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

1

Defining Moments in Medical Regulation and Licensure

David JohnsonFSMB Senior Vice-President

Jama BallFSMB 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

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

Learning objectives for today:

2

FSMB<your response>

22333

Participating with Poll Everywhere

Textvoting

FSMB

22333

FSMB

FSMB

Pollev.com/FSMB

3

US medical regulation:A system of complementary players and roles

• Education

• LicensingPublic

• Accreditation & certification• AssessmentPrivate

• Education• Licensing

• Assessment

• Accreditation & certification

Profession

Credentialing

Credentialing

Credentialing

Independent yet complementary functions

4

Road to Becoming a Physician

GAAL

MS

SC

NC

TN

KY

INIL

LA

AR

TX

OH

MI

WI

WVVA

PA

NY

RICT

MA

NJ

DEMD

OK

KS MO

IA

MN

ND

SD

NE

WY

CO

NM

HI

AK

UT

OR

ID

MT

WA

NH

CA

VT

AZ

ME

NV

FL

Separate allopathic (M.D.) and osteopathic (D.O.)

boards

5

Medical examining boards established

1870 190018901880

Sta

te M

ed

ica

l B

oa

rds

Time

North Carolina

(1859)Kansas

Oklahoma

Alaska

West Virginia

Arizona

Mississippi

New Mexico

Missouri

Minnesota

Virginia

Iowa

Maryland

Oregon

Tennessee

South Carolina

Montana

WashingtonNorth DakotaNew YorkNew JerseyNebraskaUtahConnecticutSouth DakotaPennsylvania

GeorgiaLouisiana

MassachusettsRhode Island

DelawareMaineOhio

District of ColumbiaWisconsin

IndianaNew Hampshire

VermontMichigan

IdahoNevada

Wyoming

Kentucky

Texas

California

Alabama

Illinois

Simple registration laws preceded the creation of most medical boards

Dent v. West Virginia, 1889 Hawker v. New York, 1898

1791

Origins of U.S. medical regulation

10th Amendment to the Constitution

State Federal

6

1791 1876

Origins of U.S. medical regulation

1859

Broad set of powers1st state medical board

- Set minimum qualifications

- Issuing a medical license

- License revocation

1791 1876

Origins of U.S. medical regulation

18891859

US Supreme CourtDent v. West Virginia

7

1912-15 1962

More defining moments

20151933

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

1947

Interstate medical licensing compact

Special board certification

Accreditation

1957

MEDICAL LICENSING

EXAMINATIONS

8

U.S. Medical Licensing Exams

1910 1950 1960 1970 1980 1990 2000

Available to US/Canadian graduates only

Available to all examinees

International graduates

NBME Parts I, II, III

NBOME Parts I, II, III

State Board exams

U.S. Medical Licensing Exams

1910 1950 1960 1970 1980 1990 2000

Available to US/Canadian graduates only

Available to all examinees

International graduates

NBME Parts I, II, III

FLEX

NBOME Parts I, II, III

State Board exams

U.S. Medical Licensing Exams

1910 1950 1960 1970 1980 1990 2000

Available to US/Canadian graduates only

Available to all examinees

International graduates

NBME Parts I, II, III

FLEX

NBME

ECFMG, VQE, FMGEMS

(+ state exam or FLEX) NBME I, II

(+ FLEX)

NBOME Parts I, II, III

State Board exams

9

U.S. Medical Licensing Exams

1910 1950 1960 1970 1980 1990 2000

Available to US/Canadian graduates only

Available to all examinees

International graduates

NBME Parts I, II, III

State Board exams

FLEX

NBME

ECFMG, VQE, FMGEMS

(+ state exam or FLEX)NBME I, II

(+ FLEX)

NBOME Parts I, II, III COMLEX

USMLE

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?

