Navigating the briar patch: The thorny thicket of MOC

The world of continuing medical board certification is in the midst of its own grass-roots movement, in a development befitting the times.

On one side stands a growing contingent of primary care physicians, specialists, and surgeons whose practice of medicine depends on maintenance of board certification. Many question the value of stringent maintenance of certification (MOC) requirements and decry associated costs.

On the other side sits the American Board of Medical Specialties (ABMS) and its 24 Member Boards, a venerable, once-authoritarian organization that generates hundreds of millions of dollars a year. The ABMS and its Member Boards are tasked with the challenge of assessing whether physicians remain current in the field, and in their respective specialties.

MOC explained

The ABMS Program for MOC aims to serve the public and enhance patient care by setting high standards for ongoing learning, practice improvement, and assessment activities for Diplomates of the ABMS Member Boards who have already attained initial certification.

By 1995, all ABMS Member Boards had instituted recertification programs that occur every 7 to 10 years. By 2007, most ABMS member boards had phased in MOC requirements.

In 2015, the ABMS approved new standards that focused greater importance on professionalism, patient safety, performance improvement, incorporation of judgment into assessments, and establishment of a framework that encourages Medical Boards to innovate based on specialty and diplomate needs.

MOC consists of four components:

• Professionalism and professional standing
• Lifelong learning and self-assessment
• Assessment of knowledge, judgment, and skills
• Improvement of medical practice

In an exclusive interview, MDLinx spoke with Mira Irons, MD, ABMS senior vice president for academic affairs, in an effort to gain a greater understanding of the recertification process.

“How these parts are assessed and implemented is evolving, with innovations seen throughout the Board’s community—including online assessments that may ultimately replace high-stakes secure exams,” she stated.

At the American Board of Internal Medicine (ABIM), for example, MOC for the fields of internal medicine and nephrology consists of two assessment options.

Diplomates can choose to take a traditional 10-year recertification exam at a secure testing center that lasts all day, or a Knowledge Check-In every 2 years that can be taken at home, in the office, or in a testing center—all under secure conditions—and lasts about 3 hours. Either option is “open book,” with test takers having the option to refer back to UpToDate.

ABIM will be rolling out the Knowledge Check-In for several more specialties in 2019 and 2020.

Dr. Richard Baron, MD, president and CEO of ABIM, placed the benefit of MOC into further perspective, in his interview with MDLinx.

“In the same way that you would want an in-depth validation and verification that somebody at the beginning of their career successfully completed training, you would want some way to say that this person is still practicing [current] medicine 20 or 30 years out, and that they are not practicing what they learned 30 years ago.”

National Board of Physicians and Surgeons

In a field where procedures and practices evolve and improve rapidly, physicians do agree that they should stay up-to-date on the latest advancements; however, many argue that MOC is not the way to do it.

In February 2014, Paul Teirstein, MD, chief of cardiology at the Scripps Cardiovascular Institute, became frustrated with MOC requirements. In the time before the Knowledge Check-In, MOC was more time intensive. It required 1 or 2 weeks of modules per year that Dr. Teirstein estimates took about 40 hours per year, which is time taken from seeing patients and other professional responsibilities.

Dr. Teirstein channeled his frustration into an online petition to recall changes to MOC. After 6 months, his petition had acquired 23,000 signatures.

“I’m not, by nature, a revolter,” Dr. Teirstein told MDLinx. “I was horrified at what they wanted me to do. They wanted [MOC] to be part of my life. It looked like I would have to spend 40 hours a year…Even the website was impossible to navigate.”

He presented the petition to the ABIM, but his call for change was initially declined. Consequently, he decided to form an independent certification entity, the National Board of Physicians and Surgeons (NBPAS) of which he is currently president and CEO.

Dr. Teirstein and the rest of the NBPAS board streamlined continued certification with the following general requirements:

• Candidates must be previously certified by an ABMS Member Board.
• Candidates must possess a valid unrestricted medical license to practice in at least one US state.
• Candidates must complete a minimum of 50 hours of recognized continuing medical education (CME) requirements within the past 24 months.
• Candidates who have had their medical privileges involuntarily revoked without reinstatement must maintain staff privileges for at least 24 months in another US hospital.

He stated that NBPAS provides an alternative pathway for ongoing certification and has “helped motivate the American Board to make some serious changes.” These changes include streamlining modules and improving user experience on the website.

Currently, NBPAS consists of 7,000 members and is accepted at 91 US hospitals. NBPAS physician leadership and board members are unpaid.

The NBPAS is petitioning for acceptance by insurers, and it has helped support the passage of “strong” Anti-MOC bills in five states: Georgia, Oklahoma, South Carolina, Tennessee, and Texas. Five states have passed “weak” Anti-MOC bills, with Anti-MOC legislation pending in six states.

