The MOC revolt: NBPAS fights for relevancy

Some physicians opposed to the maintenance of certification (MOC) have put their faith in an alternative certifying body, one that bills itself as low-cost, low-hassle and, most importantly, does not require an intensive recertification process.

The National Board of Physicians and Surgeons (NBPAS) has been growing steadily, but its membership is still modest. “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 as of February. It adds about 200 new members each month. 

Teirstein says his challenges include hospitals that have contracts requiring American Board of Medical Specialties (ABMS) member board certification and the intentions of payers, who are mostly mum to date. 

At least several hospitals accepting
NBPAS certification did not experience much controversy in gaining approval for that policy, according to those involved.

At Hoag Hospital in Newport, California, the medical staff voted 97% in favor of changing its bylaws to accept NBPAS, says Rick Haskell, MD, chief of staff and a cardiologist. “Who’s the best judge of whether a doctor is qualified? His peers,” he says. “That’s a better judge than whether I can answer a multiple choice question correctly. Basically, the medical staff is saying they’re practicing their specialty in a way that we think is qualified, to work at our hospital.”

The only hesitation Haskell heard: What about insurance companies? But he’s not aware of anyone who has been impacted adversely. “We don’t know what they’re going to do, and even then, they may changed their mind in the future,” he says.

The chief of staff at Texas Heart Institute/Baylor St. Luke’s Medical Center in Houston, Texas, lent a receptive ear to Scott Greenberg, MD, an electrophysiology fellow, who raised the subject of NBPAS certification, and he gained approval from the medical executive committee. This was made easier because, unlike some hospitals, its bylaws do not specifically require certification through ABMS, Greenberg says.

“When you have a chief of staff who believes in what you’re telling him, that makes it easier,” he says. Once administrators  learned more, “there was less resistance than we initially thought.”

Others still seek approval. One physician who recently signed up for NBPAS, George G. Ellis Jr., MD, says he will likely recertify with the American Board of Internal Medicine (ABIM) this year due to concerns about hospital privileges and insurance coverage. 

“Guys I know who are practicing at the [local] hospital have submitted documents in hopes of getting them to accept [NBPAS]. We’re waiting to see what happens,” says
Ellis, chief medical adviser to Medical Economics and an internist in Youngstown, Ohio.

When Howie Mandel, MD, did not recertify with the American Board of Obstetricians and Gynecologists (ABOG) at the end of 2015, he received notice that ABOG no longer considered him certified. Mandel has gained certification from NBPAS but isn’t sure what will happen when he’s up for reappointment at Cedars Sinai Medical Center, Los Angeles, in October. 

Since he’s been in good standing as a staff member, there would be an appeals process if the lack of  certification trips him up, Mandel says. If the hospital makes an issue out of MOC, “I would argue to them that they have reverse age discrimination,” he says, since doctors who were first certified only a year before him are grandfathered into MOC for life. He doesn’t take insurance, “so it’s not a problem there.” 

Robert Beaumont, MD, medical director at Waukesha Family Practice Clinic in Waukesha, Wisconsin, has certified with NBPAS and let his American Board of Family Medicine certification lapse. He no longer sees patients at Waukesha Memorial Hospital but says that was his choice and that the hospital “hasn’t gotten back to me on whether they’re going to honor it.” He says payers have not asked about certification.

Payer penalties

Others have gained at least some hospital approvals. Endocrinologist Arvind Cavale, MD, says his internal medicine certification expired last year but he’s still certified in endocrinology through 2019. 

Based in Feasterville, Pennsylvania, Cavale joined NBPAS last year and does not plan to keep his ABMS certification. St. Mary Medical Center in Langhorne, Pennsylvania, has accepted his NBPAS credentials, but Aria Health in Philadelphia, where Cavale is also on staff, has not to date.

Insurance has not been an issue for Cavale: About 70% of his patients are covered through Independence Blue Cross of Philadelphia or Highmark Blue Shield of Pittsburgh, and “when I came up for credentialing last year, I mentioned that I was certified through a new board and they accepted it and didn’t ask any questions,” he says, possibly because Cavale serves as a resource specialist for those companies. “For them to use a technical issue like this one to nail me, or get me off their panel, would probably be more damaging to them than me,” he says.

Hospital privileges have not been a problem for New York-based internist Jonathan Weiss, MD, who recertified in internal medicine in 2012 but has let his other certification lapse and recently applied to NBPAS. Catskill Regional Medical Center in Harris, New York, “fortunately, and conveniently, feels that board certification is a voluntary endeavor,” he says. “With insurance companies, it’s clearly going to, at some point, cause some concerns.”

