While Texas and Other States Seek to Ban Mandatory Maintenance of Board Certification, Some Specialty Boards Acquiesce to Change
Cover Story — September 2016
Tex Med. 2016;112(9):26-32.
By Amy Lynn Sorrel
Kim Monday, MD, worked hard to attain board certification in three different specialties: neurology, clinical neurological physiology, and sleep medicine. She knows it sets her apart, and without it, for instance, she could not have an accredited sleep lab or see certain Medicare patients. She also knows it's important for patient care that she keep up her skills and knowledge, and she doesn't mind taking a test or completing continuing medical education (CME) to stay fresh.
Dr. Monday does mind that the exhausting recertification exams she spends months preparing for are largely filled with multiple-choice questions that entail regurgitating facts often irrelevant to what she sees in daily practice. That's in addition to expensive test and material fees, ongoing peer review activities, and quality improvement projects that duplicate her existing efforts in the office or at the hospital. Multiply some of those requirements by three because she's triple-boarded.
If Dr. Monday opted out of maintenance of certification (MOC), she wouldn't lose her medical license. But she likely would lose access to hospital privileges and health insurance networks, which often require up-to-date board certification.
"The last thing doctors want to do is become less educated. We're already fighting off scope-of-practice intrusions," the member of the Texas Medical Association Council on Socioeconomics said. "We're willing to do what's reasonably necessary. But there comes a point at which we have to push back and say: This is not making us better doctors. Doctors have had enough of mandates like MOC and PQRS that don't result in quality patient care. Period."
MOC — not to be confused with maintenance of medical licensure — has long riled the nation's physicians over what doctors say are costly, burdensome, and frivolous programs to prove their medical skills are up to date. Many physicians also question the financial motives of the certifying boards, and debate the impact of MOC on patient outcomes.
The outcry has gotten lawmakers' attention: In April, Oklahoma, with support from the Oklahoma State Medical Association (OSMA), became the first state to enact a law banning the use of MOC "as a condition of licensure, reimbursement, employment, or admitting privileges at a hospital."
News of the legislation quickly prompted TMA's 2016 House of Delegates to follow suit in adopting a resolution that calls on the association to "pursue legislation that eliminates discrimination by the State of Texas, employers, hospitals, and payers based on American Board of Medical Specialties' [ABMS'] proprietary MOC program as a requirement for licensure, employment, hospital staff membership, and payments for medical care in Texas."
ABMS, the umbrella organization for 24 medical specialty boards, stands firmly by MOC as a public accountability measure and by entities' ability to use it as a credentialing standard.
"The purpose of continuing certification is really to enhance patient care, which is crucially important all the time, but especially in the transformative times we have in health care right now. Hospitals, health care systems, and others have a responsibility to identify quality credentials they wish to use, and this legislation handicaps them from using it," ABMS President and Chief Executive Officer Lois Nora, MD, said.
At the same time, she says specialty boards are tuning into physicians' protests with considerable changes. Dr. Nora points to "lots of innovations happening across the 24 boards. ABMS and member boards have made dramatic transitions in MOC, maintaining it as the public trust in a quality credential, while also making it more physician sensitive."
Show Me the Evidence
Once a lifelong credential, ABMS member boards shifted to requiring physicians to continuously re-up their board certification. But over the past decade or so, Dr. Monday says the process went from a one-time test and keeping up on specialty-specific CME of doctors' own choosing, to jumping through a series of mandated hoops, tests, and fees.
In addition to testing, for instance, physicians must regularly earn credits every few years by demonstrating competency and completing ongoing MOC activities in four categories:
- Professionalism and professional standing, shown by holding an unrestricted medical license;
- Lifelong learning and assessment, shown by participating in educational and self-assessment activities determined by each board;
- Specialty-specific skills and knowledge, shown by passing a written exam; and
- Improvement in medical practice, shown by engaging in quality improvement activities.