Evidence Basis

Members of the NBPAS and other MOC critics have argued that studies evaluating MOC have been observational, showed either no or marginal significance, focused on certification rather than recertification, and were funded and conducted by the ABMS.

Representatives from the ABMS, however, point to a number of studies that they claim support the value of MOC with respect to care for diabetes, asthma, hypertension, pediatric patients, and elderly patients, as well as the overall practice of medicine. They also link MOC to better adherence to clinical guidelines, identifying knowledge gaps, and fewer disciplinary actions.

MOC was significantly associated with improved Healthcare Effectiveness Data and Information Set (HEDIS) process measures, according to a 2018 study published in the Annals of Internal Medicine. HEDIS performance measures have emerged as the industry standard for claims-based quality measures.

This 2018 study had limitations, however, including minimally better performance in physicians engaged in MOC, which could be easily accounted for by even a small unmeasured covariate.

Exam questions

One common complaint concerning MOC exam questions is that they are at times atopical and unrelated to the Diplomate’s routine practice of medicine.

“The tension between generalism and specialism is a built-in tension to what we do,” stated Dr. Baron. “Specialists need deep knowledge in their field, but they also need some peripheral knowledge of areas that run around what they do. There is no black and white answer that says here is what you need to know, so we deal with that through processes such as [peer review].”

Physicians also help ensure relevancy of exam questions by the Blueprint Review Process.

Grandfather clause

The establishment of the grandfather clause—which exempts older physicians from MOC—has also been criticized.

“If [ABMS] claims that MOC is important and necessary, then why are they exempting the grandfathers?” opined Dr. Teirstein. “The arguments make no sense at all when 40% of the doctors are grandfathered in.”

Nevertheless, Dr. Irons at the ABMS claims that “many of these physicians elect to participate in the MOC program as they find value in the program and its effects on their practice.”

MOC Costs

The average annual cost of MOC across all specialty boards per physician is $313. Critics argue that not only is this cost substantial over time, but associated costs—including board preparation and loss of remuneration from seeing patients—are high and amount to thousands of dollars over time. Moreover, critics question issues such as high executive pay at ABMS Member Boards, which is derived in part from annual MOC fees.

Comparatively, the cost for renewal certification for MDs at the NBPAS is $145 for two years, with no associated costs.

“When you look to see what kind of money is being brought in by these institutions, it’s kind of appalling,” stated Dr. Teirstein. “The ABIM has a budget of about $60 million—almost half of that comes in from MOC.”

Dr. Baron denied that associated costs of board recertification are the responsibility of the ABIM. “The part of this that we own is our fees, and our fees are $200 to $300 a year.”

Dr. Baron asserted that to attract the best talent at ABIM and other Member Boards, executive pay needs to be competitive. Moreover, much of the revenue that is collected by the ABIM and other Member Boards is funneled back into test development.

“As doctors know,” said Dr. Baron, “executives get paid more than some clinicians, less than others.”

Looking forward

In 2015, Dr. Baron of the ABIM issued an apology to Diplomates for previously delivering an MOC program that was not yet ready for dissemination and was less meaningful than it should have been. This apology stemmed from ABIM’s previous rejection of MOC criticism and signaled a tipping point for change.

“We recognized as a board that we had made some mistakes and that we had overreached,” stated Dr. Baron. “We were created as an authority model from the 1930s in which there are experts and then there is everybody else. In those years, doctors would tell patients what to do, and patients would just do it.”

He continued: “It’s a different world. It’s a co-creative, shared-authority world. We were slow to evolve to that, but we recognize that we needed to do that. We’re changing this because we think it’s the right thing to do. And we are working closely with the community to get it right.”

In recent years, the ABMS Member Boards have made major changes to MOC, including proffering shorter assessments, streamlining processes, expanding ways to garner MOC credit, and making the system easier to use. Notably, the ABMS has recently instituted the Vision Initiative in an effort to evolve MOC.

“The Continuing Board Certification: Vision for the Future [Vision Initiative],” stated Dr. Irons, “is a collaborative process that brings together multiple stakeholders including physicians, professional medical organizations, national specialty and state medical societies, hospitals and health systems, the general public and patients, the 24 Member Boards of the American Board of Medical Specialties, and others.”

The Vision Initiative will help build a continuing certification system that is meaningful, contemporary, and relevant, she added.

On a conciliatory note, reaction to the Vision Initiative has been positive—even among MOC detractors.

“On the vision initiative committee,” stated Dr. Teirstein, “there seems to be people on the outside. There seems to be a reasonable number of people who were not previously involved with [ABIM], which is what they need because they became a bit insular.”

In conclusion, MOC is a heated issue among detractors who question its usefulness and complain about its high costs and time requirements. Recently, the ABMS Member Boards have become more receptive to these concerns and changed the process to become less cumbersome and easier to use.

The ABMS Member Boards have also enlisted the help of outside experts to contribute to the MOC process.