ABIM Reverses Course on MOC Quality Improvement Requirements
Quality Feature — May 2015
Tex Med. 2015;111(5):51-57.
By Amy Lynn Sorrel
In a surprise move, the American Board of Internal Medicine (ABIM) is changing and suspending several recent revisions to its maintenance-of-certification (MOC) program, and physicians are cautiously optimistic the February announcement heeds medicine's call for a process that remains relevant to clinical practice.
In addition to some modifications to board exams and fees, a significant portion of the changes impacts newer MOC requirements for physicians to demonstrate quality improvements within their practices. ABIM put those programs on hold for two years. Other ABIM requirements remain unchanged.
The changes affect internal medicine and its more than 20 subspecialties. It remains unclear, however, whether other specialty boards will follow suit.
"We launched programs that weren't ready, and we didn't deliver an MOC program that physicians found meaningful. We want to change that," reads a Feb. 3 statement from ABIM President and Chief Executive Officer Richard J. Baron, MD. "We got it wrong and sincerely apologize. We are sorry."
The move does not mean physicians should stop their quality improvement efforts, says Javier "Jake" D. Margo Jr., MD, a member of the Texas Medical Association Council on Health Care Quality and MOC Task Force. "Any physician worth his or her salt is always in the process of continually trying to improve themselves. That's a lot of why we go into medicine: for the lifelong learning."
It does signal, however, that "all boards should be listening to their members and looking at how they can improve, just like we are being asked to improve. As long as we are getting something out of it [MOC] without it being punitive, it will be worthwhile," the family physician from Rio Grande City said.
TMA's MOC Task Force is exploring options to ensure all Texas physicians have access to a broad range of MOC quality improvement activities they can participate in and benefit from, says task force Chair Christopher J. Garrison, MD. He directs The University of Texas at Austin Physical Medicine and Rehabilitation Residency Program at Seton Family of Hospitals and serves on MOC committees for his specialty board and the American Board of Medical Specialties (ABMS).
"The goal is to improve overall care, and the idea is to create an opportunity for diplomates across many disciplines to improve care locally in their environment for the patients they serve," while concurrently satisfying their MOC requirements, he said.
All ABMS members, such as ABIM, and equivalent boards, participate in an MOC process through which board-certified physicians must demonstrate competency to maintain the designation. The process assesses:
- Part I: Professionalism and professional standing, shown by holding an unrestricted medical license;
- Part II: Lifelong learning and self-assessment, shown by participation in educational and self-assessment activities determined by each board;
- Part III: Specialty-specific skills and knowledge, shown by passing a written exam; and
- Part IV: Improvement in medical practice, shown by engagement in activities to improve patient outcomes and demonstrated use of evidence and best practices compared to peers and national benchmarks.
Effective immediately, ABIM halted for two years several of its Part IV quality improvement programs — Practice Assessment, Patient Safety, and Patient Voice, or patient feedback. During that time, physicians are not required to complete Part IV to maintain certification. Physicians normally would get credit for Part IV by completing a quality improvement project established by their specialty board — like using quality reports to test a change — or through a "portfolio sponsor," a health care organization cleared by ABMS to develop, monitor, and approve physician quality improvement activities.
ABIM also promises to:
- Change within six months the language used to publicly report a diplomate's MOC status on the ABIM website from "meeting MOC requirements" to "participating in MOC."
- Update the internal medicine MOC exam to better reflect what practicing physicians are doing. Changes will be incorporated beginning in fall 2015, with more subspecialties to follow.
- Keep MOC enrollment fees at or below 2014 levels through 2017.
- Assure new and more flexible ways for internists to demonstrate self-assessment of medical knowledge by the end of 2015 by recognizing most forms of Accreditation Council for Continuing Medical Education-approved activities.
