American Medical Association House of Delegates Features Discussions on Affordable Care Act, Physician Payment Sunshine Act and Maintenance of Certification

The week the American Medical Association (AMA) is
holding its annual meeting. The AMA annual meeting and its House of Delegates (HOD) will discuss numerous important topics facing physicians—many of which come for the 2010 Patient Protection and Affordable Care Act (PPACA).

Interestingly, the AMA will be hosting a specific meeting on the Physician Payments Sunshine Act on Monday, June 17, 2013, from 10:00 a.m. – 11:00am. It is expected that officials from the Centers for Medicare & Medicaid Services (CMS) will attend to discuss the final rules, implementation, and to address questions that physicians may have.

In addition to the various topics on health care reform and various other ongoing changes and shifts in medicine, the AMA will also address issues regarding Maintenance of Certification (MOC)—a form of required continuing medical education (CME) required for certain medical specialties. Below is a summary of some of the activities AMA has conducted regarding MOC.

AMA Report from the Council on Medical Education Regarding MOC

The AMA published a report from its Council on Medical Education regarding an “Update on MOC, Osteopathic Continuous Certification (OCC), and Maintenance of Licensure (MOL). The AMA provided a brief explanation of each of these categories. They recognized that MOC, OCC, and MOL are distinctly different processes, designed by independent organizations with different purposes and mandates.

Currently the guiding principles for MOL, adopted by the Federation of State Medical Boards (FSMB), recognize the value of active engagement in meeting MOC and OCC requirements. MOC and OCC are not intended to become mandatory requirements for medical licensure but the boards believe they should be recognized as meeting some or all of a state’s requirements for MOL to avoid unnecessary duplication of work.

The FSMB is currently engaged in a series of pilot projects, in collaboration with the ABMS and National Board of Medical Examiners, to advance understanding of the process, structure, and resources necessary to develop an effective and comprehensive MOL system. Nine state medical boards are participating in pilot projects. The pilots will determine and identify multiple options and pathways by which physicians, including those who are not specialty certified or not engaged in MOC or OCC, may fulfill a state board’s MOL requirements.

The AMA acknowledged that it is not responsible for regulating the certification and licensure processes but is committed to monitoring the development and research being conducted in these areas on a regular basis. AMA policy encourages the ABMS and its member boards to continue to improve the validity and reliability of procedures for the evaluation of candidates for certification. In addition to traditional assessment methods that have relied significantly on multiple-choice examinations or continuing medical education activities, the certification boards are beginning to incorporate simulation-based educational and assessment formats into MOC that more closely represent how practicing physicians diagnose and treat patients.

One AMA Resolution, number 308, asserts that “[n]o evidence exists that MOC improves competence or enhances patient quality of care” and as a result, the AMA should “oppose mandatory specialty board recertification by examination” and that AMA recommend that recertification by examination not be a requirement for hospital credentialing.

Indiana Delegation Resolution 9170-I-12 – Accreditation/Certification Cost & Convenience

This proposal, introduced by the Indiana Delegation and referred to the AMA HOD, asks the AMA to adopt the following principles related to certifying and accrediting entities:

1. There should be full transparency related to the costs of preparing, administering, scoring, and reporting the results of board certifying exams.
   
2. There should be full transparency on the costs of facility documentation, review, facility inspection, scoring, and reporting of accreditation results.
   
3. There is the expectation that timely and multiple board exam sites will be available so as to minimize the need for physicians to travel long distances or wait long times for exam dates.
   
4. The accreditation process should be timely and efficient.
   
5. There is the expectation that certification and accreditation services should not be a source of substantial profit for these entities.
   

The resolution was referred for further study because many of these issues are being addressed by the Council on Medical Education, which issued three reports on MOC, OCC, and MOL and is continuing to monitor these activities.

