SB 170 Equity and Improvement of Medical Practice in Commonwealth of Kentucky

1. SB 170 Equity and Improvement of Medical Practice in Commonwealth of Kentucky

2. SB170 08RS Introduced 2/15/2008 SB 170 (BR 1772) - K. Winters, G. Neal, J. Denton, C. Gibson, J. Pendleton, D. Roeding, G. Tapp

3. SB170AN ACT relating to the Kentucky Board of Medical Licensure • amend KRS 311.530 to change membership of the board; • amend KRS 311.535 to limit members to two consecutive terms; • amend KRS 311.540 to limit officers of the board to one year terms and permit reelection for one year; • permit the board to appoint committees; • permit the president of the board to serve ex officio on any committee; • limit officers of committees to one year terms and permit reelection for one year; • create a new section of KRS Chapter 311 to require the State Board of Medical Licensure to recognize certification by the American Board of Interventional Pain Physicians; prohibit the practice of interventional pain management without training; • permit a physician certified by the American Board of Interventional Pain Physicians to advertise Feb 15-introduced in Senate

4. Why ?

5. Doctors are men who give drugs of which they know little, into bodies of which they know less, for diseases of which they know nothing at all. Voltaire

6. Radical Surgery: What’s Next for America’s health care? • The physician monopoly over how and when doctors are disciplined helps shield the medical profession from airing, before patients and public, questions of competence and willful neglect. • With meager resources and staffs hand-picked by doctors, state medical boards rarely discipline physicians for malpractice. • A troubling symptom of how poorly doctors regulate themselves is the wide variation in the number of disciplinary actions taken by defense state medical boards. • As per public citizen rating, the states with the highest disciplinary rates from 2004 to 2006 were Alaska, 7.3 actions per 1,000 physicians; Kentucky, 7.1; Wyoming, 6.37, Ohio 6.01; and Oklahoma, 5.54. Successrate is determined by number of incompetent physicians and actions rather than controlling the competency and increasing it. • The monopoly of attorneys, covered by their own blanket of self-regulation, protects lawyers who promote litigation that drives up malpractice premiums and the nation’s bill for defensive medicine, terrorizes doctors, and often exploits patients. Joseph A. Califano, Jr, 1994

7. Medical Monopoly • The state disciplinary board should be composed of a majority of non-physician members. • States should give these boards the resources to pull from their obligations to investigate patient complaints of malpractice. • Doctors themselves, the hospitals, manage-care plans, dentists, and all other professions and clinics where they practice, should be held responsible when they fail to report practitioners who are incompetent, provide substandard care, or are guilty of negligence. Adapted from Radical Surgery Joseph A. Califano, Jr.

8. Public Citizen issues annual medical board rankings • A new report said boards need to do a better job of protecting the public. Some say the study is flawed. • Public Citizen, a consumer advocacy organization, has ranked Alaska as the best state medical board at disciplining doctors in the past three years and Mississippi as the worst. • The states with the highest disciplinary rates were Alaska (7.3 serious actions per 1,000 physicians), Kentucky (7.1), Wyoming (6.37), Ohio (6.01) and Oklahoma (5.54). • The states with the lowest disciplinary rates for the three-year period were Mississippi (1.41 serious actions per 1,000 physicians), South Carolina (1.45), Minnesota (1.45), South Dakota (1.52) and Nevada (1.68). Damon Adams, AMNews staff. July 9, 2007.

9. Public Citizen issues annual medical board rankings • The rankings are not an accurate reflection of boards' effectiveness. • “To rank states solely on disciplinary actions is a misuse of the data,” said James Thompson, MD, president and CEO of the FSMB. “There is such wide variability from state to state as to how they function and in their capability of disciplining physicians that to compare one state to another really serves no purpose.” • KBML claims it is the best. • Physicians say worst states to practice: Alaska, Kentucky, Ohio, Oklahoma • KBML – one of the worst boards in the country

10. KBML: Present Status • No term limits • Never an African-American • International Medical Graduate (IMG) was on the verge of losing position • Interventional Pain Management (IPM) lost position • Secretive selection process • Only 2-3 members control board • Some members have served over 20 years

11. KBML: Background • Medicine has evolved into 24 specialties and 140 subspecialties over the last 30 years. • Along with advances in medicine, treatments have expanded but the methodology of protecting the citizens of the Commonwealth has not changed. • The mission of the Kentucky Board of Medical Licensure is to protect the public by ensuring that licensure qualifications and standards of medical and osteopathic physicians are met and that appropriate disciplinary action is taken in a timely manner when violations of the Medical Practice Act occur.

12. KBML: Background • The Kentucky Board of Medical Licensure is composed of a few insiders representing 2 or 3 specialties for unlimited periods with no consistent representation for family practice, internal medicine, surgery, and interventional pain management. • Issues related to these specialties constitute approximately 80% of cases. • This is particularly troubling when the Board renders expert advice, but is not comprised of experts trained in areas which they control. • The Board is represented by deans of 3 medical schools, the commissioner of public health, 3 citizens at large, and 7 physicians appointed by the Governor with one of them being an osteopathic physician.