10

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

11

FL

GAAL

MS

SC

NCTN

KY

INIL

LA

AR

TX

OH

MI

WI

VA

WV

PA

NY

VT

ME

RI

MA

CT

NJ

DEMD

OK

KS MO

IA

MN

ND

SD

NE

WY

CO

NM

HI

AK

AZ

UTNV

CA

OR

ID

MT

WA

= 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)

FCVS Participating State Boards - Physicians

NH

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.

= Accepting

US Virgin Islands

D.C.

MP

PR

FCVS Goals

1. Provide outstanding customer service

2. Continuous improvement

3. Best possible technology

Why FCVS?

2

3

4

1 Primary Source/Physician Information

Permanent Repository

NCQA Certified Processes

Meets JC standards

12

FCVS Credentials

1 2

3

45

6

Medical Education

Identity

GME

Licensure Exam History

Licensure and Disciplinary

History

Specialty Certification

(through ABMS)

Pathway to Privileging

Medical School

Residency begins and USMLE Step 3

FCVS Process

License issued

Eligible for privileges

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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

57%

FCVS Profiles & Physician Licenses

13

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overall Satisfaction

Survey Says:

- Streamline data entry

- Data portability

- Timeliness

Medical Staff Services & FCVS

Physician

FCVS

Credentials Verification

MSSHospital

Privileges

StateLicensure

Credentials Verification

Recent Initiatives

Entity Connect

Proactive

Reporting

Electronic Signature

eNotary

14

The Future - FCVS 3.0

Shortest = 2 hours!

Benefits of 3.0

Improved Usability

Improved Cycle Time

Improved Communication

Individual Artifact

Delivery

Enhanced Profile

15

QUESTIONS OR COMMENTS?

INTERSTATE MEDICAL LICENSING COMPACT

16

Virginia Board of MedicineActively licensed physicians with licenses in other states

GAAL

MS

SC

NC

TN

KY

INIL

LA

AR

TX

OH

MI

WI

WVVA

PA

NY

RI

NJ

DEMD

OK

KS MO

IA

MN

ND

SD

NE

WY

CO

NM

HI

AK

UT

OR

ID

MT

WA

NH

CA

VT

AZ

ME

NV

FL

Dr. William Rodman

NBME Founder

17

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

18

State Introductions and Enactments

QUESTIONS OR COMMENTS?

COLLATERAL CONSEQUENCES OF STATE MEDICAL BOARD DISCIPLINARY ACTIONS

19

594 Suspensions

268Revocations

653 Probations

2,572Other

Physicians disciplined in 2015

License surrender

License restriction

License denial

Fine

Administrative action

CME required

Letter of reprimand

900K physicians with an active medical license in 2015

FL

GAALMS

SC

NC

TN

KY

INIL

LA

AR

TX

OH

MIWI

VAWV

PA

NY

ME

RI

MA

CTNJ

DEMD

OK

KS MO

IA

MN

ND

SD

NE

WY

CO

HI

AK

AZ

UT

CA

OR

ID

MT

WA

NH

NM

D.C.

VT

NV

Power to revoke

No power to revoke

Source: 1899 Annual Report of Indiana Board of Medical Registration

Most boards lacked authority to revoke a medical license

20

Evolution of the FSMB Physician Data Center

1915 1962 1971 1981 1984 1986 1989 1999 2004

Federation Bulletin publishes board actions

FSMB creates board action database

FSMB distributes monthly board action reports

All state boards report to board action databank

FSMB computerizes board action databank

FSMB issues standardized reporting form

State boards can query board action databank via computer

FSMB creates disciplinary alert service

National Practitioner Databank (NPDB)

established in 1986

Massachusetts provides physician

profiles to the public in 1996

FSMB provides guidelines to assist boards

Disc. Alert Notification to

ABMS

PDC Profile Data Elements:

• Identifying information

• Board actions

• License

• ABMS certification

• AOA board certification

FSMB Physician Data Center: Disciplinary Alert Notification Service

60|

HI - 1

FSMB

FSMB sent __ disciplinary alerts sent to ABMS in

2015.

