CMS and our USMLE physicians

i know a few years back we were cited for lack of US licensed physicians, and there was even a movement to no longer hire physicians non USLicensed, and to assist current physicians to get their US license.  Now, we have lost most of our USLicensed physicians and  I wonder,

1.  How many physicians at LBJ currently have a US locense

2.  Will this affect our Medicare standing?




Dr. Jim Marrone's picture

Hello, ByFaith.

Hello, ByFaith.

I was there living and working at LBJ throughout pretty much all of things you mentioned in the preamble to your questions.  So for what it's worth, this is my perspective on those 2 issues:

1.  There were not many U.S. Licensed physicians (just a handful) as of my last day working at LBJ in late 2015, and my guess is that this remains the case today.

But to fill in some of the back story to all of this, it was 2006 actually when the LBJ Board of Directors decided that they were no longer going to be able to accept physicians working at LBJ without U.S. Licenses, or at least U.S. Licensability.

Now, knowing some of those folks on the Board at the time, and from what I can remember about the discussions I had with at least some of them regarding this issue, I can definitely trust that they sought proper legal counsel before making their decision.  I also believe it is very likely that they seriously looked into the CMS (and other funding/liability) ramifications of continuing with physician hiring based on the licensing determinations of our own local Licensing Board (the AS Health Regulatory Services Board - ASHRSB).  While I do not remember ever seeing hard proof of those things being thoroughly settled, it was made very clear that this was the Board's responsibility and they were taking it very seriously.  Hence, the Medical Staff then got the following very concerning news from them.

Their reasoning (which was clear and decisive at the time) was that, due to an Administrative Rule (of Law) which has been on the books at ASG (since 1987 or 1988, I believe?), up until that point the vast majority of all physicians throughout the entire Territory (not just those employed by LBJ) had been "inappropriately licensed..."  And they, as the Governing Body of the only full-fledged medical center on island, had decided that they could no longer be responsible for knowingly breaking that law (by hiring doctors who did not meet our own local licensing requirements)!

FYI, the Administrative Rule to which they were referring (which we were clearly told, has the full force and effect of law) said that physicians in the Territory either had to have 1. taken and passed the NBME (National Board of Medical Examiners) Licensing Exam(s), OR 2. be from a medical school within a very limited list of certain "approved" countries (U.S., Great Britain, Papua New Guinea, and several other countries, mostly European I believe, were on there - but Fiji clearly was not).

Anyway, it turns out this Rule was clearly there all along, although almost everyone (ASHRSB, LBJ, DOH, and even ASMADA - The American Samoa Medical and Dental Association) was either unaware of it, or at the very least had basically completely ignored it for the intervening years.  So you can imagine the shock and dismay that most of our physicians felt hearing pretty much all of a sudden that whether the ASHRSB continued to issue them local licenses to practice medicine or not, after a certain point their current licenses were simply no longer going to be considered valid to work at LBJ!  At that time were talking of about at least 80% or more of the entire LBJ physician workforce, I would estimate.

So, the Board gave everyone affected by this decision a time frame of 2 years to take and pass the appropriate Step(s) of the United States Medical Licensing Exam (USMLE), which had by then replaced the NBME both nation- and worldwide as the minimum requirement for practicing in the U.S.  Otherwise they would no longer be guaranteed further employment at LBJ, and the not so subtle implication was that they would in fact be let go from their jobs there if they did not comply.

The Board said that it was putting our Hospital and Government at serious legal risk by continuing to ignore that law, and at least hinted that it could also affect our Federal funding eligibility.  Finally they also included that they wanted to ensure a minimum standard of physician knowledge and competency for our patients, based on the kinds of standards that CMS and other such Agencies uphold.

Well, the years came and passed and no one was fired or let go because of this, but they did try to enforce it for a time at least with any new hires as I remember it.  And I believe only 2 of the LBJ physicians employed at the time took and passed their required Steps of the USMLE.  I'm not sure how many others, if any, might have attempted to do so.  I can tell you from my own experience that it's a long, grueling examination, which goes back all the way to one's first day of Medical School, and practically it's probably not all that useful for folks who are already out and practicing in a given Specialty for many years...  Like in Surgery or Emergency Medicine or Pediatrics, for example (we have "Board Certfication" for that, which is usually granted only after specific testing taken upon the completion of one's Residency training!).  The most important thing for our purposes in my mind that the USMLE does do though, besides giving someone a basic License to practice medicine as a General Practitioner in the U.S., is it makes them eligible for full Residency training (in both the Primary Care, and Specialty fields).