In addition to multiple-choice tests, for instance, MOC activities might include simulation work or other clinical skills assessments asking physicians to discern a diagnosis and recommended treatment. Newer, much-maligned requirements for physicians to demonstrate quality improvements under the ABMS Portfolio Program drew criticism for requiring projects inaccessible to smaller practices or unrelated to real-world medicine or for duplicating physicians' existing work with other institutions.
"It's a good idea to make sure doctors are keeping up with the literature and CME in their specialty. But there are other requirements that have built up that are too much to bear," Dr. Monday said. She estimates spending $10,000 to maintain her three board certifications, not accounting for the cost in time it takes to complete all the pieces involved.
Physicians also point to studies showing the recertification process has become more expensive with little to no patient care benefit. Most recent studies focus on the American Board of Internal Medicine (ABIM) — the largest ABMS member board — whose policies have drawn exceptional criticism.
A pair of 2014 Journal of the American Medical Association studies compare internists grandfathered in with lifelong certification with those subject to MOC. One report, which looked at internists providing primary care at four Veterans Affairs medical centers, found no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures.
In a second study, researchers who looked at certain preventable hospitalization measures found no difference in quality between the two groups, but a small reduction in cost growth among the MOC-required internists.
A 2015 Annals of Internal Medicine study found a 2014 increase in ABIM fees and requirements for MOC — some of which ABIM has since suspended in 2015 — would "generate considerable costs, predominantly due to demands on physician time." (See "MOC Costs for Internists.")
"Doctors are data-driven, and there's no data to support all the extra work," Dr. Monday said.
ABMS officials say the recertification standards are meant to keep up with increasingly rapid changes in medicine. They point to their own body of research showing MOC participation improves care.
A Legislative Solution
Yet, failing to maintain board certification carries serious, negative consequences affecting physicians' livelihoods, a hazard TMA is seeking to eliminate with the help of the state legislature, says TMA Council on Legislation Chair Ray Callas, MD.
The Beaumont anesthesiologist estimates his test fees to be around $3,000, plus another $1,500 to take a simulation course and the time away from his practice to study, travel, and take the exams. "Why do I need a simulator when I see patients every single day?" he asks.
ABMS says board certification is a voluntary process, above and beyond medical licensure. No states, including Texas, require MOC as a condition of licensure.
However, MOC, in effect, has become a mandatory process in some cases for physicians to keep seeing patients, Dr. Callas says, now that hospitals, public and private payers, and even some employers require continuous certification in order to practice within those entities. Medical liability coverage also could hinge on board certification, he adds.
"MOC is held over physicians' heads and made punitive, when it's financially draining and not improving the quality of care," Dr. Callas said. Nor is there much need for board-mandated MOC when physicians already must meet continuous CME requirements in their specialties to maintain their licenses. "It's a better way of allowing us to learn based on what we practice."
TMA is one of a growing number of state medical associations with policies on the books opposing compulsory MOC. New American Medical Association policy adopted in June at AMA's 2016 House of Delegates meeting in Chicago pressures boards to put an end to high-stakes exams, while reaffirming principles advocating MOC programs should be evidence-based, clinically relevant, affordable, and physician-developed. (See "AMA House Takes Action on MOC.")
Physician pushback has sparked legislative action in a number of states that has garnered medical societies' support. Most notably, Oklahoma's elimination of MOC as a condition of licensure, payment, employment, or hospital privileges becomes law on Nov. 1.
In an April letter urging Gov. Mary Fallin to sign Senate Bill 1148, OSMA officials cite instances of physicians who could not get hospital credentials because the Oklahoma Board of Medical Licensure does not officially recognize their non-ABMS specialty board for certification purposes.
"Oklahoma physicians want to be continually improving themselves to demonstrate a commitment to lifelong learning. For many physicians, MOC is a way to do that. But it is not a one-size-fits-all solution and should not be used as the sole deciding factor in a physician's ability to practice and treat patients," OSMA officials wrote.