ABMS

21

FSMB Physician Data Center: Disciplinary Alert Notification Service

61|

HI - 1

FSMB

ABMS notifies one of its 24 member

specialty certification boards.

ABMS

QUESTIONS OR COMMENTS?

CONTACTS:

David Johnson Sr. Vice President

Federation of State Medical Boards400 Fuller Wiser RoadEuless, Texas 76039817-868-4000

A l a b a m a | A l a sk a | A r i zon a | A r k a n s a s | C a l i f or ni a | C olor a d o | C onne c t ic u t | D e l awa r e | D i s t r ic t of C ol um bi a | F lor id a | G e or g i a | G ua m | H awa i i | I d a ho | I l l inoi s

| I nd i a n a | Io wa | K a n s a s | K e n t u c k y | Lo u i s i a n a | M a ine | M a ry l a nd | M a s s a c h u se t t s | M ic hig a n | M inne s ota | M i s s i s s ipp i | M i s s o u r i | M on ta n a | N e br a sk a | N e va d a | N e w

H a m p shir e | N e w J e r se y | N e w M e x ic o | N e w Yor k | Nort he r n M a r i a n a I s l a nd s | Nort h C a r ol in a | Nort h D a k ota | Ohio | Ok l a ho m a | Or e g on | Pe nn s y lva ni a | P u e rto R ic o

| R hod e I s l a nd | S o u t h C a r ol in a | S o u t h D a k ota | Te nne s se e | Te xa s | U . S . V ir g in I s l a nd s | U ta h | V e r m on t | V ir g ini a | Wa shing ton | W e s t V ir g ini a | W i s c on sin | W y o m ing

Pathway to Medical Licensure in the United States

U.S. Medical School

1st Year

U.S. Medical School

2nd Year • USMLE Step 1

• COMLEX-USA Level 11

U.S. Medical School 3rd Year• USMLE Step 2 CK

• USMLE Step 2 CS

• COMLEX-USA Level 2 CE1

• COMLEX-USA Level 2 PE1

U.S. Medical School 4th Year• Register for NRMP2

• Register for AOA Match

• Register for ERAS

• Obtain MD or DO degree

After the Start of U.S. Residency • USMLE Step 34

• COMLEX-USA Level 31,4

• Apply for state training license5, if indicated, or full and unrestricted state medical license, if eligible6

Ongoing Medical Practice • State licensure renewal7 (Maintenance of Licensure), including state-specific requirements

• Continuing Medical Education8

• Maintenance of Certification and/or Osteopathic Continuous Certification, if indicated

Before the End of U.S. Residency/Fellowship • Begin to apply for employment or make plans for independent practice

• Apply for full and unrestricted state medical license(s)6 • Apply with FCVS (may be required) • Apply with Uniform Application (available in many states) • Apply with individual state medical board(s) (if applicable) If indicated: • Apply for ABMS/AOA Specialty Board Certification Exam • Apply for hospital privileges • Apply for provider status with health insurance companies • Apply for DEA Registration, if applicable • Obtain Medicare/Medicaid privileges, if applicable

IMG Preparation for U.S. Residency3

• Obtain MD degree or equivalent

• USMLE Step 1

• USMLE Step 2 CK, USMLE Step 2 CS

• Obtain ECFMG certification

• Obtain Visa, if indicated

ProtectingAdvocating

Serving

U.S. Pre-Medical

• Register for MCAT• Apply with AMCAS and/or AACOMAS

DO MD/DO MD IMG ALL

AACOMAS: American Association of Colleges of Osteopathic Medicine Application ServiceAAFP: American Academy of Family PhysiciansABMS: American Board of Medical SpecialtiesACCME: Accreditation Council for Continuing Medical EducationACGME: Accreditation Council for Graduate Medical EducationAMA: American Medical AssociationAMCAS: American Medical College Application ServiceAOA: American Osteopathic AssociationCE: Cognitive EvaluationCK: Clinical KnowledgeCOMLEX-USA: Comprehensive Osteopathic Medical Licensing ExaminationCS: Clinical SkillsDEA: Drug Enforcement AdministrationDO: Doctor of Osteopathic MedicineECFMG: Educational Commission for Foreign Medical GraduatesERAS: Electronic Residency Application ServiceFCVS: Federation Credentials Verification ServiceGME: Graduate Medical Education

