Will Doctors Ever Accept Maintenance of Certification?

In a case of either bad timing, tone deafness, or perhaps both, in 2014 the American Board of Internal Medicine (ABIM) chose to add several requirements to its maintenance of certification (MOC) program.

In effect since the year 2000, the MOC recertification exam was already unpopular with many physicians because studying for a high-stakes test every 10 years was seen as time-consuming and costly, and they believed many of the elements were not relevant to their practice. (Some also noted that there was little or no research yet showing the MOC program had any impact on health outcomes for patients). The changes introduced in 2014 also required them to earn accreditation points on a continual basis over the 10 years between exams in areas related to practice assessment, patient voice, and patient safety. The amount of effort involved led to howls of protest and petitions denouncing the changes.

In a February 2015 attempt to quell the uproar, Richard Baron, a physician and ABIM's president and CEO, suspended the new requirements and wrote a public letter of apology to the internal medicine community: "While ABIM's Board believes that a more continuous certification helps all of us keep up with the rapidly changing nature of modern medical practice, it is clear that parts of the new program are not meeting the needs of physicians like yourself. We got it wrong and sincerely apologize. We are sorry."

So how could a certifying body like ABIM have so badly misread the needs of the physicians it serves? "To some degree ABIM simply was not keeping track of the burden of its requirements on practicing physicians," says Todd Sagin, a physician and attorney who works as a consultant to hospital boards, medical staffs, and physician organizations. "Some of that pushback with regard to burden is a reflection of the increased requirements that ABIM was putting in place, but also it was happening at a time when physicians were generally feeling burdened by other new demands being placed on practicing physicians. So in that sense it was bad timing to be pushing a more aggressive MOC agenda."

Also, ABIM was looking to increase the rigor of the MOC requirements at a time when a growing number of physicians are nearing retirement. "There is a growing cohort of physicians for whom the benefits of MOC are going to be short-lived because they will be out of practice in a relatively short number of years," Sagin adds. "About 40 percent of physicians practicing today are within a decade of retirement, so it was an unfortunate time to suddenly burden these doctors with a new set of requirements to stay in practice."

What's Happening Now?

Fast forward to 2016: What has ABIM done in the year and a half since then to become more responsive to physicians in regard to MOC? Well for one, they've assessed the scope of the problem.

In a recent survey conducted by ABIM, 69.6 percent of physicians expressed dissatisfaction with the current MOC program. However, 86 percent responded positively to the idea of taking an assessment at home or in their office rather than in a testing center, and were comfortable with tasks potentially necessary to facilitate and secure remote assessment. Additionally, 79 percent responded positively to the idea of taking shorter knowledge assessments that would allow them to skip the full-length MOC exam.

Richard Battaglia, ABIM's chief medical officer, says that the survey results were not surprising, but certainly still a disappointment. "I think one of the heartening pieces of information that came out, despite a high percentage expressing concern, is that there was also a fairly high percentage who says ABIM was doing a much better job of addressing those concerns in the recent past. We are continuing to build on our efforts to engage the community in really substantive dialog around how we can address their concerns." To this point, 38.5 percent of physicians are satisfied with ABIM's recent efforts to address the needs and concerns of the internal medicine community, while 31.4 percent were neutral.

ABIM is trying to make sure the elements of the MOC program fit more seamlessly with what physicians are doing in their practices, Battaglia says. "Much of what we heard in the past was that although the goal of the MOC program - to be sure physicians are keeping current in knowledge - was laudable, many of the activities required were not seen as user friendly or were seen as redundant in some ways."

Because many physicians are active in terms of continuing medical education (CME) courses, Battaglia says, ABIM is collaborating with the Accrediting Council for Continuing Medical Education (ACCME) to identify CMEs that meet the requirements for MOC. "Therefore, thousands of activities that weren't available for MOC credit can now be transferred to ABIM without additional work on the physician's part. It is something they are doing on a regular basis and we felt they should receive credit for it. We have been able to work on a system that is much more user-friendly for them."

ABIM is also working to create alternative options to the unpopular 10-year recertification requirements by 2018, with a task force currently working on it and gathering input from physicians. It plans to offer assessments that would be more frequent and shorter. The tests wouldn't necessitate that physicians go to secure testing centers; they could take the exams at home or in their office on their own computers. "By having them be more frequent, we can have them fit into a program of lifelong learning," Battaglia adds.

Battaglia and his staff have been traveling to professional society meetings and inviting ABIM diplomates to have an open dialogue around various issues. "Right now we are focusing those sessions on the new assessment pathway and how it might be shaped," he says.

