Maintenance of certification: inside the physician revolt

The frustration with maintenance of certification (MOC) has led some physicians to consider certifying with a new, alternative board-or opting out of recertification altogether.

New York-based internist Jonathan Weiss, MD, says that until he and others pushed back, the American Board of Internal Medicine (ABIM) was adding more requirements for MOC and reducing the time intervals between them “every time I turned around.” Not only that, but “at no point did I feel the material being asked of me was terribly germane to what I did on a day-to-day basis,” he says. “The process is fatally and fundamentally flawed.”

The outcry over proposed changes to MOC by the ABIM and many of the two dozen other boards that make up the American Board of Medical Specialties (ABMS) led in part to the creation a year ago of the National Board of Physicians and Surgeons. NBPAS bills itself as a lower-cost, lower-hassle version of the ABMS and its boards, with requirements that hew more closely to what doctors actually face in their day-to-day practices.

Related: Doctors put MOC on blast

NBPAS has been growing steadily, but its  membership is still modest. Still, its presence and the general frustration with MOC has led to a new set of questions: What happens to physicians who decide not to recertify with the ABMS boards-or decide not to recertify at all? Do they lose hospital privileges? Insurance coverage? And as a result, do they lose revenue?

Next: First-hand experiences

The experience among physicians not recertifying with ABMS boards has varied to date depending on locations and types of practice. In the meantime, the ABIM and other ABMS boards, which have withdrawn or postponed some of their proposed changes, continue to tinker with their MOC processes, while some wonder whether the

NBPAS will grow into a true alternative. Some connected with the group even could see it folding if the ABMS boards make changes that satisfy enough physicians.

“We have sign-ups every day. We still have a lot of challenges, and we’re working through those,” says Paul Teirstein, MD, a cardiologist at Scripps Clinic in La Jolla, California, and president of NBPAS, which had more than 3,300 members and had gained approval at 26 hospitals by early February. It has been adding about 200 new members per month. 

MOC, recertifications are ‘cancers’ doctors should rally against

Teirstein says his challenges include hospitals that have contracts requiring ABMS member board certification and the intentions of payers, who are mostly mum to date. “That is a matter of getting through to the right people at payers, getting them to pay attention,” he says. “They’re not against us, it’s just not on their radar.”

Lois Nora, MD, JD, president and chief executive officer of the ABMS, says she has heard scattered reports of physicians deciding not to recertify, although not many. “We are concerned about any single physician who would decide not to continue with board certification. I never want to hear and am concerned if a physician does not want to participate.”

Next: Dr. Richard Baron speaks out

Richard Baron, MD, president and chief executive officer of ABIM, knows of physicians deciding not to pursue MOC but believes the vast majority of physicians see it as a source of pride and recognition. “We think most people out there are saying, ‘We think it’s important to get this right, so we want to work with an organization that has real standards--but evolving those standards in a way that reflects how we practice,’” he says.

Demanding the end of ABIM recertification exams

By April 1, 2015, 83.3% percent of physicians due for recertification had enrolled to do so, down from 85.7% in 2014, but up from 79.2% in 2013, according to the ABIM. (See chart above.)

The measurable universe of those deciding not to recertify is relatively modest: beyond the signups to date at NBPAS, an organization called Change Board Certification, which was founded in 2010, says it has signatures from 3,275 physicians who want to abolish MOC. And Teirstein predicts a total of 5,000 to 6,000 NBPAS members by the end of 2016. 

Opinion: Doctors are lazy

The Henry J. Kaiser Family Foundation estimated there were 905,000 practicing physicians in the U.S. as of January, while the American Hospital Association (AHA) counted 5,627 registered hospitals, which includes those that are not members of AHA but still meet its registration criteria.

Not surprisingly, Baron hopes the universe of non-certifiers remains small. “But we know that many physicians are frustrated with our current program and we are working hard to listen to doctors and engage with them to make the program more relevant and more meaningful,” he says. “We will continue to improve the program based on what physicians say they want MOC to represent to themselves, their peers and their patients. It will be important to ensure that the MOC credential captures the pride they feel by staying current in their

discipline through a process with a binary, consequential assessment anchored in whether a physician is meeting a performance standard.”