IMG: International Medical GraduateMCAT: Medical College Admission TestMD: Doctor of MedicineNRMP: National Resident Matching ProgramPE: Performance EvaluationUSMLE: United States Medical Licensing Examination

¹U.S. DOs are also eligible to take the USMLE Examination.2U.S. DOs are also eligible to register for the NRMP.3IMGs are eligible to train in ACGME-accredited GME programs or AOA programs accredited by ACGME.4Medical school graduates may be able to sit for this exam before residency training. 5Training licensure requirements vary from state to state (41 state boards issue a resident/training license). 6Licensure eligibility differs from state to state.7State licensure renewals vary from 1- to 3-year cycles.8CME is usually accredited by the ACCME, AMA, AAFP and AOA.

P R O T E C T I N G T H E P U B L I C W I T H

H I G H S T A N D A R D S F O R M E D I C A L

L I C E N S U R E A N D P R A C T I C E

More info online at www.fsmb.org

©2016 Federation of State Medical Boards

A l a b a m a | A l a sk a | A r i zon a | A r k a n s a s | C a l i f or ni a | C olor a d o | C onne c t ic u t | D e l awa r e | D i s t r ic t of C ol um bi a | F lor id a | G e or g i a | G ua m | H awa i i | I d a ho | I l l inoi s

| I nd i a n a | Io wa | K a n s a s | K e n t u c k y | Lo u i s i a n a | M a ine | M a ry l a nd | M a s s a c h u se t t s | M ic hig a n | M inne s ota | M i s s i s s ipp i | M i s s o u r i | M on ta n a | N e br a sk a | N e va d a | N e w

H a m p shir e | N e w J e r se y | N e w M e x ic o | N e w Yor k | Nort he r n M a r i a n a I s l a nd s | Nort h C a r ol in a | Nort h D a k ota | Ohio | Ok l a ho m a | Or e g on | Pe nn s y lva ni a | P u e rto R ic o

| R hod e I s l a nd | S o u t h C a r ol in a | S o u t h D a k ota | Te nne s se e | Te xa s | U . S . V ir g in I s l a nd s | U ta h | V e r m on t | V ir g ini a | Wa shing ton | W e s t V ir g ini a | W i s c on sin | W y o m ing

Definitions

ProtectingAdvocating

Serving

P R O T E C T I N G T H E P U B L I C W I T H

H I G H S T A N D A R D S F O R M E D I C A L

L I C E N S U R E A N D P R A C T I C E

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AACOMAS – The American Association of Colleges of Osteopathic Medicine Application Service is a centralized application service for colleges of osteopathic medicine in the United States through the American Association of Colleges of Osteo-pathic Medicine®.

AMCAS® – The American Medical College Ap-plication Service®, a program of the Association of American Medical Colleges, is a centralized application processing service that is only available to applicants to first-year entering classes at par-ticipating allopathic (MD) U.S. medical schools.

COMLEX-USA – The Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) is a multi-part assessment given by the National Board of Osteopathic Medical Examiners (NBOME) to students and graduates of osteopathic medical education programs accredited by the American Osteopathic Association’s Commission on Osteo-pathic College Accreditation. The NBOME eligibility criterion requires COMLEX Level 1 to be taken after successful completion of the 1st academic year of an osteopathic medical school program. Level 2 Cognitive and Performance Evaluations (CE and PE) cannot be taken until after successful comple-tion of the 2nd academic year and passing Level 1. The COMLEX-USA Level 3 is usually taken during residency training and after successful completion of Levels 1-2, though in certain circumstances Lev-el 3 may be taken by osteopathic medical school graduates prior to beginning residency training.