Policy D-275.960, “An Update on Maintenance of Certification, Osteopathic Continuous Certification, and Maintenance of Licensure,” calls on AMA to continue to monitor the evolution of MOC, OCC, and MOL, continue its active engagement in the discussions regarding their implementation, and report back to the House of Delegates on these issues at the 2013 Annual Meeting. The new report builds on three previous reports and addresses the resolution and policies above by providing updates on:

1. Progress that has been made in developing MOC, OCC, and the policies and framework for MOL, which is intended to provide guidance to the state medical and osteopathic boards as they consider the results of the MOL pilot projects.
   
2. Expanded models that boards are using for secured examinations.
   
3. References that point to evidence of the benefits of specialty board certification.
   
4. How knowledgeable the public may be about MOC.
   
5. The impact of MOC, OCC, and MOL on the physician workforce.
   

Update on MOC CME

The MOC Committee established a Joint Working Group on MOC-CME. This was not a call for, or intent to form, a new credit, certifying, or accreditation system for CME, but was intended to identify CME that best fits into the continuing professional development framework for MOC 2015. The goal is to standardize the CME requirements of individual ABMS member boards and streamline the process for physicians who hold multiple board certifications and to facilitate understanding of MOC requirements by external stakeholders.

The Joint Working Group presented its final report to the MOC Committee that recommended guidelines for evaluating the quality and the quantity of MOC-CME. Some of the questions raised by the Group with regard to quality included how often is clinical content as well as the educational format evidence based, how often is learning/improvement demonstrated, and are the six competencies (professionalism, patient care and procedural skills, medical knowledge, practice based learning and improvement, interpersonal and communication skills, and systems-based practice) adequately covered in current CME programming.

Questions raised with regard to quantity included how much CME is appropriate for MOC, is the “credit” the right metric or would a point system be better, and where do learning/improvement outcomes fit. The Group recommended that the characteristics of MOC-CME include evidence-based clinical content, evidence-based learning formats (i.e., interactive, multimedia), span the six competencies, and support diplomates’ needs in demonstrating and documenting practice-based learning and improvement.

The ABMS has also developed a tool kit to advance the state medical boards’ adoption of the FSMB’s policy encouraging the state medical boards to accept MOC participation as meeting a state’s CME requirements for license renewal. The MOC4CME Tool Kit includes information about state requirements on CME, frequently asked questions, and key messages. As of December 2012, four states (Idaho, Minnesota, North Carolina, and Oregon) have adopted this policy, and four states (California, Missouri, Washington, and West Virginia) are in varying stages of discussion about the policy change.

AMA Policy H-275.923 (3), “Maintenance of Certification/Maintenance of Licensure,” states that AMA will encourage rigorous evaluation of the impact on physicians of future proposed changes to the MOC and MOL processes including cost, staffing, and time.

AMA Policy H-275.924 (4), “Maintenance of Certification,” states that any changes in the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

Oklahoma Delegation MOC Proposal

One proposal that is being introduced at the annual meeting regarding MOC came from the Oklahoma delegation of the AMA. Specifically, the proposal offers it supports to “oppose efforts by the American Board of Medical Specialties (ABMS) and the Federation of State Medical Boards (FSMB) that suggest the use of MOC as a condition of employment, licensure or reimbursement (such as occurred in Ohio in 2012 by the Ohio State Medical Association).

The proposal noted that the ABMS and FSMB have and continue to press legislation coupling insurance payments, hospital privileges and other employment opportunities to active enrollment in “time limited” board certification and the associated MOC program in a nationwide fashion, imposing this upon the practice of medicine. It also maintains that the “MOC program is expensive, unproven, directed toward bureaucratic compliance and entry level medical knowledge, wastes resources by requiring participation in time limited MOC-CME programs directly benefiting selectively the ABMS only.”

Accordingly, the proposal clarified that the AMA’s Physician Recognition Award and CME program, which was successfully formed in the late 1960’s, meets all needs of documenting lifelong commitment to learning to include individual physician’s choice and competitive offering of educational materials in CME.

Thus, the Oklahoma delegation asked that AMA’s HOD resolve that the AMA continue to support and advocate lifelong continuing medical education and lifelong Specialty Board Certification as determined by the physician him/herself, to advocate against time-limited specialty medical board certificates, and advocate against discrimination against physicians who are not certified or are certified and choose NOT to engage in corporate re-certification programs labeled as “voluntary” by the specialty medical boards (New HOD Policy).

