Interventional Community Pushes Back Against Complex MOC Program
Changes made by the American Board of Internal Medicine (ABIM) to its Maintenance of Certification (MOC) program earlier this year have ignited controversy in the interventional community. With an impending enrollment deadline, physicians across the spectrum are scrambling to understand the new requirements for recertification that emphasize continuous participation.
So far, a petition has gathered more than 10,600 signatures demanding reform.
Pre-2014 requirements for MOC included a recertification exam every 10 years and completion of a medical knowledge module and quality improvement projects. In January 2014, all 240,000 certified physicians, including 5,794 interventionalists, were informed of the changes to the MOC program. To be listed on ABIM’s website as “meeting MOC requirements,” a new designation, physicians must:
- Register for MOC on ABIM’s website by May 1, 2014 (originally March 31, 2014)
- Complete an ABIM-approved MOC activity to earn 10 points by December 31, 2015, and every 2 years thereafter
- Earn a total of 100 points in the correct distribution, including completing patient safety and patient survey modules, by December 31, 2018, and every 5 years thereafter
- Pass a secured examination every 10 years
Additionally, reception of newly issued certificates will be contingent upon meeting MOC requirements going forward and will not have a 10-year certification period. These changes will also affect the approximately 100,000 internal medicine and 11,500 general cardiology ‘grandparents,’ those who were certified before 1990 and not given time-limited certificates, many of whom have never gone through the MOC process.
In response, the petition posted March 10, 2014, asks to recall MOC for adding “significant time and expense to board certification” without proven efficacy data.
ABIM Says ‘Keeping Up’ Important
In a telephone interview with TCTMD, Richard J. Baron, MD, president and CEO of the ABIM (Philadelphia, PA), said most physicians did not take advantage of the opportunity for continuous improvement when the 10-year cycle was in effect. “Most diplomates didn’t actually do anything in the cycle until year 8 and a half or year 9, and then they experienced a fair amount of unhappiness trying to do 10 years’ worth of program in a year and a half,” he said, adding that the new program “is a way for people to have a professionally recognized framework to signal to their colleagues and their institutions and themselves that they are ‘keeping up’ in a… structured way.”
Additionally, “knowledge… and expectations for physicians are changing at a pretty dramatic rate,” Dr. Baron continued. Recertification, he said, has to keep up with that rapid pace.
Money Sparked the Outcry
Petition author Paul S. Teirstein, MD, of the Scripps Clinic (La Jolla, CA), said the petition immediately went “viral,” as it gained 200 signatures within a day. What initially sparked an emotionally charged email chain among interventionalists that led to the petition’s creation and an open letter to the ABIM, Dr. Teirstein told TCTMD in a telephone interview, was the confusion he felt during his first log-in to the ABIM’s website. “I thought I have to log on… all for what? So I can give these guys $350,” he commented.
Ajay Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), had a similar experience. “I was asked to pay $384 simply to update my profile on the web,” he explained. “Had I not paid that, the website would have stated that I was not maintaining my status. Because I paid it and filled out a survey about my practice—but had no learning whatsoever—the website designation changed. That seems very burdensome.”
The new fee structure allows physicians to either pay for 10 years at once ($1,940 for internal medicine and $2,560 for any subspecialty) or 1 year at a time ($194 for internal medicine and $256 for any subspecialty). For physicians who maintain certification in more than 1 area, they receive a 50% discount on the lower cost certificate.
“What upsets a lot of people,” Dr. Kirtane told TCTMD in a telephone interview, is the fact “we are being asked to incur the cost of a system that has not definitively demonstrated actually changing specialty-specific competency.”
The money “sends up a lot of red flags,” Dr. Teirstein continued. “All doctors are making less money now, and we’re all trying to do more for less. Here comes along the ABIM giving a 50% increase in the cost and a lot more work that doesn’t have any value.”
Dr. Baron reported the increase was needed to “catch up” with the fact that fees have not increased for several years. Forty percent of ABIM’s annual revenue goes toward exam development and delivery, he said, emphasizing that all of its funding comes from doctors, not industry. The fees imposed by ABIM are “comparable… actually, on the low side” relative to the other 23 boards that fall under the American Board of Medical Specialties umbrella, he said.
