When choosing a doctor, patients have long relied on the idea of board certification. It’s a stamp of approval meant to assure them their provider knows current medical practices.

But a rebellion among doctors over recertification requirements has put that stamp in flux, potentially complicating what patients can expect to know about their doctors.

The national credentialing organization has directed the 24 boards that oversee specific medical specialties, such as surgeons, anesthesiologists and internal medicine doctors, to toughen their requirements for renewal of board certification. But pushback from a number of doctors — especially internists — has sparked a debate in the medical community about the best way to evaluate what doctors know and how effective they are at treating patients.

Specialist and primary care doctors who want to stay board certified – a guideline hospitals and insurance plans often look to when evaluating a physician’s quality – already must pass a written exam every 10 years and take classes intended to keep them studying medicine. But the American Board of Medical Specialties is seeking to boost those efforts.

Following the ABMS guidance, the American Board of Internal Medicine last year moved to add a new component to its maintenance of certification program, requiring certified internists to provide information every five years about how they interact with patients and keep them safe. That was supposed to start this year. But the heavy criticism it elicited from a number of doctors led the ABIM to suspend the requirement.

Now, the board is starting over, soliciting more input, said Richard Baron, ABIM’s president.

All 24 specialty boards have been required to expand maintenance of certification. Internal medicine, which is the largest of the groups, is the only one so far to suspend its requirements. However, the Association of American Physicians and Surgeons, a trade group of private physicians that advocates limiting government influence on medical care and more independence for individual doctors, filed a lawsuit against ABMS challenging the recertification efforts in all specialties in 2013. The U.S. District Court in Chicago is weighing  the suit.

But while many internists have praised the ABIM decision to take a harder look at what’s required to maintain board certification, patient advocates have expressed concern that the move could potentially foreshadow a diminished focus on elements like patient safety.

“ABIM is issuing a mea culpa to physicians, that they’ve held them to too many standards,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that emphasizes patient safety. “And I think that message has some hazards to it.”

More thorough standards for physicians are worth the effort, said Robert Wachter, a professor of medicine at the University of California at San Francisco who previously chaired ABIM and is now a trustee at the ABIM Foundation, the board’s nonprofit arm. The board, he said, correctly thought that “the public deserved and would want to know that physicians were doing more [to stay certified] than a process that they were doing for a few months every 10 years.”

The goal was to develop ways to assess patient care and patients’ perceptions of their doctors.

Physicians say, however, they were worried that, as proposed, ABIM’s requirements could be too cumbersome without effectively measuring quality. They would have been required to review old charts and paperwork every five years, collecting data to indicate what they had done in treating relevant diseases, as well as surveying patients about the level of care they received.

Doctors “viewed this as a significant burden – very time-consuming,” said Steven Weinberger, CEO of the American College of Physicians, and at the same time, “they weren’t really clear that it actually improved the practices of medicine and the care that they gave to patients.”

And such criticism, Wachter said, convinced board members that “the methods we had to assess those things were too imperfect and too onerous to force physicians to do them right now.”

But some have said even the existing process is too expensive – completing the ABIM protocol for maintenance of certification, including the exam, costs about $2,000 every decade. Others have argued the exam doctors must take, for which the content is also being re-evaluated, isn’t always relevant, a qualm that could suggest it is not worth the energy and expense of completing.  For instance, a physician who works only with breast cancer patients might still be required to demonstrate knowledge about prostate cancer, colon cancer or other forms of the disease.

“How relevant do you need to make the exam?” Weinberger said. “Does the certificate say that I’m in fact competent in a broader area? It’s a very nuanced question.”

But despite these reservations, finding a way to somehow hold doctors accountable is essential when it comes to patient safety, Binder said.

“We are in an environment where there are so many significant problems in quality and safety in health care,” she said. “I hope they will turn around quickly and that the new standards they set will be more appropriate and at the same time tougher.”

The prevalence of organizations assessing doctors actually makes a strong board credential more important, Wachter argued.

