FSMB: Defining Moments in Medical Regulation and Licensure

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FSMB: Defining Moments in Medical Regulation and Licensure Session Code: MN16 Date: Monday, September 19, 2016 Time: 2:45pm - 4:15pm Total CE Credits: 1.5 Presenter(s): David Johnson, MA and Jama Ball

Defining Moments in Medical Regulation and Licensure

David Johnson FSMB Senior Vice-President

Jama Ball FSMB Senior Director

Federation of State Medical Boards

501(c)6 non-profit established in 1912

185+ staff in Texas and Washington DC

Our membership: 70 state medical boards

Learning objectives for today:

Provide brief overview of… • Origins of medical regulation • Medical licensing examinations • Federation Credentials Verification Service (FCVS) • Interstate medical licensing compact • Collateral consequences of medical board discipline

1 Participating with Poll Everywhere

Text 22333 voting FSMB

FSMB

22333

FSMB

Pollev.com/FSMB

2 US medical regulation: A system of complementary players and roles

• Education Credentialing Public • Licensing

• Accreditation & certification Private • Assessment Credentialing

• Education • Licensing Credentialing Profession • Assessment • Accreditation & certification

Independent yet complementary functions

3 Road to Becoming a Physician

MT ND ME NH MN OR NY VT MA ID SD WI RI MI CT WY PA NJ IA NE OH DEMD IN IL NV UT WV CO VA CA KS MO KY NC TN OK AZ SC NM AR Separate allopathic (M.D.) GA AL MS and osteopathic (D.O.) boards TX LA FL AK

4 Medical examining boards established

Washington 1870 1880 1890 North Dakota 1900 New York New Jersey Kentucky West Virginia Nebraska North Carolina Texas Arizona Utah Kansas (1859) California Mississippi Connecticut Oklahoma Alabama New Mexico South Dakota Pennsylvania Illinois Missouri Georgia Alaska Minnesota Louisiana Virginia Massachusetts Rhode Island Iowa Delaware Maryland Maine Oregon Ohio District of Columbia Tennessee State Medical StateMedical Boards Wisconsin South Carolina Indiana Montana New Hampshire Vermont Michigan Idaho Nevada Wyoming Time Dent v. West Virginia, 1889 Hawker v. New York, 1898

Simple registration laws preceded the creation of most medical boards

Origins of U.S. medical regulation

10 th Amendment to the Constitution

1791

State Federal

5 Origins of U.S. medical regulation

1791 1859 1876

1st state medical Broad set of powers board - Set minimum qualifications - Issuing a medical license - License revocation

Origins of U.S. medical regulation

1791 1859 1876 1889

US Supreme Court Dent v. West Virginia

6 More defining moments

Special board certification

Interstate medical licensing compact

1912-15 1933 1947 1957 1962 2015

US Supreme Court: FTC v. North Carolina Board of Dental Examiners

Accreditation

MEDICAL LICENSING EXAMINATIONS

7 U.S. Medical Licensing Exams

Available to US/Canadian graduates only

NBME Parts I, II, III NBOME Parts I, II, III

Available to all examinees

State Board exams

International graduates

1910 1950 1960 1970 1980 1990 2000

U.S. Medical Licensing Exams

Available to US/Canadian graduates only

NBME Parts I, II, III

NBOME Parts I, II, III

Available to all examinees FLEX State Board exams

International graduates

1910 1950 1960 1970 1980 1990 2000

U.S. Medical Licensing Exams

Available to US/Canadian graduates only

NBME Parts I, II, III

NBOME Parts I, II, III

Available to all examinees

FLEX State Board exams

International graduates ECFMG, VQE, FMGEMS (+ state exam or FLEX) NBME NBME I, II (+ FLEX ) 1910 1950 1960 1970 1980 1990 2000

8 U.S. Medical Licensing Exams

Available to US/Canadian graduates only

NBME Parts I, II, III NBOME Parts I, II, III COMLEX

Available to all examinees FLEX USMLE State Board exams

International graduates ECFMG, VQE, FMGEMS (+ state exam or FLEX) NBME NBME I, II (+ FLEX ) 1910 1950 1960 1970 1980 1990 2000

Today’s examinations

° Utilized by all state medical and osteopathic boards ° Multi-part assessments ° USMLE Steps 1, 2, 3 ° COMLEX-USA Level 1, 2, 3 ° Nationally administered ° computer-based MCQs & ° clinical skills component ° Developed by volunteers drawn from academic, licensing and practice communities

QUESTIONS OR COMMENTS?

9 FEDERATION CREDENTIALS VERIFICATION SERVICE (FCVS)

Background

Deemed necessary in 1993 by state boards to eliminate redundant work between boards and to expedite secondary licenses.

