In the past, obtaining board certification in a medical specialty was straightforward. One completed a residency, studied, took and passed a test, and was deemed “board certified”. Later, certificates required a re-test after ten years. Now, the process of Maintenance of Certification (MOC) has taken hold of essentially all medical specialties.
MOC involves meeting certain requirements every few years, culminating in a re-examination at the end of each ten-year cycle.
Keeping up with MOC involves paying fees and completing various tasks purported to keep the physician up-to-date with the latest developments in their field. The specific tasks vary by specialty. How this improves existing continuous medical education (CME) programs is not known. It is known that the MOC process involves substantial time and money. Meeting the requirements often diverts doctors from clinical practice. There is minimal evidence that increasing certification requirements improves patient outcomes, affects malpractice statistics, or otherwise impacts any healthcare metric, other than money spent in the MOC effort.
Maintaining competence and knowledge in medicine is important, but MOC does not represent progress in medical education. Organization against the MOC requirements has begun forming, notably with the website changeboardrecert.com. Rather than advocating for an elimination of the program, the organization seeks removal of the more onerous MOC criteria, while preserving some of the continuing education elements.
From the site:
“We are all for staying current with medical changes, but the onerous MOC program is no way to achieve this. It’s a money-making juggernaut with scant data to support any benefit for improving patient care and safety or for making one a better physician. And it lacks reasonable financial transparency.”
It is fascinating that the MOC requirements for physicians are increasing, at a time when health reform stands poised to turn much of the American primary care system over to non-physicians.
It remains to be seen if opposition efforts will alter MOC programs, but the resistance highlights the pitfalls that occur when sweeping programs are implemented without evidence that they have any benefit.
Arthur Caplan, a leading bioethicist at the University of Pennsylvania, published a Medscape video editorial on August 4th discussing the ethics of concierge medicine. Titled “Concierge Practice: Unjust for Patients and Doctors Alike”, this three minute, thirty-eight second editorial presented Professor Caplan’s view that concierge medical practice is unjust.
I think the first two minutes of the presentation were fine. Dr. Caplan outlined the reasons why approximately 6,000 U.S. primary care physicians adopted a concierge model. For more background on concierge medicine, see a prior post here. The remainder of the piece presented two arguments against concierge medicine, underlined below and followed with my own respectful disagreement.
Argument 1: When doctors enter concierge medicine, they remove themselves from the general pool of primary care providers, leaving more work for the doctors left behind.
I don’t agree, for several reasons. Doctors have an individual responsibility to their patients, but they do not have (as yet) a system-wide obligation to suffer because of the current business model of private-practice medicine. Most of those problems are not due to doctors or even insurance companies. They result from the gradual intrusion of top-down government control over healthcare, beginning in 1965. This control has now progressed to the point where instead of addressing market failures, government behavior has caused them. Leaving more work for other physicians is not a valid argument against concierge medicine.
That line is more appropriately applied to resident physicians who slack off during training, leaving more work for their trainee-colleagues. (This is a cardinal offense in the world of residency). If doctors are operating private businesses on government-mandated pricing systems, they have little choice but to make other adjustments to keep their businesses viable, since they cannot raise prices. If a business cannot raise prices when needed, its options to keep itself viable are limited. One can assume that if market forces were allowed to operate, the value of primary-care office visits would float based upon service, clinical skill, reputation, and management skill (controlling overhead). I don’t know what a typical primary care office visit should cost, but neither do government price-setters.
Argument 2: Patients may end up with less quality care, since they will be seeing more physician extenders.
I disagree with this as well. In many primary care practices, physician extenders have been required to maintain viability even in non-concierge practices. Furthermore, non-concierge hospital primary care groups with employed physicians already make liberal use of physician extenders. The “trend to extend” has been driven by many other forces, the least of which is the growth of concierge medicine, itself just now becoming a blip on the national radar. In some rural areas, unsupervised physician extender primary care practices are already a reality. Discussing the proper role of physician extenders and whether or not there is a quality difference is itself a large and distinct topic. Extenders are here to stay, and patients will have less control over whether they see an extender or a physician, especially as health reform plays out.
Concierge medicine may not be perfect, but it represents market forces attempting to assert themselves, now that the centrally-planned model (administered prices) has been strained to its natural breaking point. We don’t have these sorts of arguments on the price differentiation common in all other service-industries, such as consulting, law, accounting, etc. Yet in medicine, we seem to feel that price differentiation is somehow inappropriate. Prof. Caplan does acknowledge longstanding concierge-like models of care, such as executive physicals and specialty clinics.
Virtually all industries have participants targeting low, middle and high market segments. Medicine is not that different, and promoting wide access to good-quality care for all who require it can be done without more top-down control of the system. If anything, it is that control which has exacerbated the healthcare system’s problems.