MOC: An examination of costs and impact to physicians

It's considered onerous, expensive and its impact on patient outcomes is debatable. The controversy about making maintenance of certification (MOC) mandatory has triggered new policy action from the American Medical Association (AMA) calling to keep MOC voluntary and to investigate the feasibility of a study to examine the impact of MOC and osteopathic continuous certification (OCC) on physician recruitment and retirement.

The study should also probe the negative impacts of failing certification tests as they relate to health plan participation, access to hospital privileges, and a physician’s reputation in the community.

While June’s action reignites the debate about the need for such a rigorous re-certification program, the concept of continuous professional development was adopted more than 14 years ago by the 24 boards comprising the American Board of Medical Specialties (ABMS) to focus on six core competencies: medical knowledge, patient care, practice-based learning, systems-based practice, professionalism, interpersonal and communications skills.

From these roots, a multi-million dollar continuing education infrastructure was born to help physicians keep pace with the accelerating growth of medical knowledge. While proponents of the MOC process believe it improves healthcare delivery, its critics want more proof that it is worth the high costs and time away from their families and practices, and truly benefits patients. The issues surrounding MOC are so contentious that they have sparked a lawsuit and an online petition with 17,000 signatures.

In the latest round, AMA delegates sided against mandating MOC, and they want to explore the feasibility of conducting an impact study on MOC requirements as they relate to entry into the profession, retirements or recertification lapses, practice costs, outcomes and patient safety.

Next: AMA's call to action on MOC

Robert B. Goldberg, DO, dean and professor of Tuoro College of Osteopathic Medicine and president of the Organization of State Medical Association Presidents (OSMAP), was a key supporter and coauthor of anti-MOC resolutions last year. He describes the AMA’s new policy statement this way: “(MOC) is expensive, disruptive, and it not flexible enough to address the active practice of physicians that fall under its umbrella. We need a lot more information. When we look at workforce study projections, this is going in wrong direction. (MOC) is the same as having a state legislature pass a medical liability bill as opposed to tort reform.”

Following a request for interview by Medical Economics, the AMA released this statement: “As an advocate for physicians nationwide, the AMA continues to ensure the MOC process does not disrupt physician practice or reduce the capacity of the overall physician workforce. AMA policy supports physician accountability, life-long learning and self-assessment. At the same time, the AMA has concerns that center on the need for relevance to the daily practice of physicians and the better integration into physician practices to optimally support learning and improvement. The AMA continues to urge and provide feedback to ABMS and other organizations that develop and implement MOC and maintenance of licensure (MOL) to make sure the process is not overly burdensome or costly to physicians while assuring the public of the highest quality of physician performance.”

Next: Proponents of MOC say it promotes learning

Proponents: MOC promotes learning, assures quality care

Maintenance of certification is not perfect, but it is the medical profession’s best attempt at ensuring that doctors keep their skills and knowledge up to date and provide their patients with high-quality care.

That, in a nutshell, is the defense of MOC put forth by executives at the specialty boards responsible for certification, and other defenders of the process. “If your kid wakes up tomorrow in the emergency department, wouldn’t you like to know their care comes from someone participating in a rigorous program of MOC?” asks Lois Nora, MD, JD, president and chief executive officer of the American Board of Medical Specialties (ABMS). “We believe that board certification is appropriately recognized as a substantial quality indicator for doctors.”

The fact that more than a million people visited the ABMS’s website last year to learn about physicians’ certification status is evidence that the public sees certification as a quality marker, Nora says.

Although one-time board certification used to be enough to assure public confidence, the rapid pace of change in all facets of healthcare now require recertifications, says Richard Baron, president and chief executive officer of the American Board of Internal Medicine (ABIM), the largest of the ABMS’ 24 member boards.

“It’s clear that for physicians doing high-stakes clinical practice, a credential issued once at the beginning of the career is neither relevant nor meaningful to their patients, institutions, or themselves,” he says. “Having a more continuous program helps them keep track of their own learning and benchmark it against professional expectations.”

While initial pass rates for doctors recertifying in internal medicine subspecialties are in the mid-80s, the ultimate pass rate is 95% to 98%, Baron says. “I would say that the change in ultimate pass rates is evidence that knowledge acquisition is happening as a result of the testing process.” MOC provides the added benefit, he says, of overcoming the inevitable decay in knowledge that occurs as time passes since their training.

Critics charge MOC is not truly voluntary, since hospitals, insurance companies, and government agencies use certification as a criterion in decisions that affect doctors’ livelihoods, but Nora notes that many physicians choose never to board and are still able to practice. The fact that outside organizations use MOC participation as a credential “attests to the quality of the credential,” Baron says.