FCVS began operations in 1996: ‹ 1996 – 2011: Legacy system ‹ 2011 – 2016: Fast Track ‹ 2016 : FCVS 3.0

10 FCVS Participating State Boards - Physicians

WA ME

MT ND VT NH MN MA OR NY ID SD WI CT MI PA NJ WY RI IA NE MD OH DE IN NV IL UT WV CO VA D.C. KS MO CA KY NC TN OK AZ NM AR SC

GA MP AL MS

TX US Virgin Islands LA

FL AK PR

HI = Requiring (KY, LA, ME,NC (existing FCVS physicians, IMGs), NH, NY (IMG’s only), NV-Osteo, OH, RI, SC, UT Med, UT Osteo, VI, WY) = Accepting Some states have separate licensing boards which may or may not be represented by the above map. Please see a complete listing under Participating Boards.

FCVS Goals

1. Provide outstanding customer service

2. Continuous improvement

3. Best possible technology

Why FCVS?

1 Primary Source/Physician Information

2 Permanent Repository

3 NCQA Certified Processes

4 Meets JC standards

11 FCVS Credentials

Identity 1 2 Medical Education 6 3 Licensure and GME Disciplinary History 5 4 Specialty Licensure Exam Certification History (through ABMS)

Pathway to Privileging

Medical FCVS Eligible for School Process privileges

Residency License begins and issued USMLE Step 3

FCVS Profiles & Physician Licenses

Total USA New Licenses Issued FCVS Profiles Submitted to SMB's

80,000

70,000

60,000

50,000

40,000 57% 30,000

20,000

10,000

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

12 Overall Satisfaction 100%

90%

80%

70%

60% Survey Says: 50% - Streamline data entry 40% - Data portability 30% - Timeliness 20%

10%

Medical Staff Services & FCVS

Credentials Hospital MSS Verification Privileges Physician Credentials State FCVS Verification Licensure

Recent Initiatives

Entity Connect Proactive Reportin g eNotary

Electronic Signature

13 The Future - FCVS 3.0

Shortest = 2 hours!

Benefits of 3.0

Enhanced Improved Profile Usability

Individual Improved Artifact Cycle Time Delivery Improved Communication

14 QUESTIONS OR COMMENTS?

INTERSTATE MEDICAL LICENSING COMPACT

15 Virginia Board of Medicine Actively licensed physicians with licenses in other states

Dr. William Rodman NBME Founder

WA ME MT ND VT NH MN NY OR ID WI SD RI MI WY PA NJ IA NE OH DEMD IN UT IL WV NV CO VA CA KS MO KY NC TN OK SC NM AR AZ GA AL MS TX LA

FL AK

16 License portability

Historical barriers:

• Different medical licensing examinations

• Different licensing requirements

• Different state laws

Doctors have similar feelings about licensing

Interstate Medical Licensing Compact

• Full and unrestricted license to practice medicine • Specialty certified or hold a time unlimited specialty certificate • No discipline on any state medical license • No discipline related to controlled substances • Not under investigation by any licensing or law enforcement agency • Pass USMLE or COMLEX within 3 attempts • Completed a GME program

17 State Introductions and Enactments

QUESTIONS OR COMMENTS?

COLLATERAL CONSEQUENCES OF STATE MEDICAL BOARD DISCIPLINARY ACTIONS

18 Physicians disciplined in 2015

License surrender 594 268 Suspensions Revocations License restriction License denial

Fine 2,572 653 Administrative action Probations Other CME required

Letter of reprimand

900K physicians with an active medical license in 2015

Most boards lacked authority to revoke a medical license

WA ME MT ND VT NH OR MN NY MA ID SD WI MI WY PA NJ RI CT IA MD NV NE OH IN DE UT IL WV VA CO CA KS MO KY D.C. NC OK TN AZ AR SC NM GA MS AL TX LA FL AK Power to revoke

HI No power to revoke

Source: 1899 Annual Report of Indiana Board of Medical Registration

19 Evolution of the FSMB Physician Data Center

Massachusetts provides physician profiles to the public in 1996

FSMB creates All state boards FSMB issues FSMB creates board action report to board standardized disciplinary alert database action databank reporting form service 1915 1962 1971 1981 1984 1986 1989 1999 2004

Federation FSMB FSMB State boards can Bulletin publishes distributes computerizes query board Disc. Alert board actions monthly board board action action databank Notification to action reports databank via computer ABMS

National Practitioner Databank (NPDB) FSMB established in 1986 provides guidelines to assist boards

PDC Profile Data Elements:

• Identifying information • Board actions • License • ABMS certification • AOA board certification

FSMB Physician Data Center: Disciplinary Alert Notification Service

ABMS

FSMB sent __ disciplinary alerts sent to ABMS in FSMB 2015 .