13. KBML: Background • While the Governor in theory has control over the appointments, the total control rests with the Kentucky Medical Association (KMA). • The KMA makes these appointments with 3 names which are decided usually by a few people in a closed door process. The Governor is provided with one preferred candidate. • The Governor can deviate slightly, but the Governor has no true power in controlling the appointments. • The Board is essentially controlled by the KMA • Vision of KMA (AMA) is to be an essential part of the professional life of every physician. • The Governor is held as hostage • KMA is very powerful !!! • KMA represents only 1/3 of physicians

14. KMA Position • KMA strongly opposes any effort to require designated positions, as the first responsibility of the Board of Licensure is to protect the public, not serve as an advocate for any medical specialty or practitioner. • False • While not every medical specialty is represented on the Board of Licensure, the Board does use qualified medical consultants that have expertise in specific cases that come before the Board. • False • KMA takes its responsibility to nominate candidates for the Board of Medical Licensure very seriously. • False

15. Proclamation by KMA: 2007 • KMA believes there is no room for improvement. • The improvement depends on measurements. • Statistics may be presented in different ways. • One agency may say that the KBML is number one • Physicians and other experts say KBML ranks 50th. • The present evaluation is based on how many physicians have been disciplined. • Does disciplining more doctors provide better medicine? • It essentially means we have more problem doctors. • If it continues to happen over and over again, then the Board will not be able to control or improve medical care.

16. Potential Issues: KMA 2007 • Once some practitioners allowed, others (toe specialties, right and left ear specialties) will also want to serve on the Board. • It will be perfectly fine if these other specialties can come to the legislature and convince the legislature to do the same. • It is not a big hindrance since the present classification allows most common and essential specialties serving on the Board. • If it is proven essential - add it. • The Board members are not paid a salary - it would not be a great expense. If it can provide better service to the community, it is not really that bad. • Proof is in the pudding • Interventional Pain Management • Representation on CAC

17. Potential Issues: KMA 2007 • Need for Interventional Pain Management physician • We don’t need one, because we have consultants. • But consultants have their own minds. • The medical board issues one-sided judgment with only one consultant reporting about one person. It is not fair for the citizens of the Commonwealth. There should always be 2 sides. • One can only make a decision after 2 sides are heard. • Pain management issues comprise almost 60% of the issues in front of the Board. • Half of the Board members do not prescribe many of the controlled substances. • it will be hard to get a fair shake for a person who is being presented and the person who is filing a complaint.

18. Potential Issues: KMA 2007 • Policy of no reservations based on region or race. • Federal and State governments and legislatures want minorities to be represented. • International medical graduates are a minority, even though they represent almost 20% of the practitioners in the state. • Sometimes they have different issues in front of the Board. For them to be understood appropriately, representation is required. • Never an African-American • Never an internist

19. Small States with 6 or less Congressional Districts: Number of Positions(2-17) per district Same size or smaller than Kentucky with 6 Congressional Districts • Alaska (1) 8 = 8 • Arkansas (4) 13 = 3 • Connecticut (5) 15 = 3 • Delaware (1) 16 = 16 • Hawaii (2) 11 = 6 • Idaho (2) 10 = 5 • Iowa (5) 10 = 2 • Kansas (4) 15 = 4 • Maine (2) 9 = 5 • Mississippi (4) 9 = 2 • Montana (1) 11 = 11 • Nebraska (3) 17 = 6 • Nevada (3) 9 = 3 • New Hampshire (2) 9 = 5 • New Mexico (3) 9 = 3 • North Dakota (1) 12 = 12 • Oklahoma (5) 9 = 2 • Oregon (5) 12 = 2 • Rhode Island (2) 13 = 7 • South Dakota (1) 9 = 9 • Utah (3) 11 = 4 • Vermont (1) 17 = 17 • West Virginia (3) 15 = 5 • Wyoming (1) 8 = 8 66% or 16 of 24 have 4 or more members per Congressional District with a Range 2 – 17 per Congressional District. Kentucky = Less than 2 ( ) Number of Congressional Districts

20. Mid Size States with 7 to 12 Congressional Districts: Number of Positions(0.5-3) per district • Alabama (7) 15 = 2 • Colorado (7) 13 = 2 • Indiana (9) 7 = 1 • Louisiana (7) 7 = 1 • Maryland (8) 21 = 3 • Massachusetts (10) 7 = 0.5 • Minnesota (8) 16 = 2 • Missouri (9) 9 = 1 • Ohio (18) 12 = 1.5 • Tennessee (9) 12 = 1.5 • Virginia (11) 18 = 1.5 • Washington (9) 21 = 2 • Wisconsin (8) 14 = 2 ( ) Number of Congressional Districts

21. Large states with 13 or more Congressional Districts: Number of Positions(0.5-1.5) per district • California (53) 21 = 0.5 • Florida (27) 15 = 0.5 • Georgia (13) 13 = 1 • Illinois (19) 7 = 0.5 • Michigan (15) 19 = 1 • New Jersey (13) 4 = 1.5 • New York (29) 22 = 1 • North Carolina (13) 12 = 1 • Pennsylvania (19) 10 = 0.5 • Texas (32) 19 = 0.5 ( ) Number of Congressional Districts