‘Line in the Sand’
Bonnie H. Weiner, MD, of Saint Vincent Hospital (Worcester, MA), told TCTMD that none of the petition writers, herself included, “disagree with the concept of lifelong learning.” The problem with MOC, she said in a telephone interview, is that the “process seems to reinforce activities just for activities’ sake, as opposed to integrating that learning and experience into daily practice, which is where it is most effective and important.”
Dr. Teirstein further called MOC “a waste of time” in an era with “so much overregulation right now of our business and of our industry.
“We fill out so many forms all day long that don’t really help patients,” he continued, noting that insurance companies, hospital requirements, and CME already pull clinicians in different directions. “And now we are putting this other layer on it—at one point I just thought we should draw a line in the sand and say enough of this.”
Although he did not sign the petition, Eric R. Bates, MD, of the University of Michigan Medical Center (Ann Arbor, MI), said he was sympathetic to its concerns. “There has been a lot thrown at people in the last couple of years. You spend more time doing medical records, you get paid less. Salary-wise this is just another expense added to the other expenses that have been going up, so I think people are feeling a little bit put upon by the regulatory folks,” he told TCTMD in a telephone interview.
Little Chance for Debate
Others question the way that ABIM rolled out the new MOC. “Decisions appear to have been made in a vacuum without involving the stakeholders in the process,” Dr. Weiner said. “There did not appear to be any thought about what the impact would be on people’s practices.”
Dr. Bates cautiously agreed. “I’m not quite sure why these conversations didn’t occur earlier,” he said, adding that it is unclear whether the program is fully developed or if there was enough public vetting of the changes.
The fact that the ABIM has already begun enforcing the new program, Dr. Kirtane said, and physicians “have to essentially comply with [it while] not necessarily [understanding] what is involved, shows you that there is probably imperfect communication going on.”
Even with the “premature” debut of the MOC, Dr. Bates observed, “I don’t know how much of this they can roll back. If they can make some compromises, knock down the cost, cut back some of these different requirements, and not have 5 parts we have to comply with, that would be nice. But I don’t think it’s going to go away.”
Dr. Baron did not refute the complicated nature of the new requirements, stressing that “the board is really trying to meet internists and internal medicine subspecialists in the various settings in which they practice.” The ABIM includes approximately 200,000 physicians practicing in “everything from solo practices in rural America to those embedded in different health systems like Kaiser or Mayo,” he noted.
The easiest way for physicians to determine what is required of them individually, he said, is to login and view their ‘status pages.’ Approximately 93% of currently certified interventional cardiologists have logged on and enrolled in the program thus far, according to the ABIM, with more intended to comply before the May 1 deadline.
“Could we have communicated about it better? Sure,” he acknowledged. “[But] I don’t think with a program this complicated you’re ever going to be able to say all the kinks are worked out.”
What About CME?
MOC may be redundant, especially for physicians who spend large amounts of time planning, executing, and organizing large medical conferences, Dr. Kirtane explained. When giving a talk “at any major medical meeting, I always do a full literature search of all the data on that specific topic within the last year,” he said. “That requires not only doing a search but reading the articles and learning. Now why is that not an equally viable means of bolstering learning?”
Dr. Kirtane also questioned why MOC “is the only process by which people can obtain competency as opposed to participating and learning at a CME event or sitting on a panel or preparing for a talk. [It] seems arbitrary.”
Dr. Weiner agreed. “If a process could be initiated that uses things that we do every day as part of our own learning and quality experiences to fulfill [MOC] requirements, then I think there would be a general acceptance of the process,” she said.
Some say CME is too passive, but Dr. Teirstein countered that the programs can be “incredibly valuable. People [voluntarily] spend money and go…. To a certain extent, you have to trust that the doctor is going to take [their training] seriously.”
Dr. Baron said the overlap between CME and MOC is expected to grow as the program develops. He cited activities like the American College of Cardiology (ACC)/American Heart Association (AHA) D2B initiative, medical meetings, national registries, and the ABIM’s ‘portfolio program’ as all offering MOC credit. For example, TCT 2014 will offer MOC sessions in Washington, DC, this September.
“A core strategy that the board has had,” he said, “is to have lots of pathways that people could get through the program using products that were created by others which are recognized by the board for MOC purposes.”
However, Dr. Baron continued, “we are not prepared at this time to say that anything that counts for MOC will count for CME…. We need to have standards about participation in those kinds of programs, but we’re absolutely interested in finding ways to recognize meaningful clinical work that doctors do in their practices for credit under MOC.”
