Board entities can state that the fees are not for “recertification” but for testing.
The fee limit doesn’t apply to onerous extra CME’s required for MOC and the costs of travel and time away from the practice.
|(h) It requires only a specified number of continuing medical education hours for recertification.
(REPLACED BY FHA-Supported Amendment:)
(h) It requires, at a minimum, a specified number of continuing medical education hours in the physician’s area of specialty for recertification.)
|An easy goal for boards to achieve for the doctors that “volunteer” to do MOC.
Boards can still require an onerous amount of CME, as long as it is “specified” (e.g. 200 CME hours every 3 years would be fine if it is “specified” in writing).
The FHA-supported version now says the CME’s must be “specialty specific!
That means even less opportunity to use general CME’s to do MOC.
AGain, the FMA did NOT oppose this ammendment at the Senate Health Policy Committee meeting. The Florida AAPS did!
|(3) The Board of Medicine and the Board of Osteopathic Medicine may adopt rules to implement this section. These rules may impose additional requirements on applicants for a recognizing agency certificate.||FMA claims their amendment “…in no way empowers government to further push MOC on physicians.”||The Board may impose additional requirements.
Those could be the exact same requirements that each Board now uses – e.g. Practice improvement modules, completion of online evaluations, and submission of practice data.
Perhaps the ABMS will lobby to have Florida DOH impose requirements on the NBPAS to get a certificate.
|PASSED “BONUS” AMENDMENT Supported by
the Florida Hospital Association.
The FMA did not oppose this in committee –
Florida AAPS did oppose it.
| i) It has a practice improvement program to encourage continued improvement within medical practice. The program must focus on recent scientific developments, improved patient safety, improved patient or population health outcomes, improved access to health care, improved patient experience, and increased value to the health care system. The program must require physician participation in practice improvement programs within the context of the health care team and system of practice.
|FMA said nothing against or about this amendment at the Committee Hearing.
FMA still claims that the Senate Passed amendments that gutted the original MOC Control bill: ““…in no way empowers government to further push MOC on physicians.”
|This imposes MACRA style “best practices”, cost controls, population health and patient satisfaction surveys directly into MOC.
This absolutely empowers the government to further push MOC on physicians.
The Government will REQUIRE these onerous MOC requirements to get a seal of approval from the state!
The FMA did not even oppose this language!
The FMA now BRAGS that the Senate version of their gutted MOC bill will “prohibit onerous maintenance of certification requirements (MOC) on Florida physicians”.
The facts speak otherwise!
|(4) A physician who holds a current board certification from a recognizing agency approved by the board pursuant to department rules may advertise himself or herself as a board certified specialist.
|This means that NO DOCTORS IN FLorida can advertise themselves as Board certified unless they are doing MOC!
This is a DISATROUS consequence of the major FMA blunder that provided the platform for this central planning of MOC by government.
Go to the MOC Action Center and contact the Banking and Insurance Committee to “REPAIR SB 1354” – this will undo the FMA damage to MOC control.
Florida Doctors are losing the MOC fight in Tallahassee and it is in no small part due to a betrayal of Florida doctors by the Florida Medical Association. Yesterday in the Senate Health Policy Committee the FMA wrote, proposed and supported language that completely deleted the entire MOC bill and replaced it with law to make MOC a government function in the state of Florida. That is right, rather than insisting that the MOC bill pass as is, the FMA decided to support deleting it. The FMA will argue that without their language, the bill would have died in the Senate as it never would have been given a committee hearing and a vote. This begs the question: is the FMA – the largest, most storied Medical advocacy organization in Florida history – incapable to moving a bill that parrots their own policy and responds to one of the deepest concerns of Florida doctors? Why can’t the FMA simply tell the Senators who they helped elect that the MOC control bill was a top priority and they would go to battle to protect doctors from the insurance companies and hospitals that demand the bill fail? The answer is that the FMA has been soft on critical issues for doctors for the last several years and has a recent history of betraying its own policy so it can remain relevant to the power brokers in Tallahassee. The FMA is willing to sacrifice the clearly stated needs and interests of Florida doctors for its own benefit.
What happened? The MOC control bill (SB 1354/HB723) is moving well in the House thanks to sponsor Rep. Julio Gonzalez, M.D. (R-Venice). They bill overcame opposition from the insurance and hospital lobbies at its first House committee stop with an 11-4 vote. However the Senators have been getting worked hard by insurance companies, hospitals and the ABMS against MOC. The Bill would prohibit hospitals and insurance companies from requiring doctors from participating in MOC to practice as part of medical staff and insurance panels. The bill would also prohibit MOC as a requirement to achieve state licensure. The FMA claims they were advised that opposition to the bill meant that there would be no hearing without some “compromise” language.
However, the FMA did not come up with compromise language. Rather, it proposed and supported and amendment that removed ALL of the MOC control language in the bill. The FMA amendment substituted the entire bill with language that empowered the Florida department of health (DOH) to determine what MOC means. The original FMA language grants the DOH with the ability to determine what requirements for MOC would be. This of course would allow all Board certifying entities and allies to get the DOH to put their seal of approval on their MOC program. On cue, another amendment was presented, supported by the Florida Hospital Association (*see dangerous amendment language below), that would then state that a DOH-approved MOC entity must have “Quality Improvement Program” addressing patient safety, population health and “value” (meaning cost). This would not have been possible without the original FMA amendment. The FMA, in their attempt to satisfy some politicians, gutted a good bill and provided the sword by which the Boards could then get the state of Florida to further disable doctors through MOC. By the way, their amendment and failure to fight for MOC control violates their own policy that states the FMA will support Legislation to ensure that “health care providers shall not be required, by any public or private entity to comply with maintenance of certification requirements after achieving initial board certification”.
Way to go FMA.