ABIM Chair David H. Johnson, MD, explains the reversal follows the board's move in January 2014 from a once-every-10-year MOC program to a more continuous one — a rather sudden shift that drew what he called "fair" criticism from internists and medical societies like the American Medical Association and the American College of Physicians (ACP).
"Really, what we are trying to do — and clearly we didn't achieve it — is elevate the practice of medicine. What we are hearing is a lot of support for the values we hope MOC represents, but criticism for failing to actualize those principles," said Dr. Johnson, chair of the Internal Medicine Department at The University of Texas Southwestern Medical Center in Dallas. "We do want practices to be of the highest quality, be up-to-date, and do things that are meaningful and useful. We want to make sure that physicians don't just know to screen their patient population with mammograms, but that they are doing it. But we're not interested in having physicians waste their time."
He also urges physicians to continue their quality improvement efforts. Although ABIM suspended the requirement to complete Part IV to maintain certification, physicians may still get credit for projects they currently participate in, including the ABMS portfolio program, which has not been suspended.
Moreover, "all physicians should be engaged in meaningful quality improvement," and all boards share that goal, he added. ABIM also recognizes that, formally or informally, most physicians already participate in such activities and that they are time-consuming. "So we want to harmonize [MOC] as much as possible. Clearly, we didn't do that."
Medicine's Voice Heard
The about-face appears to follow some of the MOC principles AMA adopted at its November 2014 Interim Meeting amid a firestorm of criticism of ABIM's new continuous certification requirements. (See "Physician-Friendly MOC.")
"We are delighted that the ABIM is listening to physicians' concerns and recognizes the need to better align the requirements of its MOC program with physician learning and practice improvement needs," AMA said in a statement. "The AMA will continue to work with the appropriate organizations to ensure the MOC process supports physicians' ongoing learning and practice improvement."
ACP governor and Dallas internist Sue Bornstein, MD, is hopeful for substantive changes.
Physicians in a multihospital system, multispecialty group, or medical home, for instance, are able to and already implement and monitor measures of quality and patient safety, she says. But it was never "a given" that those activities would count toward MOC.
On the other hand, small or solo practices don't always have the mechanisms or resources to complete those tasks, and "a lot of primary care doctors are barely keeping their heads above water these days. So it was perceived to be a hardship," Dr. Bornstein said. The Patient Voice program, for example, requires the distribution, collection, and evaluation of patient surveys, something most small practices cannot afford.
Meanwhile, for physicians like Dr. Bornstein who are in administrative medicine or nontraditional practices, meeting the quality improvement requirements was nearly impossible without a patient panel to draw on for quality data.
Those were three key concerns ACP communicated to ABIM during the shift, she says, adding that the one-size-fits-all exam also was "troublesome" when many internists subspecialize these days.
She did praise, however, ABIM's switch to reflect physicians' ongoing participation in MOC even if they have not yet completed their recertification, and Dr. Johnson says ABMS is making the same shift.
Physicians perceived by hospitals or insurance companies as not meeting MOC requirements risked losing their credentialing, and "that's a real concern that could have an adverse impact on physicians' livelihood," Dr. Bornstein said. "ABIM changed the rules, and they did it pretty much unilaterally. All of these things [quality improvements] are good, but it's a matter of the real world of medicine. We want it to be meaningful and useful in our practice."
Meaningful and Useful
For Houston internist Lisa Ehrlich, MD, the process proved redundant.
The chair of TMA's Council on Health Care Quality already participates in Medicare's Physician Quality Reporting System and meaningful use of electronic health records program, as well as Bridges to Excellence (BTE), a commercial value-based care program. By themselves, those activities do not count toward MOC. But last year, Dr. Ehrlich decided to try to use BTE to get Part IV credit.
Fortunately, it worked — but not without putting in extra hours to go back through patient charts to cull data on her asthma patients, set a benchmark, and document any improvements. "We shouldn't have to reinvent the wheel and show how we put it together," Dr. Ehrlich said. "At the end of the day, it should be a learning experience, not just busywork."