Professional Societies Stand Up
Professional societies including the ACC and the Society for Cardiovascular Angiography and Interventions (SCAI) have made the issue a priority with the former issuing a 10-question survey to their members.
Last week, SCAI president Theodore A. Bass, MD, of the University of Florida College of Medicine (Jacksonville, FL), sent out a letter to its members about MOC. In a telephone interview with TCTMD, Dr. Bass said, “It is our responsibility at least to get involved [in having] dialogue with the ABIM to discuss concerns and see if we can find some common ground where we can still have quality competency programs and maintenance of competency programs, but they would be more sensitive to the physicians [who] are asked to participate in them.”
He said SCAI has “started a dialogue” with the ABIM, noting that his letter received much positive feedback. “There is a large part of the interventional community that understands that we are accountable for quality care… and that is part of our social contract with our patients and society. It’s not about that. It is about making [MOC] meaningful and not so burdensome,” Dr. Bass said.
Putting ‘the Horse Back in the Barn’
Dr. Bates emphasized that the issue is “bigger than interventional cardiology, bigger than cardiology, and bigger than the American Board of Internal Medicine…. So I’m just dealing with the fact that since it’s [been] given to us, let’s do it best.” According to Dr. Teirstein, this stance is like saying the horse is out of the barn. “Well, I thought, let’s put it back in the barn,” he said.
Not every petition signer agrees with the explicit goals of that appeal, Dr. Kirtane said. “But the reason I signed it is because I do think it’s important for this voice to be heard. I don’t think everyone has to agree entirely with MOC, and I don’t think everyone has to agree entirely with the petition. But what’s clear is that there has been a communication gap and a disconnect between the process that was imposed and what clinically matters to many physicians—it’s frustrating. That needs to be heard not only by the ABIM, but also by the societies and especially by the public as well.”
Dr. Weiner said she had similar thoughts. “I would have hoped that the dialogue would have occurred before we got to this point in the process,” she indicated. “But at least the dialogue is happening now, and I think that’s what’s important.”
ABIM Responds
Although the amount of physician pushback he has received regarding MOC was not surprising, Dr. Baron said there is also no definite consensus of how people would ideally like to complete MOC, reporting that although the petition wants the removal of everything but the test, other feedback he has received calls for elimination of only the test.
That discrepancy “illustrates that it’s very complicated to run an MOC program,” he said. “Under the structure of the ABIM, the people making those choices are internists and internal medicine subspecialists. It’s a peer-review process in action.”
In a public statement released yesterday, Dr. Baron reiterated all that he stated to TCTMD, adding that the expected annual MOC time commitment will range from 5-20 hours, longer in exam years. He additionally cited research justifying the value of all parts of MOC.
“Please know that we take very seriously the feedback we hear about our products and programs,” he writes. “MOC is a continuously evolving program in which we focus on improving the value and relevance of the credential, and we continue to welcome constructive diplomate feedback on how to enhance our assessments.”
He additionally stressed the tendency for physicians to shrug off the importance of their certification when they are constantly surrounded by other physicians with similar qualifications. “The most important thing is that this certificate has always been about doctors being proud of having a certain kind of knowledge and expertise that other people don’t have. It remains being about that,” he commented. “This credential is a way to signal that you have that knowledge and you’re keeping it up and you’re maintaining it.”
While pleased the ABIM “is taking the petitioners complaints seriously,” Dr. Teirstein said he is not satisfied with Dr. Baron’s response. He specified that concrete evidence is still lacking that MOC is the best method for keeping physicians up-to-date and costs remain “too high.”
Yael L. Maxwell is Senior Medical Journalist for TCTMD and Section Editor of TCTMD's Fellows Forum. She served as the inaugural…
Read Full BioSources
Ting HH, Bates ER, Beliveau ME, et al. Update on the American Board of Internal Medicine Maintenance of Certification program: a report of the American College of Cardiology’s Educational Quality Review Board. J Am Coll Cardiol. 2014;63:92-100.
Disclosures
- Dr. Baron reports serving as the President and CEO of the ABIM.
- Dr. Bates reports serving on the ABIM’s interventional cardiology exam writing committee and working with SCAI and the ACC in various capacities.
- Drs. Teirstein and Weiner report serving on the petition-writing committee.
- Dr. Bass reports serving as the President of SCAI.
- Dr. Kirtane reports no relevant conflicts of interest.
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