The one negative consequence for him is that he is no longer retained to do independent medical evaluations in pulmonary care. “I asked the company why on December 31, 2014, I was perfectly capable of doing these things, and on January 1, 2015, I wasn’t,” Weiss says. “They said our clients want this, and we’re very sorry we can’t use you, you did good work.” The lawyers for whom he worked “bought into this notion that the only capable doctor is one who is board-certified. Many of us would dispute that, but that’s what’s been put out there very effectively by entities like ABIM.”

Tim Wingo, MD, certified through NBPAS in June 2015 and let his ABFM certification lapse at the end of the year. The attorneys for whom he handles case reviews haven’t had any issues either, says Wingo, a family physician with Atlas Healthcare in Mount Pleasant, South Carolina. One told him, “It looks better if you’re board certified,” but did not press the point. The other told him, “If you choose not to do it, then you simply tell them, ‘No, I have my own way of staying current. I like to spend my day seeing patients.’ ” 

Dermatologist H.L. Greenberg, MD, has garnered 400 signatures-more than the 320 necessary-to force a bylaws amendment that he planned to present to the American Board of Dermatology (ABD) secretary-treasurer. Greenberg, who practices at Las Vegas Dermatology, plans to recertify in 2022 but says, “There’s a monopoly in place that I didn’t choose to have put over me.” 

A true alternative?

But will the NBPAS grow into a true alternative, gaining acceptance from a sufficient number of hospitals and insurance companies to be viable in the long run?

The NBPAS requires initial certification by an ABMS board and 50 hours of continuing medical education every two years. “That’s what we substitute instead of doing computer modules and taking repeat tests,” Teirstein says. “It’s equally good, more meaningful and less onerous. Both methods are unproven. There’s no proof that any of this matters.”

Paul Mathew, MD, an NBPAS board member and neurologist at Harvard University Medical School and Brigham’s & Women’s Hospital in Cambridge, Massachusetts, believes ABIM and other ABMS boards will need to move in the direction of the NBPAS model--including lowering fees (which are $169 for two years at NBPAS) in addition to keeping requirements more reasonable-to stave off ongoing competition. “NBPAS is a great alternative in the event that the ABMS boards don’t buckle,” Mathew says. “If they do buckle, who knows? NBPAS may end up disbanding if it leads to the adequate reforms that a lot of us are looking to see.”

ABMS and its boards have been paying attention to NBPAS and the comments of those associated with it to improve, says Lois Nora, MD, JD, president and chief executive officer of ABMS. She also notes that NBPAS requires ABIM board certification at the outset. But beyond that, “candidly, I disagree with the criteria they have put in place,” she says. “Continuing education is important, but we believe it is only part of a larger construct. We believe that an independent assessment by a board made up of physicians in that specialty is exceedingly important.”

Richard Baron, MD, president and chief executive officer of ABIM, expects the NBPAS will continue forward but agrees with Nora that requiring only “passive” MOC through CME is inadequate. “What the community of doctors have to decide is, is that a standard that’s meaningful for them?” he says. “Do they have confidence in that? Should anybody else have confidence in that? Ours, you have to demonstrate that you didn’t just go to a course but that you have knowledge. Doctors are looking at that and making a choice.”

Westby Fisher, MD, a cardiologist and electrophysiologist at NorthShore Hospital, in Glenview, Illinois, says he’s working to change his hospital’s bylaws to accept NBPAS and encourages other physicians to do the same. He believes getting payers to go along will be critical to NBPAS’s success. 

“Once Paul Teirstein gets Aetna and Blue Cross to accept his board, people won’t do this ABMS stuff anymore,” Fisher says. “Already plenty of people are quietly not doing it. Hospitals are going to say, ‘We can’t just send this guy a letter, he’s our most productive person.’ They’re going to say to insurance companies, ‘Hey, back off.’”

Some doctors who have issues with MOC don’t believe NBPAS is the answer. Ashesh Patel, MD, an internist in Washington, D.C., says he’s certified through ABIM until 2019 and does not believe NBPAS certification goes far enough in ensuring physicians are keeping current. “Something in between, I think, is a better option,” he says. “Hopefully ABIM is moving toward that.”

Still, Patel says NBPAS has applied pressure to ABMS boards. “Having competing viable boards in existence that allow physicians to choose where they are certified from will at least make ABMS/ABIM’s ‘my way or the highway’ approach to board certification untenable as a business model.”

Jay Alexander, MD, who practices at NorthShore Cardiology in Bannockburn, Illinois, isn’t convinced that enough hospitals and payers will ultimately accept NBPAS. “I personally don’t see it becoming the certifying body for cardiology,” he says.

Greenberg does not see the NBPAS as viable. “It’s a paper tiger,” he says.