22. Appointments • Governor - 49 states • Board of regents = New York • Occasionally shared by: • Assembly (1) • Senate (1) • Elections (1)

23. Appointments • Recommended by: • State Medical Association/Society (advice and recommendation) = 7 states • Arkansas, Colorado, Delaware, Oregon, North Carolina, Virginia, Washington • Multiple societies = 3 • Louisiana, Minnesota, Utah • Mandated by State Medical Association = 6 • Idaho, Kansas, Kentucky, New Mexico, North Carolina, Oklahoma continued

24. Appointments • Governor to member society • Rhode Island • Elections • South Carolina • Legislative (1) or Senate (17) consent • Alaska, Florida, Georgia, Illinois, Iowa, Louisiana, Maryland, Mississippi, Missouri, Montana, Nebraska, New Hampshire, Oregon, Pennsylvania, Vermont, West Virginia, Wisconsin, Wyoming

25. Term Limits • Total = 36 states • 4 – 10 years

26. African American Involvement CommonwealthPopulation 4,041,769 African American Population in KY 311,878 7.7% African American licensed physicians  180 2% Never represented on KBML Source: 2000 Census data

27. IMG involvement • Approximately: 15 states • Mandated: Florida • Kentucky IMG population = 21%* * Source: 2007 State Physician Workforce Data Book

28. Interventional Pain Management Involvement Escalating Drug Abuse Medical Non-medical High death rate due to drug poisoning Prescription drugs Illicit drugs Highest proportion of cases related to drugs Increasing health care costs Malprescribing Lack of education

29. What is going on?

30. More lay members sought as lawmakers challenge who sits on medical boards Proposal changes from 3 to 6 • Lawmakers this year filed bills in Florida, Georgia, New Jersey and New Hampshire to add more public nonphysician members to the boards and give patients a greater voice in overseeing physicians. • Board leaders said such legislation is part of a steady trend of placing more non-physicians on boards, which some view as a way to keep physicians honest about regulating other doctors. • A physician and three patients filed a lawsuit in North Carolina, claiming that the state medical society has too much power over the medical board. • The suit asks that the process calling for the society to nominate physicians for board appointment be declared unconstitutional. • All states are changing the process. • Less influence of Medical Societies • More public members Damon Adams, AMNews. April 23/30, 2007.

31. North Carolina changes medical board nomination process • Starting Jan. 1, 2008, a nine-member review panel, which will include six physicians, will recommend potential board members to the governor. • Not Medical Society Damon Adams, AMNews staff. Sept. 3, 2007

32. Public active on medical boards • Having non-physicians on state medical boards is seen as a credibility-builder for panels seeking more public trust. • Physicians cannot be trusted to police other physicians, and non-physicians are needed to keep the "old-boy network" from sweeping problems under the rug. Andis Robeznieks, AMNews staff. Nov. 11, 2002

33. Moving Toward Transparency and Equity

34. SB 170Equity and Improvement ofMedical Practice in Commonwealth of Kentucky Proposed Legislation - I i) The commissioner of public health; ii) The dean or designee of the University of Kentucky College of Medicine; iii) The dean or designee of the University of Louisville School of Medicine; iv) The dean or designee of the Pikeville College School of Osteopathic Medicine; and

35. SB 170Equity and Improvement ofMedical Practice in Commonwealth of Kentucky Proposed Legislation - II • Four (4) mandated members appointed by the Governor. • One (1) osteopathic physician • One (1) African-American physician • One (1) international medical graduate • One (1) interventional pain physician

36. Proposed Legislation - III Six (6) members – Physicians One (1) from each congressional district Six (6) members – Non-Physician citizens One (1) from each congressional district SB 170Equity and Improvement ofMedical Practice in Commonwealth of Kentucky

37. Committee of same people Hog wash recommendations Tough stance Possibly – somewhat open process – But, still play the same game Governor was held hostage Governor on 8/11 made few changes KMA Actions

38. Interventional Pain Management Interventional Pain Management is the discipline of medicine devoted to the diagnosis and treatment of pain-related disorders principally with the application of interventional techniques in managing sub-acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment NUCC Definition 2002/2003

39. Interventional Pain Management Techniques Interventional pain management techniques are minimally invasive procedures, including percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves and some surgical techniques, such as laser or endoscopic diskectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of chronic, persistent or intractable pain MedPAC Report, 2001

40. American Board of Interventional Pain Physicians Bridging the gap between theory and practice

41. Diplomate: Part 1: Written examination or AMBS pain medicine plus CCCSM & CCCPM Part 2: Technical Competency FIPP

42. Diplomate Eligibility : ABIPP requires all applicants to be certified in the primary specialty by an ABMS-approved Board Fellowship in an Accredited program Or 4 years of full-time teaching and/or practice in interventional pain management, and 200 hours of continuing medical education in pain medicine of which 50 hours is in cadaver experience Unrestricted License

43.  public representation  public protection  minority representation  essential representation Overall good change for Commonwealth citizens SB 170Equity and Improvement ofMedical Practice in Commonwealth of Kentucky Win – Win – Win