On Jan. 11, the Medicare Payment Advisory Commission voted to recommend scrapping the Merit-Based Incentive Payment System because it “cannot succeed.” One can only hope that this is a sign that the US health policy community is finally ready to face the fact that there is no problem in American health care that government has not made worse. ObamaCare rules have been more about wishful thinking, power, and cronyism than patient welfare or any realistic commitment to policies known to improve health care cost and quality.
For a small example of how ObamaCare cronyism increases costs, one needs to go no farther than the Affordable Care Act’s change to Section 1848 of the Social Security Laws. It defined a “Maintenance of Certification Program” (MOC) as “a continuous assessment program, such as qualified American Board of Medical Specialties (ABMS) Maintenance of Certification program or an equivalent program (as determined by the secretary).”
Physicians who participated in the ABMS MOC program became eligible for an additional Medicare incentive payment equal to 0.05 percent of their total estimated Medicare Part B Physician Fee Schedule reimbursements. The Medicare incentive payment morphed into the Merit-Based Incentive Program. It still bases payments on participation in ABMS MOC programs.
When ObamaCare passed, ABMS had a virtual monopoly. The Affordable Care Act used the standard tactic of creating market power by listing specific requirements that only the ABMS program could meet. Among other things, “equivalent programs” would have to report patient data to a registry, require periodic exams, and conducting periodic “practice assessments.”
The ABMS acts as an umbrella organization for a foundation and 24 specialty boards. Those specialty boards have historically given examinations to licensed physicians who have completed residency training in an accredited specialty program. Physicians passing those exams received a lifetime designation as “Board Certified” diplomates of one of the specialty boards. In 1990, the ABMS began requiring reexamination every 10 years. Its successful push to have its process inserted into the ObamaCare statute turned one time Board credentialing into a continuous process of tests, reporting, and “practice improvement modules.” Doctors paid test fees that created a revenue stream worth an estimated $1 billion in 2014.
Though Medicare does not require ABMS Maintenance of Certification, hospitals and health systems interested in collecting the Medicare money may require specialty physicians to participate in the ABMS MOC program as a condition of employment, reimbursement, and hospital staff privileges. This has become so burdensome for qualified physicians that states are considering legislation to protect physicians from losing their job if they fail to do ABMS bidding.
Existing evidence suggests that the program provides minimal benefit and that the entire ObamaCare physician quality metric enterprise rests on decidedly shaky evidential ground. Physicians who have taken MOC exams report questions based on outdated material and questions unrelated to their medical practice. They waste time studying to memorize the “right” answer rather than the medically correct one for each patient they treat.
A 2014 study published in the Journal of the American Medical Association (JAMA) compared ambulatory care-sensitive hospitalizations and average per-patient cost growth for patients treated by physicians who took Board exams one time and those subject to continuous MOC certification. They found no difference in ambulatory sensitive hospitalizations. A study of VA patients found no difference in standard quality of care measures.
In internal medicine, conservative estimates of ten year costs for ABMS MOC suggest that they can run as high as $52,196 per physician for subspecialties requiring multiple tests. Without making an obvious difference in physician quality, Obamacare MOC requirements raise costs, divert physician time from treating patients, and make running nonprofit quality metric and testing programs more lucrative than treating patients.
In 2011, when the average specialist in pediatrics made around $150,000 a year, the top board member of the American Board of Pediatrics received over $900,000 in compensation. When board-certified internists made just under $200,000 a year, compensation for Dr. Christine Cassel, the head of the non-profit American Board of Internal Medicine, was almost $790,000.
In addition to runaway salaries, conflicts of interest remain a significant problem for the non-profit entities that run the federal quality metrics show. In 2013, Dr. Cassel became president and CEO of the National Quality Forum, a nominally non-profit group that produces measures used in federal “public reporting and pay-for-performance programs.“ At the same time, she received $235,000 as a board member for Premier, a North Carolina company with $249 million in revenues from selling supply chain services, data, quality metrics, and efficiency improvement strategies. From 2010 to 2012 she received over $500,000 for serving on the Board of the Kaiser Foundation Health Plans and Hospitals. Kaiser operates Medicare Advantage plans. It benefits if Medicare adopts its quality measures.
After a 2014 article in Pro Publica pointed out the obvious conflicts of interest, Dr. Cassel left the Kaiser and Premier Boards. She was appointed planning dean of Kaiser’s new medical school in 2015.
In practice, the dedicated professionalism of American physicians has always been the most important ingredient in quality medical care. States, practice groups, professional organizations, and hospitals have ensured that physicians keep up with medical progress with continuing education requirements, peer review, and peer training. Unlike the ABMS MOC program, continuing education is a competitive market. Its providers are accountable for their product quality because physicians generally will not enroll in courses that waste their time.
If Congress is interested in lowering health care costs for everyone, following the Medicare Payment Advisory Commission’s recommendation to scrap the Merit-Based Incentive Payment System and its payments for ABMS Maintenance of Certification is a good place to start.