OSMA Executive Vice President Ken King says it's too early to determine the law's impact. The legislation drew pushback from patient safety groups, and OSMA continues to monitor hospitals' reaction because nothing in the law expressly prohibits the facilities from making MOC a criterion of hospital privileges.
But OSMA maintains such actions would interfere with the practice of medicine because SB 1148 bans forced MOC by amending the state medical practice act.
"We think it's a solid law," Mr. King said. "At the end of the day, doctors felt it was time to step up and say, 'Look, there's no evidence MOC does anything to improve the quality of care doctors provide to patients. We pride ourselves on being evidence-based, and there's just no evidence for this.'"
TMA's Council on Legislation is tracking similar laws brewing in other states: A narrower Kentucky law prohibits MOC as a condition of licensure; a pair of Missouri bills build on the Oklahoma law saying CME suffices to demonstrate professional competency; and several Michigan measures go further to expressly prohibit hospitals and insurers from denying privileges or network credentials based solely on MOC.
"Maintenance of certification red tape and insurance company policies far too often stand in between physicians and their patients. That's not just a hassle — that's dangerous," Michigan State Medical Society President Rose M. Ramirez, MD, states in a press release promoting the organization's MOC reform campaign.
Lawmakers in those states also have gotten behind the bills in part to discourage physicians from leaving practice at a time when many states face shortages. Oklahoma's law was carried by physician legislator, state Rep. Mike Ritze, DO (R-Broken Arrow).
As TMA similarly courts Texas physician legislators to carry the torch in the Lone Star State, Dr. Callas emphasizes TMA's legislative advocacy will ensure a pathway for those physicians who want to pursue MOC, but that pathway should be voluntary and meaningful.
"Do we believe MOC is important? Heck, yeah. But it should be state-driven, specialty-driven, and medical association-driven so your education is going to improve the health care of patients you take care of, not just your test-taking skills," he said. "The freedom to choose is something we gain at the state level through legislation, rather than being held hostage to one single entity."
Boards in the Spotlight
Boards, while not backing down, are taking notice.
Dr. Nora says board certification, including MOC, remains voluntary, and ABMS policy maintains the process should not be the sole credential to determine physician competency.
"That being said, we believe it is a very important credential. We would not be doing our public responsibility if we did not insist board certification was an ongoing process. It shouldn't mean what your doctor did 40 years ago is what they are doing now," she said. "We have not made it mandatory, but hospitals, health systems, and others recognize that board certification and MOC are associated with enhanced quality." Taking away that prerogative, she said, would be "detrimental to patients and detrimental to physicians."
Dr. Nora acknowledges, however, that boards, too, must continuously improve, pointing to recent innovations.
A neurologist, Dr. Nora says she understands, for instance, the stress and burden created by a high-stakes exam every 10 years. She says many boards are piloting remote proctoring and access to materials, while tailoring exams and quality improvement activities more closely to actual physician practice. ABMS also set up what she calls an "MOC directory" where doctors can find approved learning opportunities outside those created by the boards — at medical schools or medical societies, for example — and expanded the number of sponsoring institutions in the portfolio program.
ABMS is attentive to reducing fees where possible, and Dr. Nora anticipates some of these changes will help moderate costs. She says fees tend to balance out to a few hundred dollars a year, and physicians would be doing many activities, like completing CME or attending specialty meetings, anyway. Because costs translate to value, however, "as physicians find this more and more relevant to their specific practices, they are less concerned."
Testimony at the AMA's House of Delegates meeting in June also highlighted improvements. Several boards, for instance, are looking to replicate the Board of Anesthesiology's "MOCA Minute," which replaces lengthy exams with periodic, interactive quizzes. Other changes would make simulation activities optional. (MOCA stands for MOC-Anesthesiology.)