“We wanted to create a process that we thought was appropriate and credible for the public” and that others could use as a gold standard for evaluating physicians, Wachter said.

And though continuing medical education (CME) programs  already exist, they aren’t a substitute for being certified, Weinberger said, especially given how relatively unstandardized the courses can be. “When you’ve seen one CME program, you’ve seen one CME program – they’re all very different in terms of what their goals are and how effective their goals are.”

Balancing physician and consumer needs can get tricky, Binder said, but effective and stringent standards are important given the significance doctors hold in patients’ lives.

“Physicians are an elite profession – one that is revered and admired by all of us,” she said. “And in return for that admiration and respect, I think, they should reassure us that they are holding themselves to very high standards.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Affordable Care Act is once again before the Supreme Court.

On March 4, the justices will hear oral arguments in King v. Burwell, a case challenging the validity of tax subsidies helping millions of Americans buy health insurance if they don’t get it through an employer or the government. If the court rules against the Obama administration, those subsidies could be cut off for everyone in the three dozen states using healthcare.gov, the federal exchange website. A decision is expected by the end of June.

Here are five things you should know about the case and its potential consequences:

1: This case does NOT challenge the constitutionality of the health law.

The Supreme Court has already found the Affordable Care Act is constitutional. That was settled in 2012’s NFIB v. Sebelius.

At issue in this case is a line in the law stipulating that subsidies are available to those who sign up for coverage “through an exchange established by the state.” In issuing regulations to implement the subsidies in 2012, however, the IRS said that subsidies would also be available to those enrolling through the federal health insurance exchange. The agency noted Congress had never discussed limiting the subsidies to state-run exchanges and that making subsidies available to all “is consistent with the language, purpose and structure” of the law as a whole.

Last summer, the U.S. Court of Appeals for the Fourth Circuit in Richmond ruled that the regulations were a permissible interpretation of the law. While the three-judge panel agreed that the language in the law is “ambiguous,” they relied on so-called “Chevron deference,” a legal principle that takes its name from a 1984 Supreme Court ruling that held that courts must defer to a federal agency’s interpretation as long as that interpretation is not unreasonable.

Those challenging the law, however, insist that Congress intended to limit the subsidies to state exchanges. “As an inducement to state officials, the Act authorizes tax credits and subsidies for certain households that purchase health insurance through an Exchange, but restricts those entitlements to Exchanges created by states,” wrote Michael Cannon and Jonathan Adler, two of the fiercest critics of the IRS interpretation, in an article in the Health Matrix: Journal of Law-Medicine.

In any case, a ruling in favor of the challengers would affect only the subsidies available in the states using the federal exchange. Those in the 13 states operating their own exchanges would be unaffected. The rest of the health law, including its expansion of Medicaid and requirements for coverage of those with pre-existing conditions, would remain in effect.

2: If the court rules against the Obama administration, millions of people could be forced to give up their insurance.

A study by the Urban Institute found that if subsidies in the federal health exchange are disallowed, 9.3 million people could lose $28.8 billion of federal help paying for their insurance in just the first year. Since many of those people would not be able to afford insurance without government help, the number of uninsured could rise by 8.2 million people.

A separate study from the Urban Institute looked at those in danger of losing their coverage and found that most are low and moderate-income white, working adults who live in the South.

3: A ruling against the Obama administration could have other effects, too.

Experts say disallowing the subsidies in the federal exchange states could destabilize the entire individual insurance market, not just the exchanges in those states. Anticipating that only those most likely to need medical services will hold onto their plans, insurers would likely increase premiums for everyone in the state who buys their own insurance, no matter where they buy it from.

“If subsidies [in the federal exchange] are eliminated, premiums would increase by about 47 percent,” said Christine Eibner of the RAND Corporation, who co-authored a study projecting a 70 percent drop in enrollment.

Eliminating tax subsidies for individuals would also impact the law’s requirement that most larger employers provide health insurance. That’s because the penalty for not providing coverage only kicks in if a worker goes to the state health exchange and receives a subsidy. If there are no subsidies, there are also no employer penalties.