Anyway, several more years passed, and Governor Togioloa even issued an Executive Order at one point not only protecting those physicians already on staff from being let go because of this, but also officially allowing the Hospital to continue to recruit folks from outside who had never taken the USMLE.

Then under the new CEO Michael Gerstenberger, somewhere around 2011-2012 (along with the next generation of the Hospital Board), the decision was made to look more towards "clinical competency in practice" standards.  So, as proven experts in that area, the P.A.C.E. Program (Physician Assessment and Clinical Education Program) at the University of California San Diego was contacted, and an agreement was made to bring them out to formally review our medical staff.

That whole process took at least a couple of years, and included something like 7 different phases of overall assessment for all of the "at risk" physicians on staff at LBJ (direct observation, peer review, chart review, oral examination, and written examinations were all included in their assessment, among other items).  It also cost a good deal of money, but I believe that Grant(s) were sought out and secured for this purpose, which at least were supposed to have covered most of it?  In the end though, now even more time has passed, yet to my knowledge no results nor conclusions from this Program have ever been released (not even to those that went through the entire process).


2.  With regards to CMS funding and eligibility, it's another interesting and fairly unique situation in AS.

In terms of Medicare (basically National Health Insurance for the elderly, mostly for folks who have contributed salary taxes throughout their lifetime which then earns them these benefits, plus some with serious disabilities), apparently the requirements are very strict.  As such, if you are not U.S. Licensed (or "equivalent," which is very uncommon but possible in certain cases), you and/or your employer simply cannot apply for reimbursement from CMS while providing care to these patients.  So the list of physicians at LBJ who can bill for their services under Medicare has for a long time already been very short, and I strongly suspect that it still remains so.

On the other hand, for Medicaid (State/Territorial Medical Insurance for the poor only, without regard to age or earned benefits or contributions made, etc.), the standard is considerably more lenient.  In fact, mainly what I remember being pointed out was that you simply have to be actively licensed in the State/Territory where you practice to be eligible to request that reimbursement.  The obvious problem with this for AS however, is that there is still a law on their own books which directly contradicts the licensability of almost all of their working doctors!

Finally, the easiest solution to all of this, at least as many of us saw it, was that by now THE FONO CAN AND REASONABLY SHOULD HAVE ALREADY CHANGED THIS LAW!  Again to my knowledge however, and even though they have definitely discussed it at certain times (several of us were called in at one point on the matter), this has never been prioritized to the point of making any newly proposed Legislation.

So, the questions and potential conflicts remain, and while I am certainly no expert on these things, I think this recap suffices with most of the relevant background information and chronology on the medical Licensure conundrum in AS.  I certainly encourage others with knowledge and/or experience on these matters to help fill in these remaining question marks for all of us!

"Problems with a Quick Fix"

Hello Jim,

   I appreciate your synopsis of the USMLE/Staffing problems extant in American Samoa, and as related to LBJ.

   I would like to refer you to a comment I made under "USMLE" within the "Home" section. It was a brief description, as I recall the (referred to) conference, which, perhaps, you had attended, Iwould guess approx. 2008/2009, while Pat Tyndall was CEO. The letter is a follow up to Mr Lovelace's comment.

  I would appreciate your input. 

  It seems abundantly clear that very little has changed at LBJ, esp. Regards, financial woes, inadequate staffing and "politics". 

  Wow........Really sad, as many of the staff work SO HARD to do the best they can........ Larry Bethoney, MD


Dr. Jim Marrone's picture

Talofa Lava, Dr. Bethoney!

Talofa Lava, Dr. Bethoney!

     So nice to hear word from you.  Indeed, it was for many years that both of us worked there.  While I must preface these comments with the caveat that since late 2015/early 2016 I have not worked nor lived in AS, I'm sorry to say that from my personal perspective anyway, things have certainly not substantially changed...  At least, not for the better!

     I believe in fact I was at the meeting you referenced (it was most certainly Dr. Fred Urhle you are remembering), and in fact there were several meetings just about like that over time, starting as early as 2006 when the Hospital Board's edict first came down about the legal necessity for all of the Medical Staff to take and pass at least the first 2 stages of the USMLE.