Next: Truth about consequences

Truth about consequences

But what will happen to the admitting privileges and insurance coverage of the 0.36% of physicians who are members of NBPAS (not to mention others who have not recertified at all) if they’re practicing at one of the 99.5% of hospitals not yet officially taking NBPAS credentials? In many cases, the answer is still unclear.

ABIM: Time to heal thyself

America’s Health Insurance Plans (AHIP), the trade association representing many commercial payers, has not taken an official position. “Our member plans will evaluate board certifications among a number of qualifications for inclusion of providers in their networks,” Clare Krusing, press secretary for AHIP, said in an emailed statement. The American Hospital Association (AHA) did not return calls and e-mails seeking comment. 

Blue Cross/Blue Shield Senior Manager of Media Relations Robert Elfinger declined to comment, while Aetna, for the moment, is continuing to require certification either through ABMS affiliates or the American Osteopathic Association, although that could change, says Andrew Baskin, MD, national medical director for clinical policy and national appeals.

“We’re following [the discussion] closely, no doubt about that,” he says. “We’d kind of like to see where it settles out. We don’t see a reason to make an immediate, sudden change.”

Next: Creating chaos

The ABMS and its affiliates are known entities with which Aetna has had a long history, Baskin says, and he’s not sure whether NBPAS’s requirements are robust enough. “A lot of it centers around completing adequate amounts of CME. Most states already have requirements for CME to get a license,” he says. “I’m not sure yet that there’s enough extra value in that [NBPAS] board certification.” 

Baskin says Aetna will know more once the ABMS boards finish their tweaking of MOC requirements. “We’d like to see how the boards respond to their membership,” he says. “I’m convinced that the [ABMS] does not want this to drag on much longer. … Let’s give them a chance to see if they’re going to make any changes that are going to be acceptable to their constituency.”  

Jay Alexander, MD, who practices with NorthShore Cardiology in Bannockburn, Illinois, is Illinois governor for the American College of Cardiology and is board-certified in internal medicine, says he is aware of “plenty” of physicians who have foregone certification. 

“It has really created a lot of chaos in this whole recertification process. That chaos is very problematic,” Alexander says. Hospital administrators are concerned about allowing physicians to practice in their institutions, he says, and advises colleagues to continue because “no one knows what happens if you don’t.” 

The consequences of not recertifying would vary by location and type of practice, Baron believes. He recalls moving from a
rural hospital in Tennessee that had no cardiologists on staff to a hospital in Philadelphia where he needed to consult with a cardiologist on heart-related matters because he was not certified in that specialty.

Next: What is the likelyhood physicians will skip?

It’s unlikely that many physicians will skip recertification, given the increasing trend toward employed relationships within hospital systems that require MOC, along with similar mandates among payers to be included in their networks, believes Geoffrey Rose, MD, chief of cardiology at Sanger Heart & Vascular Institute in Charlotte, North Carolina, who recently recertified in cardiology through ABIM. 

“You may have some one-offs here and there, in certain situations, where they remain in private practice and it doesn’t seem important,” he says. “But for the majority of practicing physicians, particularly in the way medicine is organizing itself into larger delivery care systems, board certification is becoming as important as one’s licensure. I don’t think opting out is going to be an option for most.”

Those associated with the NBPAS mostly agree that physicians will continue to pursue certification, even if not necessarily with the ABIM and other ABMS boards. “They won’t be able to work in hospitals if they do that [fail to recertify],” Teirstein predicts.

Paul Mathew, MD, a board member of NBPAS and neurologist at Harvard University Medical School and Brigham & Women’s Hospital, Cambridge, Massachusetts, suspects some of those deciding not to recertify are unaware of the alternative the NBPAS presents. “That doesn’t really make sense,” he says of the decision not to recertify. “If people know the story, they’re not going to be not board-certified.”

Physicians will pressure hospitals to change their bylaws to get rid of recertification requirements , predicts Paul Kempen, MD, an anesthesiologist with Trinity Health System in Steubenville, Ohio. “Trouble is going to come up, when patients say, ‘What the hell? I had a doctor,’ ” he says, if hospitals jettison physicians as a result of a lapse in MOC. “There will be a big, freaking lawsuit, not against ABIM but against the hospital ordering [MOC].”