The rally against Maintenance of Certification (MOC) continues as more and more doctors have signed a petition to recall the American Board of Internal Medicine’s (ABIM) new changes to its MOC requirements. ABIM now requires MOC activities be performed every two years and for every two years thereafter. The petition, which opened on March 10, 2014, has more than 15,000 signatures.
ABIM is one of the American Board of Medical Specialties’ (ABMS) 24 specialty member boards designed to develop programs to allegedly “enhance[ ] the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care.”
But this certification process is not a charity. The “ABMS Maintenance of Certification” brings in many tens of millions of dollars in revenue to ABMS and the 24 allied corporations. The Association of American Physicians and Surgeons (AAPS) argues: “Though ostensibly non-profit, these corporations then pay prodigious salaries to their executives, often in excess of $700,000 per year. But their recertification demands take physicians away from their patients, and result in hospitals denying patients access to their physicians.”
While many doctors understand the importance of continuing medical education (CME) and in staying up-to-date on the latest medical news, they generally feel MOC programs are burdensome, costly, and have little known positive impact on patient outcomes. A recent survey by AAPS showed that only 9.5% of 167 respondents thought that “maintenance of certification is good; we should support it.” In an earlier survey, only 22% of physicians who had been through the process said they would voluntarily do it again (AAPS).
Quite simply, MOC fails the “cost-benefit analysis,” and the number one victims are patients. In an era where new doctors have so many administrative burdens that their average patient time is eight minutes, anything that further minimizes doctor-patient contact cannot be considered beneficial without strong evidence to support its value. In the case of MOCs, such evidence does not exist.
In a recent AAPS webinar, Dr. Paul Kempen, argued that the board certification process has never been validated as improving healthcare by outcome-based studies. Kempen noted that the “fallacy of certification was openly admitted recently by the ABMS on its website, where it states: ‘FACT: ABMS recognizes that regardless of the profession—whether it is healthcare, law enforcement, education or accounting—there is no certification that guarantees performance or positive outcomes.'”
Furthermore, Kempen argued, no one regulates either the Federation of State Medical Boards (FSMB) or the ABMS—the organizations regulate themselves and push their agenda on others. For example, ABMS’s website states: “ABMS: recognized as the “gold standard” in physician certification, believes higher standards for physicians means better care for patients” (emphasis added).
Kempen also analyzed disciplinary actions in Ohio to show that more time-consuming testing is not justified. According to Kempen, during 2010, the Medical Board issued 208 formal disciplinary actions (all groups) with 155 physician actions (0.37% rate). However, competency issues in 2011 were possibly 1/42,102, which equates to 0.002% incidence among healthcare practitioners.
Most problematic, member boards of the ABMS are highly conflicted in their promotion of maintenance of certification, since mandating this process generates a large amount of annual revenue for the member boards. According to AAPS, ABMS does the public a disservice by inviting patients to search on which physicians have “recertified” and which ones have not, despite the lack of evidence that there is any difference in malpractice rates between the two categories (See ABMS’ “Is Your Doctor Certified?” website). “ABMS should try to make money by helping patients, rather than disparaging the many thousands of good physicians who spend their time caring for patients rather than on ABMS’s self-serving recertification scheme,” AAPS argues.
Despite the dearth of evidence linking MOC to patient protection, participation in MOC is increasingly becoming mandatory for doctors across the country. For example, the Centers for Medicare and Medicaid Services (CMS) has aligned itself with MOC requirements. This year, physicians “will have the opportunity to earn the Physician Quality Reporting System incentive and an additional incentive of 0.5% by working with a Maintenance of Certification entity,” CMS states. However, starting in 2015, this 0.5% reward becomes a penalty tax that increases as the years go on.
Kempen argues that this PQRS-MOC program was conceived by ABMS to secure MOC enrollment of all physicians via what he deems “regulatory capture.” This “occurs when special interests co-opt policymakers or political bodies—regulatory agencies, in particular—to further their own ends.”
In an article entitled “Maintenance of Certification must go: One physician’s viewpoint,” Kempen also argues that: “Due to the increasing employment of physicians by hospitals, this regulatory capture may undermine the already tenuous fiscal stability of community hospitals, in particular.” He states that “[t]he increased costs to physicians’ practices will be carried by employer hospitals, facilitating the “dumbing down” of medical care via replacement of physicians with less expensive and less-educated midlevel providers, who for now are not required to undergo MOC, but are reimbursed by CMS.”
Kempen concludes: “It is time to stop the multiple ABMS “legacy organizations” from repackaging their products into an unproven, wasteful, unnecessary, and expensive yearly subscription payment requirement of all physicians. Taxpayers, as patients, will ultimately pay for this increased cost of doing business for physicians or simply suffer quality decline by receiving care from “cheaper” midlevel providers.”
ABIM: Decline of Internal Medicine Recertification Pass Rates
In addition to the backlash against the recertification changes, the American Board of Internal Medicine recently published the “First-Time Taker Pass Rates – Maintenance of Certification.” The chart is reproduced below:
In 2009, there was a 90% pass rate for internal medicine certification. In 2013, it had dropped to 78%. Dr. Kevin Pho, of KevinMD argues that the drop is alarming, “[e]specially considering that maintaining certification is a condition of staying employed by many hospitals and health systems. And while physicians can retake the exam, it’s a time consuming and stressful process. Especially when their jobs are on the line.”
Dr. Pho argues that two reasons underlie the low pass rates. “First is the continuing stratification of internal medicine. With hospitalists becoming more prevalent, it’s uncommon for general internists to see both hospitalized patients and outpatients,” he argues (emphasis added). Second, “is the increasing bureaucratic demands that internists already face on the job.” Not only “burdensome pre-authorizations and paperwork, but also shifts to electronic records, and data gathering to meet pay for performance requirements.” Dr. Pho states that such “mandates require significant resources and time, which doctors in the past didn’t have to deal with.”
“Combine this with MOC’s time-consuming practice assessment component,” he argues, “and it’s no wonder that internists have less time than ever to prepare for the exam.”
I sent a detailed comment yesterday but no acknowledgement Cannot seen to access the comments. The MOC is a great example of an unexplored frontier in Pay for performance of the the health care regulatory baggage industrialization.