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!

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.