HI - 1

60 |

20 FSMB Physician Data Center: Disciplinary Alert Notification Service

ABMS

ABMS notifies one of its 24 member specialty FSMB certification boards.

HI - 1

61 |

QUESTIONS OR COMMENTS?

CONTACTS:

David Johnson Sr. Vice President Federation of State Medical Boards 400 Fuller Wiser Road Euless, Texas 76039 817-868-4000

U.S. Pre-Medical Pathway to Medical Licensure IMG Preparation for U.S. Residency3

• Register for MCAT in the United States • Obtain MD degree or equivalent • Apply with AMCAS • USMLE Step 1 and/or AACOMAS • USMLE Step 2 CK, USMLE Step 2 CS • Obtain ECFMG certification MD IMG ALL DO MD/DO • Obtain Visa, if indicated U.S. Medical School 1st Year U.S. Medical School U.S. Medical School After the Start of U.S. Residency

3rd Year 4th Year • USMLE Step 34 U.S. Medical School • USMLE Step 2 CK • Register for NRMP2 • COMLEX-USA Level 31,4 • USMLE Step 2 CS • Register for AOA Match • Apply for state training license5, if indicated, or full 2nd Year 6 1 and unrestricted state medical license, if eligible • COMLEX-USA Level 2 CE • Register for ERAS • USMLE Step 1 1 • COMLEX-USA Level 11 • COMLEX-USA Level 2 PE • Obtain MD or DO degree Before the End of U.S. Residency/Fellowship

• Begin to apply for employment or make plans for AACOMAS: IMG: American Association of Colleges of Osteopathic International Medical Graduate independent practice Medicine Application Service MCAT: Medical College Admission Test 6 AAFP: American Academy of Family Physicians MD: Doctor of Medicine • Apply for full and unrestricted state medical license(s) ABMS: American Board of Medical Specialties NRMP: National Resident Matching Program • Apply with FCVS (may be required) ACCME: Accreditation Council for Continuing Medical Education PE: Performance Evaluation • Apply with Uniform Application (available in many states) ACGME: Accreditation Council for Graduate Medical Education USMLE: United States Medical Licensing Examination • Apply with individual state medical board(s) (if applicable) AMA: American Medical Association AMCAS: American Medical College Application Service If indicated: AOA: American Osteopathic Association ¹U.S. DOs are also eligible to take the USMLE Examination. • Apply for ABMS/AOA Specialty Board Certification Exam CE: Cognitive Evaluation 2U.S. DOs are also eligible to register for the NRMP. • Apply for hospital privileges CK: Clinical Knowledge 3IMGs are eligible to train in ACGME-accredited GME programs or AOA • Apply for provider status with health insurance companies COMLEX-USA: Comprehensive Osteopathic Medical programs accredited by ACGME. • Apply for DEA Registration, if applicable Licensing Examination 4Medical school graduates may be able to sit for this exam before • Obtain Medicare/Medicaid privileges, if applicable CS: Clinical Skills residency training. DEA: Drug Enforcement Administration 5Training licensure requirements vary from state to state DO: Doctor of Osteopathic Medicine (41 state boards issue a resident/training license).

ECFMG: Educational Commission for Foreign Medical Graduates Ongoing Medical Practice 6Licensure eligibility differs from state to state. ERAS: Electronic Residency Application Service 7State licensure renewals vary from 1- to 3-year cycles. FCVS: Federation Credentials Verification Service • State licensure renewal7 (Maintenance of Licensure), 8 GME: Graduate Medical Education CME is usually accredited by the ACCME, AMA, AAFP and AOA. including state-specific requirements • Continuing Medical Education8 PROTECTING THE PUBLIC WITH More info online at • Maintenance of Certification and/or Osteopathic Continuous HIGH STANDARDS FOR MEDICAL www.fsmb.org Certification, if indicated LICENSURE AND PRACTICE