4: Consumers could lose subsidies almost immediately.

Supreme Court decisions generally take effect 25 days after they are issued. That could mean that subsidies would stop flowing as soon as July or August, assuming a decision in late June. Insurers can’t drop people for non-payment of their premiums for 90 days, although they have to continue to pay claims only for the first 30.

Although the law’s requirement that individuals have health insurance would remain in effect, no one is required to purchase coverage if the lowest-priced plan in their area costs more than eight percent of their income. So without the subsidies, and with projected premium increases, many if not most people would become exempt.

5: Congress could make the entire issue go away by passing a one-page bill. But it won’t.

All Congress would have to do to restore the subsidies is pass a bill striking the line about subsidies being available through exchanges “established by the state.” But given how many Republicans oppose the law, leaders have already said they will not act to fix it. Republicans are still working to come up with a contingency plan should the ruling go against the subsidies. Even that will be difficult given their continuing ideological divides over health care.

States could solve the problem by setting up their own exchanges, but that is a lengthy and complicated process and in most cases requires the consent of state legislatures. And the Obama administration has no power to step in and fix things either, Health and Human Services Secretary Sylvia Burwell said in a letter to members of Congress.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

When the annual sign-up period for individual Obamacare coverage ended earlier this month, it meant that in general, people are locked into their plans for the year. There are exceptions, however, for those who experience life changes such as marriage, the birth of a child or the loss of their job-based coverage.

The list of situations that trigger a special, 60-DAY enrollment period will get longer in April, when a new rule issued by the Department of Health and Human Services takes effect.

The rule’s additional circumstances include:

— Losing a dependent or dependent status because of divorce, legal separation or death. This provision would enable someone who no longer needs family coverage, for example, to switch to single coverage. Although not required until 2017, exchanges are encouraged to offer this as soon as possible.

— An increase in an individual’s income to the federal poverty level in states that haven’t expanded Medicaid to adults with incomes up to 138 percent of the federal poverty level ($16,243 in 2015). At that income level, the person could qualify for premium tax credits that are available for those with incomes between 100 and 400 percent of the poverty level to make marketplace coverage more affordable.

Last year, such individuals could also qualify for a special enrollment period, “but we read this as a bit broader,” says Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities. Last year, “you had to have applied for Medicaid to qualify.” Now, that’s not necessary.

–If a court order requires someone to provide health insurance, the coverage must be available the first day the court order takes effect.

“It’s extremely important for ensuring the coverage of children,” says Dania Palanker, senior counsel at the National Women’s Law Center.

–People who are currently enrolled in non-calendar year plans will qualify for a special enrollment period when that coverage ends, even if they could renew them.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Mary Agnes Carey speaks with Melissa Attias of CQ- Roll Call about Department of Health and Human Services Secretary Sylvia Burwell’s visit to Capitol Hill, where she faced a torrent of questions about the pending Supreme Court arguments concerning health law subsidies and the impact the ruling may have on the millions of people who now have coverage because of the subsidies.

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https://kaiserhealthnews.files.wordpress.com/2015/02/022615_khn_hoth.mp3

MARY AGNES CAREY: Welcome to Health on the Hill, I’m Mary Agnes Carey.  Department of Health and Human Services Secretary Sylvia Burwell faced some tough questioning today on Capitol Hill about the upcoming Supreme Court arguments concerning health law subsidies that help millions of people afford coverage. With us now is Melissa Attias, who was at that House hearing and covers health care for CQ-Roll Call. Thanks for joining us.

MELISSA ATTIAS, CQ-ROLL CALL: Thanks for having me.

MARY AGNES CAREY: As expected, several Republicans on the House Energy and Commerce Health Subcommittee asked Sec. Burwell about how the administration intends to respond if the court rules that people in about three dozen exchanges that are run by the federal government are no longer entitled to get subsidies to help purchase coverage. But subcommittee Chairman Joe Pitts asked the secretary about an alleged 100-page HHS document detailing potential actions that the agency could take if the court rules that the subsidies can’t exist in federal exchanges. What was her response?