Will It Work?

So will the listening sessions and new approach signal enough change to address longstanding concerns and win the confidence of disgruntled physicians? The response from some physicians seems to be "too little, too late."

In June 2016, the Pennsylvania Medical Society's board of trustees voted to take a position of no confidence in ABIM. Scott Shapiro, a clinical cardiologist and president of the society, says some boards, such as the American Board of Anesthesiology, worked with physicians to make adjustments so that the physicians were satisfied with the MOC process. However, he says ABIM is failing physicians who are well-qualified at unprecedented rates, requiring them to pay exorbitant fees and spend hours reviewing for courses that are unrelated to their medical practice. "And they are unwilling to change the process," he says. Shapiro and other physicians also criticize ABIM's leadership for what they consider lavish executive salaries and other perks.

ABIM's Battaglia responded that the nonprofit organization is transparent about its finances. Its IRS Form 990 is available on its website. "A variety of people who have looked into those areas have come away feeling comfortable that the accounting practices are fine," he says, adding that he couldn't say why the critics are so focused on that aspect of ABIM's practices.

Sagin says that critics who focus on ABIM's finances are picking on issues that trigger emotions rather than rational considerations. "We could always quibble over whether somebody's salary is too much or too little, but that certainly is not the basis on which you decide whether maintenance of certification is a professional activity worth pursuing," he says. "There are a lot of reasons why board certification came about in the first place and lots of reasons to continue to keep it effective and relevant. It is one of the important elements of a profession that wants to be able to self-regulate."

An Alternative?

Another physician upset with ABIM's 2014 changes was Paul Teirstein, chief of cardiology and director of interventional cardiology at Scripps Clinic in La Jolla, Calif. "They tried to make the MOC woven into a physician's work flow," he says. "That was when many of us got frustrated." He started a petition and got 23,000 signatures, and presented it to ABIM. "They did nothing, so we started an alternative organization." His National Board of Physicians and Surgeons (NBPAS), an attempt to create an alternative to ABIM's MOC, relies on physicians knowing what they need to study to stay current in their practice area and to prove it by gaining CME credits in those areas. It still supports requiring initial board certification, just not using ABIM's MOC.

Teirstein says the biggest challenge NBPAS faces in its startup phase as an alternative certification board involves the insurance companies. "Hospitals that employ doctors, such as large academic medical centers, have a problem because their contracts with insurance companies require providers to have board certification by ABIM, not the National Board. So getting that changed is a laborious process. It is not high on the insurance companies' or the hospitals' list of priorities. So doctors just have to demand it. And it is happening," he claimed. "I don't think this happens overnight. When I talk to hospital administrators about it today, it is a completely different conversation than last year. Last year they looked at me like I was nuts. This year they all understand the problem."

Organizations such as NBPAS face an uphill battle, Sagin says. Based on his experience as a consultant, he estimates that approximately 70 percent of hospitals require board certification to join a medical staff, and half of those require maintenance of certification. "Specialists who don't maintain board certification may not retain hospital privileges and that is a significant barrier to their practice of medicine," Sagin says. "As we move into Accountable Care Organizations, they have to have credentialing criteria. If physicians are going to participate in these kinds of insurance networks, they are going to have to meet the requirements for membership. And at least some of them are going to distinguish themselves by having doctors who are board certified and maintain their certification."

Some state governments are intervening with their own plans regarding MOC. A bill passed by the Oklahoma Legislature and signed by Gov. Mary Fallin states: "Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment or admitting privileges at a hospital in this state."

Battaglia says that whether or not ABIM can win back groups such as the Pennsylvania Medical Society is up to those organizations. "We have had ongoing dialogue with the majority of the professional societies, even ones that have been critical, to understand their concerns and put in place modifications to address those concerns," he says. "That is how we need to continue to define the program: Physicians helping us understand how best to set it up, make sure it is rigorous but also user-friendly, and fitting into the day-to-day lives of physicians. This is going to be an ongoing effort. This is not a short-term fix. We are transforming the culture of the way we administer and refine the program over time."

ABIM is indeed under close scrutiny, Sagin says. "They are the biggest of the ABMS [American Board of Medical Specialties] boards and they got into the most hot water," he says. "I think the other boards will be watching them closely as well. All of them have tackled MOC in a slightly different way, and I think they are all looking to learn from the ABIM experience."

David Raths, is a freelance writer for Healthcare Informatics, Campus Technology, T.H.E Journal, Public CIO, and Physician Practice magazines. He can be reached at editor@physicianspractice.com.