While ABMS gives the various boards leeway to address quality improvement engagement in a specialty-specific way, physicians across the spectrum echo similar concerns.
Not all boards have put their Part IV MOC programs into motion. Edward Buckingham, MD, of Austin, is board certified in facial plastic surgery and otolaryngology, and neither board has fully launched its quality improvement requirements.
As a director of the smaller American Board of Facial Plastic and Reconstructive Surgery, Dr. Buckingham said, "We still haven't figured how to do that part in a way that's feasible from a cost standpoint [for the board] and not burdensome [for physicians]." For now, there are some requirements for collecting and reviewing a sampling of his practice data, like operative reports, which he does not consider too onerous.
"What we are really trying to accomplish is, physicians practicing medicine to the best of their ability so patients get the best of outcomes. And there ought to be a way to peer into a practice in a relatively easy way," Dr. Buckingham said.
Quality improvement also should be individualized, Dr. Margo says. The family physician does not spend the traditional 40-hour week in an office setting; instead, he works full time in the emergency department, delivering babies, or visiting nursing homes all over Rio Grande City.
Similar to ABIM, his family medicine board offers quality improvement projects for physicians to benchmark and track a particular quality measure. "But I have nowhere near the patient volume you would need to fulfill the requirements for one of these studies."
Dr. Margo has a small, but limited, choice of alternatives and instead completed practice modules that turned out to be a mixed bag. The module on cultural sensitivity he found "helpful"; the module on informatics he found of "little value."
Even if some physicians prefer a more worthwhile demonstration, in some geographic areas, they have limited access to the tools or to physician or hospital partners they need to carry it out, says Dr. Garrison.
TMA's MOC Task Force is looking for ways to help physicians bridge those gaps. Through a portfolio sponsor program, for example, physicians in different specialties or locations can connect on a single quality improvement project. "We want to have a venue and a method to help physicians improve their practices locally," Dr. Garrison said.
Back to Work
ABIM's Dr. Johnson clarified that the board's shift has no bearing on and was not intended to influence other specialties. "But we do communicate, and there's no question this puts pressure on them."
In a statement, ABMS says it supports ABIM's actions, which "clearly demonstrate that ABIM is listening to the internal medicine community and serious about making changes." An American Board of Pediatrics statement says while it plans to make no changes, it is "well aware of the current debate throughout the medical community" surrounding MOC and is "looking closely at the ABIM's changes and the reasons behind them."
ABIM continues to seek input from physicians as it moves forward, and internists can give their feedback through online blogs and forums. Dr. Johnson also emphasized the board's accountability to the public for delivering high-quality care, from whom ABIM is soliciting input, too.
"We've gotten a lot of feedback from the public about suspending Part IV. They don't understand it's not about abandoning our principles, but that it's not fair to ask physicians to do things that are not helpful," he said. At the same time, "we are granted the privilege by society to self-regulate, and if we don't do that, someone else will."
Overall, Dr. Johnson credits the changes to a proactive physician community that mobilized through their state, national, and specialty organizations to voice their concerns. ABIM also points out that it is "not business as usual" under the new leadership of Dr. Baron, the first nonacademic physician to lead the board.
"We feel genuine remorse, and we are going to get back to work," Dr. Johnson said.
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
TMA policy calls for a "substantially more physician-friendly" maintenance-of-certification (MOC) process. AMA policy also says MOC programs should:
- Include representation from actively practicing physicians on specialty boards developing MOC.
- Base activities on evidence, identify performance gaps and unmet needs, and provide direction and guidance for improvement in physician performance and delivery of care.
- Periodically measure physician satisfaction, knowledge uptake, and intent to maintain or change practice.
- Promote continuous improvement.
- Not be a mandated requirement for licensure, credentialing, payment, network participation, or employment.
- Be relevant to clinical practice.
- Not be cost-prohibitive or present barriers to patient care.
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