Florida doctors are going to need to call the FMA and get them to fix the massive damage they caused. Florida doctors should contact their officers and legislative staff and tell them “Support the original bill language”. There is an opportunity to get the original bill language reinstated in the Senate Banking and Insurance Committee when they meet (if they take it up).
If the FMA can’t fix the damage they caused, they Florida Doctors need to reconsider whether they are worthy of the $450 dues. There has been one group standing up for Florida doctors without compromise: The Florida AAPS (A state chapter of the Association of American Physicians and Surgeon). National dues of $350 grants automatic membership to the Florida chapter, however contributions are needed for our lobbying fund. The FMA also betrayed doctors by supporting MACRA (2015) (while profiting from building an ACO). The FMA supported the ban on so-called “Surprise Medical Billing” (2016) which meant that non-contracted doctors now must take what the insurance company pays for hospital care. The FMA supported legislation that expanded the ability of insurance companies to deny payment for reasonable care patients need (SB 784, 2015). Each of these FMA advocacy efforts directly violated FMA policy. The FMA is now completing its transformation into the AMA and doctors should look to the Florida AAPS for a better advocate for their interests.
” * 9 (i) It has a practice improvement program to encourage
10 continued improvement within medical practice. The program must
11 focus on recent scientific developments, improved patient
12 safety, improved patient or population health outcomes, improved
13 access to health care, improved patient experience, and
14 increased value to the health care system. The program must
15 require physician participation in practice improvement programs
16 within the context of the health care team and system of
By David McKalip, M.D.
As President of the Florida Chapter of the AAPS, I submitted comments today to the Centers for Medicare and Medicaid Services on their proposed “MIPS” rules. MIPS (Merit-based Incentive Payment System) is an onerous command and control structure for doctors using financial and administrative penalties to coerce medical practice away from the interests of individual patients and toward the interests of government and corporate third parties. The law that allows the Obama administration to create MIPS was called MACRA (HR2) and passed last year with the full and enthusiastic support of the AMA and 49 of 50 state medical societies (only New York refused to support it).
These rules will harm patients and their doctors, placing a wedge between them that will break the most critical bond of the patient-physician relationship: trust. Patients will now wonder, “Is my doctor withholding medical care simply to obtain a government bonus?” Patients will ask, “Is my doctor giving me the best care for my individual needs in his judgment or simply following a government cookbook to serve another master?” Doctors will ultimately wonder, “Why did I try to get the bonus, instead of simply taking care of my patient?”
Excerpts of the comments are reproduced below and the full letter, with detailed references to exact rule and law language is available for download here.
“Comments by Florida Chapter, Association of American Physicians and Surgeons and David McKalip, M.D., June 24, 2017 on MIPS Rules pursuant to MACRA”
“We (AAPS-FL and David McKalip, M.D.) write to point out that the proposed rules are an invalid exercise of delegated parliamentary authority. They are written in an arbitrary and capricious fashion and violate applicable administrative and other law. They are over-broad and will cause harm to physicians and their patients. These rules would cause patients harm by 1) causing physicians to alter practice patterns to satisfy the rules to achieve a bonus, avoid a penalty or avoid other harm to their practices and 2) interfering with the ability to practice medicine independently and in the best interest of their patients. The rules will cause substantial and unacceptable unfunded expenses and burdens on physician practices and deprive physicians of their time with patients since they must instead be coerced to spend time on onerous compliance activities.”
“(1) Mandatory Participation is unlawful.
There is a glaring and obvious violation of the law. The rule states that all MIPS eligible clinicians “MUST” (emphasis added) submit data and more.
“§ 414.1325 Data submission requirements. (a) Data submission performance categories. MIPS eligible clinicians and groups must submit measures, objectives, and activities for the quality, CPIA, and advancing care information performance categories.”
The law authorizing these rules (HR2, 114th Congress, “MACRA”) specifically denies the ability of any agency of the government to require submission of any data under MIPS. Title I, Section 101 indicates that participation in the MIPS program is completely voluntary. Page 41 of HR2 (as published by the GPO) indicates that Title I, Section 101, (c)(1)) amends Section 1848 of the Social 7 Security Act (42 U.S.C. 1395w–4) and adds the following language:…”
“The rules do not Improve physician payments and make payment to physicians harder to obtain for their services to patients. The rules impair the ability of physicians not only of maintaining a cost-effective practice, but of practicing medicine at all in the manner in which they see fit, especially in a private or small practice. This violates Section 1801 of the Health Insurance for the Aged Act that says “Nothing in this [subchapter] shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine, or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services….” (Title 42, Section 1395, USC).
In addition, the rule harms access to care by Medicare patients by creating compliance protocols that are primarily based on cost of care and administrative factors. These rules specifically refer to a budget neutrality goal. The rule refers to withholding “incentives” from doctors who do not obtain arbitrarily defined budget and spending goals that can only amount to a rationing of medical care. Furthermore, physicians are coerced to comply with so called “quality measures” and are penalized for not obtaining arbitrary compliance thresholds set by the government and these rules. Such compliance fails to recognize the unique needs of individual patients, including those covered by Medicare. This amounts to a “one-size-fits-all (or most)” program that denies the specific medical care required by individual patients at different times in their lives based on the training, experience and judgment of the patient’s physicians. In addition, compliance with such measures has been specifically shown, in valid scientific studies, to directly injure or cause death to some patients and interfere in access to care for higher risk and other patients. Such programs do not increase access to Medicare, but decrease it, and these rules thus fail to comply with the law as proscribed by Congress.
We suggest modifying these rules substantially to address these and many other concerns. The MIPS program should not be implemented by the administration as currently envisioned by the proposed rules.
David McKalip, M.D.
Independent Neurological Surgeon
President, Florida Chapter of the Association of American Physicians and Surgeons”