     I too (just as background/full disclosure here), spoke out openly and clearly against the requirement, especially with it's "deadline..."  Not because I thought it was a bad idea for our Staff to be equivalently certified (not to mention reimbursable/billable!) mind you, but mainly because it would have been practically impossible!  Impossible for all of the working/full-time employees go back, study, and pass those exams at the same time while still working (I certainly wouldn't/don't want to have to do it again!), but also clearly impossible for those of us who have already met that requirement to continue staffing all of the often busy Wards and Services and Clinics down there while the rest of the Medical Staff might be away (studying and/or test-taking, etc.)!  And I did not see any tangible plans at all really for replacing those missing practitioners while such a large portion might be away, so under those terms and conditions and realities it was just not going to work, PERIOD.  Doesn't mean we couldn't have changed the Law, you know, or that any number of other such "think out of the box"-type solutions couldn't have been tried, but just letting them all go was, yes, very likely to probably chase away the rest of us as well.

     Furthermore, I agree you are right, it would have been the vast majority of the Medical Staff that would have been thusly ruled out with essentially the stroke of a pen, you know, from one night to the next, I mean whenever the Board decided it would actually be enforced (originally slated for like mid-2008, I believe).  My best estimate would be like about 80-90% overall of the then-working Medical Staff would have had to have been summarily dismissed, and some Departments didn't even have one physician at that time with the necessary "Steps" of the USMLE under their belts.

     So clearly, another solution would need to be come up with, and as you also mentioned, it was not.  Not without some of us trying, however!  And certainly not without some of us (yourself included) speaking out on this.  Also of note, there were a small handful who took the initiative (and time off, Leave without Pay, whatever they needed!) to take and pass those Exams!  Drs. Ben Siatu'u (Ophtho.), and Akapusi Ledua (Orthopedic Surgery) immediately come to mind, but there may have also been one or two others...  And as I understand it, they are both now running there respective Departments, achievements which are very well deserved and, clearly hard won.  Malo, Foma'i(s)!


     Also, it's interesting that you mentioned Pediatrics as the only Dept. around that time to be more adequately staffed...  We were certainly that, but only at certain times mind you, and when we were I'd say it was due in very large part to the intense recruiting efforts made from within our same Dept.!  Then at other times, due to I believe to a much larger set of circumstances (at least a serious number of which were essentially totally out of our control), we also lagged pathetically.

     When my Contract was not renewed near the end of 2015, for example, there were just 2-3 Pediatricians sharing all of the on-call work remaining, and maybe 1-2 others covering the Peds. Clinic the best they could, with no direct relief in sight.  This despite all of my (and my colleagues') most earnest efforts to the contrary.  We simply couldn't get, much less retain, enough qualified recruits through the whole process during certain periods over the years, and money/salaries (while certainly an important factor there) was definitely not the only hindrance!

     Which reminds me, it is one thing to make note of and complain about the amount of Federal money that comes in every year, or at least the amount of money that the Federal Govt. earmarks for Healthcare in the Territory.  It's another thing entirely however, to find out how much of that money actually gets spent elsewhere, often before even coming into the Hospital's coffers...  There have been a string of recent CEOs and/or CFOs whom I'm sure could more eloquently expound on these issues, but let's just say that with better forethought, organization, expert planning and follow-through, the people of AS (heck, the people of the greater U.S. for that matter, because in all actuality it really is largely U.S. taxpayer $ that supports our Insular Areas) really ought to be getting substantially more "bang for their bucks."  If nothing else, I reference the almost non-existent and much maligned "Off Island Referral Program" at LBJ.  Which is all but a shadow of its former self, while it could be easily argued that right now it's actually needed so much more than ever.  Many, many SamoaNews and Talanei stories have been done on these issues, some of which I've seen referenced on this site.


     In any case, please feel free to help this community and/or the FaceBook page continue this discussion!  Contact your friends, colleagues, Representatives and Authorities, you name it.  It would be wonderful as well to hear from more local folks about how they feel, you know, especially the Matais and such, but clearly everyone in/from AS deserves a voice in the delivery of their healthcare, and although it probably goes without saying, people are still dying down there in pretty significant numbers!  Let's hope and pray it's not unnecessarily so, right?!  Take care, Sir.  Looking forward to hearing more from you, and folks like you!  Warm regards, JIM M.

Dr. Jim Marrone's picture

Recent/current CMS Audit?

I would like to know if anyone has any substantive information on where the Territory stands with regards to the most recent visit from Federal CMS Inspectors?  Is LBJ still not meeting enough of their "Conditions of Participation" such that it might be removed from the at risk list?

It has been (I believe) well over a year now since they last came, and the loss of or even just significant curtailing of part of the funding from that program which LBJ absolutely depends upon could be catastrophic for Healthcare in the Territory.  If anyone has this type of information, or even just a well-reasoned opinion on the matter, please feel free to post it here, and/or in the linked Facebook page!

Blessings and best of luck to you, people of AS!  Your patience is remarkable.