Definitions

AACOMAS – The American Association of Colleges (IMGs) to assess their readiness prior to entering to one of continuous professional development UA – The Uniform Application, a service of the of Osteopathic Medicine Application Service is into ACGME-accredited residency or fellowship – ABMS Maintenance of Certification® (ABMS Federation of State Medical Boards, is a Web- a centralized application service for colleges of training programs in the United States. MOC®). In 2006, all Member Specialty Boards based application that standardizes, simplifies and osteopathic medicine in the United States through received approval of their ABMS MOC programs, streamlines the licensure application process for the American Association of Colleges of Osteo- ERAS® – The Electronic Residency Application which have 8-10 year renewal cycles. MDs, DOs and Residents. Applicants fill out the pathic Medicine®. Service (ERAS®) was developed by the Associa- online UA once and then use it whenever they ap- tion of American Medical Colleges (AAMC) to allow MOL – Maintenance of Licensure (MOL) is a ply for a license in another state for the rest of their AMCAS® – The American Medical College Ap- medical school students and graduates to apply policy initiative endorsed by the FSMB’s House of careers. The UA is a standard licensure application plication Service®, a program of the Association electronically for residency positions in accredited Delegates as a framework in 2010, calling for all form that serves as the core of a state’s license of American Medical Colleges, is a centralized U.S. programs of graduate medical education. state medical boards to require physicians seeking application without replacing unique state-level application processing service that is only available license renewal to provide evidence of participation requirements, which are collected and submitted to applicants to first-year entering classes at par- FCVS – The Federation Credentials Verification in a program of continuous professional develop- via a state-specific addendum. ticipating allopathic (MD) U.S. medical schools. Service, a service of the Federation of State ment (CPD) that is practice-relevant, informed by Medical Boards, establishes a permanent, lifetime objective data sources, includes activities aimed USMLE® – The United States Medical Licensing COMLEX-USA – The Comprehensive Osteopathic repository of primary-source verified core creden- at improving performance in practice and follows Examination® (USMLE®) is a jointly sponsored Medical Licensing Examination (COMLEX-USA) tials (medical education, postgraduate training, a 5-6 year renewal cycle. While no state has yet program of the Federation of State Medical Boards is a multi-part assessment given by the National examination history, board action history, board adopted a formal requirement for MOL, several and the National Board of Medical Examiners®. Board of Osteopathic Medical Examiners (NBOME) certification and identity) for physicians and physi- state boards are studying MOL implementation in The USMLE is open to students/graduates of to students and graduates of osteopathic medical cian assistants. This repository can be forwarded, their jurisdictions. accredited medical school programs issuing the education programs accredited by the American at the applicant’s request, to nearly any state medi- MD or DO degree and to students/graduates of in- Osteopathic Association’s Commission on Osteo- cal board, hospital, health care facility or other NRMP® – The National Resident Matching ternational medical schools eligible for certification pathic College Accreditation. The NBOME eligibility entity. Program provides a uniform date of appointment by the ECFMG. In general, Step 1 is usually taken criterion requires COMLEX Level 1 to be taken after to positions in graduate medical education (GME). at the end of the 2nd academic year of medical successful completion of the 1st academic year MCAT® – The Medical College Admission Test® is It provides an impartial venue for matching ap- school; Step 2 Clinical Knowledge (CK) and Step 2 of an osteopathic medical school program. Level a standardized, multiple-choice examination de- plicants’ and programs’ preferences for each other Clinical Skills (CS) are generally taken before the 2 Cognitive and Performance Evaluations (CE and signed to assess the examinee’s problem solving, consistently. end of the 3rd academic year. Most examinees PE) cannot be taken until after successful comple- critical thinking, knowledge of science concepts take Step 3 within the first 18 months of residency tion of the 2nd academic year and passing Level and principles prerequisite to the study of medi- OCC – The American Osteopathic Association training, though under certain circumstances some 1. The COMLEX-USA Level 3 is usually taken during cine. A new version of the test is expected in 2015. (AOA) Bureau of Osteopathic Specialists consists IMGs and U.S. medical school graduates may take residency training and after successful completion of 18 specialty-certifying boards. Effective in 2013, Step 3 prior to beginning residency training. of Levels 1-2, though in certain circumstances Lev- MOC® – The American Board of Medical Special- each AOA specialty certifying board requires an el 3 may be taken by osteopathic medical school ties (ABMS) assists 24 approved medical specialty Osteopathic Continuous Certification (OCC) process graduates prior to beginning residency training. boards in the development and use of standards for all doctors of osteopathic medicine (DOs) with in the ongoing evaluation and certification of physi- time-limited certifications. OCC runs on a 6-10 year ECFMG® – The Educational Commission for For- cians. In 2000, the 24 Member Boards of ABMS cycle depending upon the specific specialty board. eign Medical Graduates (ECFMG) provides a certifi- agreed to evolve their recertification programs cation program for international medical graduates

PROTECTING THE PUBLIC WITH Texas Office: 400 Fuller Wiser Road Washington, D.C. Office:1300 Connecticut Avenue, NW HIGH STANDARDS FOR MEDICAL Euless, TX 76039 • (817) 868-4000 Suite 500, Washington, D.C. 20036 • (202) 463-4000 LICENSURE AND PRACTICE