ECFMG® – The Educational Commission for For-eign Medical Graduates (ECFMG) provides a certifi-cation program for international medical graduates

(IMGs) to assess their readiness prior to entering into ACGME-accredited residency or fellowship training programs in the United States.

ERAS® – The Electronic Residency Application Service (ERAS®) was developed by the Associa-tion of American Medical Colleges (AAMC) to allow medical school students and graduates to apply electronically for residency positions in accredited U.S. programs of graduate medical education.

FCVS – The Federation Credentials Verification Service, a service of the Federation of State Medical Boards, establishes a permanent, lifetime repository of primary-source verified core creden-tials (medical education, postgraduate training, examination history, board action history, board certification and identity) for physicians and physi-cian assistants. This repository can be forwarded, at the applicant’s request, to nearly any state medi-cal board, hospital, health care facility or other entity.

MCAT® – The Medical College Admission Test® is a standardized, multiple-choice examination de-signed to assess the examinee’s problem solving, critical thinking, knowledge of science concepts and principles prerequisite to the study of medi-cine. A new version of the test is expected in 2015.

MOC® – The American Board of Medical Special-ties (ABMS) assists 24 approved medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physi-cians. In 2000, the 24 Member Boards of ABMS agreed to evolve their recertification programs

to one of continuous professional development – ABMS Maintenance of Certification® (ABMS MOC®). In 2006, all Member Specialty Boards received approval of their ABMS MOC programs, which have 8-10 year renewal cycles.

MOL – Maintenance of Licensure (MOL) is a policy initiative endorsed by the FSMB’s House of Delegates as a framework in 2010, calling for all state medical boards to require physicians seeking license renewal to provide evidence of participation in a program of continuous professional develop-ment (CPD) that is practice-relevant, informed by objective data sources, includes activities aimed at improving performance in practice and follows a 5-6 year renewal cycle. While no state has yet adopted a formal requirement for MOL, several state boards are studying MOL implementation in their jurisdictions.

NRMP® – The National Resident Matching Program provides a uniform date of appointment to positions in graduate medical education (GME). It provides an impartial venue for matching ap-plicants’ and programs’ preferences for each other consistently.

OCC – The American Osteopathic Association (AOA) Bureau of Osteopathic Specialists consists of 18 specialty-certifying boards. Effective in 2013, each AOA specialty certifying board requires an Osteopathic Continuous Certification (OCC) process for all doctors of osteopathic medicine (DOs) with time-limited certifications. OCC runs on a 6-10 year cycle depending upon the specific specialty board.

UA – The Uniform Application, a service of the Federation of State Medical Boards, is a Web-based application that standardizes, simplifies and streamlines the licensure application process for MDs, DOs and Residents. Applicants fill out the online UA once and then use it whenever they ap-ply for a license in another state for the rest of their careers. The UA is a standard licensure application form that serves as the core of a state’s license application without replacing unique state-level requirements, which are collected and submitted via a state-specific addendum.

USMLE® – The United States Medical Licensing Examination® (USMLE®) is a jointly sponsored program of the Federation of State Medical Boards and the National Board of Medical Examiners®. The USMLE is open to students/graduates of accredited medical school programs issuing the MD or DO degree and to students/graduates of in-ternational medical schools eligible for certification by the ECFMG. In general, Step 1 is usually taken at the end of the 2nd academic year of medical school; Step 2 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) are generally taken before the end of the 3rd academic year. Most examinees take Step 3 within the first 18 months of residency training, though under certain circumstances some IMGs and U.S. medical school graduates may take Step 3 prior to beginning residency training.

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