“I know that may internists don’t experience the program as voluntary, and I appreciate that makes the board credential feel scary and consequential,” he adds. “But it’s not the boards driving this. It’s healthcare institutions demand for accountability on the part of physicians.”

ABMS and its member boards are aware of physicians’ complaints and criticisms regarding MOC, and have been taking steps to address them. Nora cites the fact that some member boards are studying the possibility of remote proctoring of exams, so that physicians don’t have to take time off to travel elsewhere to take an exam. An ABMS member board, the American Board of Allergy and Immunology, has cut exam fees and prices for patient communication modules.

In some ways, MOC has become a proxy for the frustration many doctors feel about the problems of the nation’s healthcare system and the growing number of demands being placed on them, Nora says. “Someone once described [MOC] to me as ‘it just got on my last nerve after so many other things that are going on.’ MOC may not be a perfect program right now, but we believe it is an important program and that it needs to be rigorous and relevant to physicians.”

Next: Critics say MOC wastes time and money

Critics: MOC wastes time and money

Opponents say the issue is simple: MOC is expensive, time-consuming and unnecessary, and one more in a long list of burdensome requirements that distract physicians from patient care.

After completing the exam portion of recertifying a decade ago, “I vowed never to do this again,” says Ron Benbassat, MD, a board-certified internist in Los Angeles, and a founder of the anti-MOC organization Change Board Recertification. “I found it to be a colossal waste of time and energy and money. I did not benefit from it, and there was no evidence to support it. It didn’t make one a better physician, it didn’t improve patient care and safety. And 10 years later it still doesn’t.”

Moreover, after taking the self-evaluation modules, finding answers to questions he answered incorrectly would have required joining the American College of Physicians, which at the time cost nearly $1,000. “At that point it became clear this wasn’t about education or making anyone a better doctor. It was simply about money,” he says.

Paul Kempen, MD, a board-certified anesthesiologist in Pittsburgh adds, “I’ve published, I give my patients good care. If I take a test, how does that make me a better physician? There’s no causality to it.”

Writing in the June 2014 issue of Anesthesia & Analgesia, Kempen calls recertification and MOC “untested, unnecessary, ethically questionable, and lucrative to academic-based physicians, board corporations, and national medical specialty societies.”

In response to physician unhappiness with MOC, earlier this year the Association of American Physicians and Surgeons sued ABMS in federal court in Trenton, New Jersey, alleging restraint of trade and that it limits patients’ access to physicians. The lawsuit was moved to a court in Chicago, where ABMS is located, and remains pending.

In March, Paul Teirstein, MD, chief of cardiology at the Scripps Clinic in La Jolla, California, started an online petition calling for certification to be limited to testing every 10 years. The petition alleges that there is no scientific data that shows the benefits of MOC and that the process detracts from patient care and other educational opportunities. As of early July the petition had garnered more than 17,000 signatures. 

While the specialty boards cite studies demonstrating links between MOC and improved patient care, Kempen, Benbassat, and others are skeptical. Kempen says he has not found one study proving that board-certified physicians provide better care.

Most of the studies that the ABMS and ABIM cite, he says, are retrospective reviews and are largely authored by people affiliated with the ABMS or one of its member boards.

Next: MOC requirements

Critics also dispute the boards’ contention that MOC is voluntary. They point out that participating in continuous certification is being used as a criterion for granting admitting privileges and participation in some insurance networks, as well as bonus payments from Medicare under the Physician Quality Reporting System. They also express fears that MOC-related activities eventually be linked to licensure.

“For it to be truly voluntary, MOC should be just another pathway to completing continuing medical education (CME) requirements,” Benbassat says.

Most MOC critics, he says, are not opposed to initial certification. “We’re just opposed to these increased onerous requirements and regulations on an already overregulated profession. It doesn’t make you a better doctor, and there’s no need for it in a world where we already have CME requirements.”

In place of MOC, patients can use referrals from friends and family members and online rating services to find a physician. “If you want good healthcare, you find a family doctor with a good reputation and who can refer you to the right people,” Kempen says.

Kempen and Benbassat admit there are few options for physicians opposed to MOC requirements. Kempen urges doctors to pressure their state medical boards to persuade ABMS to forego the requirements, since the states are ultimately responsible for regulating medical licenses. Benbassat advocates a “viral campaign” using social media. “We’re on the right side of the truth,” Benbassat says.