MELISSA ATTIAS: Pitts asked about this document. He said he had heard from a source within HHS that it exists, and Burwell said she was not aware of the document. She instead cited a letter that she sent out to Republican offices on Capitol Hill Tuesday that said her department doesn’t know of any administrative action that could undo the damage that would happen if the court ruled against the government and that therefore they don’t have a plan that could accomplish that kind of action. And she also reiterated that she thinks the Obama administration is going to prevail in the court case. The Supreme Court is going to hold oral arguments next week, March 4, and a ruling is expected by the end of June.

MARY AGNES CAREY: Hasn’t the administration acted before in the sense of changing requirements on the employer mandate – is one that comes to mind – or the special enrollment period they just created for people who find out they owe a penalty this year because they didn’t have health coverage? Why doesn’t that power extend to having an answer on the subsidy issue?

MELISSA ATTIAS: The administration has already taken a number of actions administratively to smooth implementation of the law, you named the employer mandate; that’s a great example, so I think it would surprise many people if the administration isn’t making some sort of contingency plan, because most would expect that the administration is going to do anything they can to soften the blow if the subsidies are taken away from the federal exchange.

MARY AGNES CAREY: While Republicans focus their questions today on the upcoming Supreme Court case, Democrats looked into a different area. Can you tell us about that?

MELISSA ATTIAS: Sure, Democrats were asking Burwell, whether she was aware of any Republican plans that provide comparable coverage to the Health Care law and they repeatedly tried to hammer home that point one after another. Congressman Eliot Engle who is a New York Democrat urged lawmakers to pass legislation if the court rules against the administration to make sure that people can continue to get affordable coverage through the health exchange. He said that’s what Democrats intended and congressman Kurt Schrader of Oregon also said he thinks its ironic that Republicans keep asking for the administration’s contingency plans for the case, but he thinks it Congress’ responsibility and noted that the Republicans control both chambers of Congress right now.  Democrats also pointed out that Republicans are the ones supporting the lawsuit. Chairman Pitts of the health subcommittee for example is one of those who has signed on to a friend of the court brief in support of the challenge.

MARY AGNES CAREY:  Chairman Pitts also asked about an issue in California that deals with health insurers and abortion coverage. What’s happening there?

MELISSA ATTIAS:  Pitts said he was deeply concerned about a lack of HHS action in California, where there is a new policy for health plans to cover abortion. And Pitts said that policy is in violation of the Weldon amendment; that refers to an amendment that’s attached to annual spending bills and it bars funding for a federal agency or state or local government and I’m going to quote here and the quote is that : “Subjects any institutional or individual health entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of or refer for abortion,.“ So Burwell said they have opened an investigation within the office for civil rights and that they take the issue seriously. The issue also came up at a house appropriations sub-committee hearing yesterday.

MARY AGNES CAREY: I want to ask you about another item that came up at the hearing I know it’s on your radar screen. We’ve talked about it before.  This is the sustainable growth rate; the way Medicare pays physicians. The current formula expires at the end of March. What’s new there?

MELISSA ATTIAS: Lawmakers came up with a bipartisan compromise on the policy last year. But they weren’t able to find a way to pay for it, so they went with a patch as you mentioned which as you mentioned expires at the end of March.  The cost of the policy proposal recently went up by $30.5 billion earlier this month because the Congressional Budget Office added another year to the budget window compared to an estimate the Congressional Budget Office released in November. And the latest estimate is that the cost $174.5 billion from fiscal 2015 to 2025.  At the hearing Congressman Michael Burgess, who’s a Texas republican, said he’s looking at the Medicare changes President Obama proposes his budget for offsets.

MARY AGNES CAREY: Thank you Melissa Attias of CQ-Roll Call

MELISSA ATTIAS: Thanks for having me.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.