Letter from Clarke Newman, O.D., FAAO - June 12, 2009

[The following is a response to an editorial by Jerome Legerton]

Dear Jerry:

I read your commentary in the June 2009 PCON, and I agree entirely with what you say—we need to find the “WOE’s” lest the process divide the profession. So, let me say this—our lack of Board Certification is hurting us right now. Let me give you an example. In the Medicare Medical Home Demonstration Project, as promulgated in the Section 204 of the Tax Relief and Health Care Act of 2006, nine states were selected to demonstrate the value of the medical home concept in delivering Medicare services. This project is being implemented right now for a January 2010 launch.

While ophthalmology was excluded from being a medical home, optometry was not. However, another requirement was that only Board Certified physicians could participate. As you know, we are defined under the Social Security Act as “physicians.”

We lost an opportunity to be included on the ground floor of what will likely become the model of how Medicare services are delivered. As Chair of the AOA Medical Home Project Team, I have looked at these models ad nauseum, and there is no doubt in my mind that, if we cannot be a part of these medical homes, then we will be cut out by the natural referral patterns that pediatrics, intern medicine, family practice, and geriatric medicine have with ophthalmology. That exclusion is hurting us now, and it is the tip of the iceberg.

As a member of the State Governmental Relations Center, we have been tracking hundreds of bills that reference “certification,” “maintenance of certification,” and “value-driven health care initiatives.” So many bills contain these references that we simply cannot keep track of everything that is happening with them. That is going on now. Some of these bills will pass in the next year or two—it is just inevitable. There is a growing momentum for these changes, and the downturn in the economy has been a further catalyst.

I think the Iraq War is a poor analogy for this issue. What happened in Iraq is that poor decisions were made based on poor intelligence because we had no hard reconnaissance presence on the ground in Iraq. That is not happening in this case. We have boots on the ground and eyes directly on the reconnaissance of this issue. We have solid intelligence on the development of changes towards the demonstration of competence through certification and the maintenance thereof at the state level, the federal level, and within the private payer community.

Every major third party payer, from Blue Cross on down, is looking at adding these requirements right now, and they are all waiting to see what happens in Washington this year.

The lack of board certification is hurting us now in our scope efforts. Medicine is using this argument because it is resonating with legislators who are already primed by all of the legislative activity in this arena. This year, the lack of board certification was used effectively as an argument against the legislation that was being pursued by South Carolina. Trustee David Cockrell was asked during his testimony if optometrists could pass the board certification part covering the area into which South Carolina wanted to expand. Of course, he answered, “Yes.” If you want to watch what was being said by ophthalmology regarding our lack of board certification and what optometry’s response was, you can watch it for yourself on the SCOA’s website.

Jerry, if you are looking for a proper analogy, then think of this issue as a storm and you are looking at the meteorological data. It doesn’t have to be raining yet to have credible evidence that you’d better prepared for rain. This situation is sort of like seeing a storm, but not owning foul weather gear. You have to look at the radar and the clouds in the sky and make a good faith guess that a storm is headed your way, and you have to do it far enough in advance that you have time to go buy foul weather gear before the storm hits.

Our competition, ophthalmology, recognized this storm several years ago, and beefed up their foul weather gear by overhauling their certification requirements. They did so without any whining from within their ranks. They knew this change was coming, and now they are positioned in such a way that they have a significant competitive advantage over us. You do not need your MBA to see that. If MOC becomes a legislated part of health care reform this year, they will be in and we will be out or relegated to a tier two payment schedule from the government. That would be a step backwards.

The upcoming vote on this issue will be as important to our future as the decision in the 1960’s to remain a drugless profession when we had the opportunity to seize the day. We have been fighting scope bills ever since because we made the wrong choice. The untold treasure and human effort wasted on these scope battles because we made the wrong decision has altered our profession in ways that can hardly be contemplated. However, I dare say that none of those alterations have been for the better when compared to where we would be today had the profession made a better choice.

Earlier this year, Senators Max Baucus (D-MT), Chairman of the Senate Finance Committee and Chuck Grassley (R-IA), ranking Republican member had the following to say about health care reform:

“A new PQRI participation option would be added to the existing options described above. Eligible professionals could also receive PQRI incentive payments for two successive years if, on a biennial (every two year) basis, the physician (1) participates in a qualified American Board of Medical Specialties certification, known as the Maintenance of Certification or MOC, or equivalent programs, and (2) completes a qualified MOC practice assessment.”

Just as with other PQRI initiatives, they will be voluntary at first, and then permanent. These are the words of the top two members of the committee that will decide this issue. These two men are driving the “Call to Action 2009” that you will see if you go the Senate Finance Committee’s website.

That we are forced to look far into the future does increase the chance that our view of the storm is incorrect. Weather data is always more accurate closer to the day in question. It will take four years to get this program up and running. I do not want to wait until it starts raining to get my foul weather gear. Yes, I will look silly in foul weather gear on a sunny day, but I’ll look pretty smart if the weatherman is right.

In closing, I will say this. Jerry, I applaud your effort to keep this issue focused on the issue and for entertaining the possibility that we may really need board certification. I have tried to do the same. This discussion has degenerated into vitriol that clouds the issue completely. The last thing we need with a storm on the way is fog to block our view of it.

I hope that some of what I have said will help you decide one way or the other.

Sincerely,
Clarke D. Newman, OD, FAAO