The delegation also resolved to assert that AMA assist states in efforts to seek legislation that will prohibit discrimination by hospitals and any employer, state licensure boards, insurers, Medicare, Medicaid, and other entities, which might restrict a physician’s right to practice medicine without interference (including economic discrimination by varying fee schedules) due to lack of certification, lack of participation in FSMB/ABMS prescribed corporate programs including Maintenance of Licensure or expiration of time limited Board Certification (Directive to Take Action).

Other MOC Related Policies

D-275.960 An Update on Maintenance of Certification, Osteopathic Continuous Certification, and Maintenance of Licensure – AMA will encourage the ABMS and the specialty certification boards to continue to explore other ways to measure the ability of physicians to access and apply knowledge to care for patients as an alternative to high stakes closed book examinations. Our AMA will continue to monitor the evolution of Maintenance of Certification, Osteopathic Continuous Certification, and Maintenance of Licensure, continue its active engagement in the discussions regarding their implementation, and report back to the House of Delegates on these issues at the 2013 Annual Meeting. (CME Rep. 10, A-12)

H-275.996 Physician Competence – AMA: (1) urges the ABMS and its constituent boards to reconsider their positions regarding recertification as a mandatory requirement rather than as a voluntarily sought and achieved validation of excellence; (2) urges the FSMB and its constituent state boards to reconsider and reverse their position urging and accepting specialty board certification as evidence of continuing competence for the purpose of re-registration of licensure; and (3) favors continued efforts to improve voluntary continuing medical education programs, to maintain the peer review process within the profession, and to develop better techniques for establishing the necessary patient care data base. (CME Rep. J, A-80; Reaffirmed: CLRPD Rep. B, I-90; Reaffirmed: Sunset Report, I-00; Reaffirmed: CME Rep. 7, A-02; Reaffirmed: CME Rep. 7, A-07; Reaffirmed: CME Rep. 16, A-09; Reaffirmed in lieu of Res. 302, A-10)

H-275.949 Discrimination Against Physicians Under Supervision of Their Medical Examining Board – AMA opposes the exclusion of otherwise capable physicians from employment, business opportunity, insurance coverage, specialty board certification or recertification, and other benefits, solely because the physician is either presently, or has been in the past, under the supervision of a medical licensing board in a program of rehabilitation or enrolled in a state-wide physician health program. 2. Our AMA will communicate Policy H-275.949 to all specialty boards and request that they reconsider their policy of exclusion where such a policy exists. (Sub. Res. 3, A-92; Reaffirmed: BOT Rep. 18, I-93; Reaffirmed: CME Rep. 2, A-05; Appended: Res. 925, I-11; Reaffirmed in lieu of Res. 412, A-12)

H-275.932 Internal Medicine Board Certification Report–Interim Report – AMA opposes the use of recertification or Maintenance of Certification (MOC) as a condition of employment, licensure or reimbursement. (CME Rep. 7, A-02; Reaffirmed: CME Rep. 2, A-12)

H-275.944 Board Certification and Discrimination – (1) Where board certification is one of the criteria considered for purposes of measuring quality of care, determining eligibility to contract with managed care entities, eligibility to receive hospital staff or other clinical privileges, ascertaining competence to practice medicine, or for other purposes, the AMA oppose discrimination that may occur against physicians involved in the board certification process including those who are in a clinical practice period for the specified minimum period of time that must be completed prior to taking the board certifying examination.

(2) AMA reaffirms and communicates its policy of opposition to discrimination against member physicians based solely on lack of American Board of Medical Specialties or equivalent American Osteopathic Board certification. (3) AMA continues to advocate for nomenclature to better distinguish those physicians who are in the board certification pathway from those who are not. (Sub. Res. 701, I-95; Appended: Res. 314, I-98; Appended: Sub. Res. 301, I-99; Reaffirmed: Sub. Res. 722, A-00; Reaffirmed: CME Rep. 7, A-07)