In the face of vehement criticism, ABIM suspended its quality improvement and patient safety requirements in February 2015 until more meaningful standards are defined, while overhauling other MOC components, including:
- No longer requiring underlying certifications for MOC in some disciplines. A physician boarded and subspecializing in interventional cardiology, for instance, no longer has to recertify in general cardiology.
- Creating a new partnership with the Accreditation Council for Continuing Medical Education to accept more forms of CME for MOC credit.
- Providing an alternative for diplomates in good standing to take assessments at home or in the office versus traveling to testing centers.
A big shift underlying those changes was altering ABIM's governance structure to better communicate with physicians and incorporate doctors' feedback into program redesign, says ABIM President and Chief Executive Officer Richard J. Baron, MD. In updating exams, for instance, ABIM asks practicing physicians to rate blueprints for relevance and importance.
Drs. Baron and Nora both disagree that CME by itself is adequate. ABMS publically rebuked the new AMA policy opposing exams.
While a crucial component of lifelong learning, "CME is an entirely passive standard," Dr. Baron said. "Adult learning theory says assessment drives learning, but a part of what makes you retain knowledge is testing on it. CME is enough for licensure. But 81 percent of licensed doctors in the country are board-certified and always felt they met a higher standard.
"I get that physicians are feeling frustrated and pushed around and overly regulated," he said. "When you think about how much medical knowledge has changed since I finished my training 32 years ago, our program can provide reassurance to doctors themselves, to colleagues they work with, and reassurance to the public and health care institutions that they meet a defined standard and are practicing today's medicine."
Dr. Monday sees the MOC tide shifting in the right direction. "Physicians value lifelong learning; we are just requesting reasonable requirements and more meaningful standards."
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.
MOC Costs for Internists
The American Board of Internal Medicine's (ABIM's) 2014 increase in fees and required modules for its maintenance of certification (MOC) program has had an impact on physicians. A 2015 study published in Annals of Internal Medicine sought to compare the total cost of the 2015 version of the MOC program with the 2013 version.
The study found internists will incur an average of $23,607 in MOC costs over the course of 10 years for the 2015 version of the ABIM test. The fees range from $16,725 for general internists to $40,495 for hematologist-oncologists. When factoring in the much greater cost of physician time spent on MOC, researchers calculated time costs account for 90 percent of MOC costs.
Cumulatively, the study states, 2015 MOC will cost $5.7 billion over 10 years, which is $1.2 billion more than the 2013 MOC program. The estimate includes $5.1 billion in time costs (32.7 million physician-hours spent on MOC) and $561 million in testing costs.
The study's authors call for a rigorous evaluation of the ABIM MOC program on clinical and economic outcomes in an effort "to balance potential gains in health care quality and efficiency against the high costs identified in this study."
Source: "A Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program," Annals of Internal Medicine, Sept. 15, 2015
Back to article
AMA House Takes Action on MOC
Physicians’ growing discontent with maintenance of certification (MOC) programs bubbled over at the 2016 Annual Meeting of the American Medical Association House of Delegates.
A group of state medical associations, supported by Texas, pushed the house to endorse tough language. The house directed AMA to "call for the immediate end of any mandatory, secured recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process for all those specialties that still require a secure, high-stakes recertification examination."
Delegates also adopted a new report from the AMA Council on Medical Education that examined the cost and relevance of MOC activities.
Delegates approved new policy statements in the report, including directives to AMA to:
- Examine the activities that medical specialty organizations have under way to review alternative pathways for board recertification;
- Determine whether there is a need to establish criteria and construct a tool to evaluate whether alternative methods for board recertification are equivalent to established pathways; and
- Ask ABMS to encourage its member boards to review their MOC policies regarding the requirements for maintaining underlying primary or initial specialty board certification in addition to subspecialty board certification to allow physicians the option to focus on MOC activities most relevant to their practices.
Back to article
September 2016 Texas Medicine Contents
Texas Medicine Main Page