There are numerous issues with the Maintenance of Certification (MOC) process: Age discrimination, the cost, the time involved to prepare for and complete the maintenance of certification process and the clinical relevance/irrelevance. One issue that is of great concern among physicians of course is the cost of the MOC process. With the rising costs of running one's medical practice, diminishing reimbursements from insurance companies and looming health care reform on the horizon further impacting our livelihood, there is controversy regarding the financial impact that MOC process has on one's practice. Another big issue is the constantly changing requirements that do not allow physicians to adequately prepare for and understand the examination. One might ask, how did we get to this point? Here is some background information.
The American Board of Medical Specialties (ABMS) assists 24 approved medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physicians (ABMS website). The ABMS dictates to each of its boards that Maintenance of Certification (MOC) requires six competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) and four components (professional standing, Lifelong learning and self-assessment, cognitive expertise, and practice performance assessment). These guidelines are what each specialty board uses to determine its MOC process.
Currently, MOC requirements are supported by major medical organizations, including the American Medical Association (AMA), American Hospital Association (AHA), National Board of Medical Examiners (NBME), Federation of State Medical Boards (FSMB), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Accreditation Council for Graduate Medical Education (ACGME), among others.
However, the FSMB, ABMS, JCAHO, AHA and other parties are starting to coordinate and use MOC in licensing of physicians, inclusion in insurance plans and as requirements for hospital privileges, thereby essentially making MOC mandatory for all practicing physicians who want to maintain on insurance panels and have hospital privileges. At some point MOC may even be tied to state licensure. Thus the argument that many physicians who have been "grandfathered" from having to endure the maintenance of certification process make about not needing to get involved is false. Soon, we will all be involved in MOC unless we ALL do something about it now.
In response to the ABMS guidelines each specialty board has widely disparate requirements to achieve MOC, whose variations include, but are not limited to the costs associated with the examinations, the locations used, the time required to prepare for and complete the certification, the time allowed between periods of recertification, the timeliness of the material which must be mastered, and the percentage of applicants who qualify for certification.
While the MOC process is intended to improve the quality of healthcare by assessing physician competency, improving patient safety, and ensuring compliance with current standards of practice, there is little or no statistically valid data available to demonstrate that MOC achieves these goals.
While all the boards differ, they are given the six competencies and four components from the American Board of Medical Specialties. Here is an example from the American Board of Internal Medicine.
As of 2011, from the ABIM website:
Cost to Enroll
Your Maintenance of Certification (MOC) enrollment fee includes one secure examination and access to an unlimited number of ABIM self-evaluation products. There is a separate fee for each additional exam taken, in the event that you are maintaining multiple certifications or if you are re-attempting to pass an exam.
All Specialties (except Hospital Medicine)
- $1,675 for physicians who only hold certification in Internal Medicine
- $1,840 for physicians who have held or currently hold a subspecialty certification
- $775 for each additional exam
- $500 for international test center fee
Diplomates currently certified by another member Board of the American Board of Medical Specialties (ABMS) are eligible for a 30% discount of the MOC enrollment fee.
Hospital Medicine, Focused Practice
- $2,055 for physicians not enrolled in MOC
- $2,220 for physicians not enrolled in MOC who already hold a subspecialty certification
- $380 for physicians already enrolled in MOC
- $775 additonal exam fee for enrolled physicians who have already taken an MOC exam
Note: If your current MOC enrollment expires before you complete the Focused Practice in Hospital Medicine MOC program requirements, you will need to re-enroll in MOC.
Add to these costs the time required to complete all the Self Assessment Medical Knowledge Modules, the Practice Improvement Modules as well as the Peer and Patient Evaluations and then multiply this over the course of a 40 year career, and the costs escalate into the tens of thousands. Also to be considered in the cost are the study materials, review courses and missed days of work for the exam itself.
In fact since 2004, with the inclusion of the Maintenance of Certification program requirements, the fees and time involved to complete the process have significantly increased.
Physicians across the country are in agreement: with the rising costs of running a medical practice, diminishing reimbursements from insurance companies and the cost of maintaining a medical practice with its inherent responsibilities, these Board Recertification requirements are discriminatory, expensive, time consuming and simply not necessary.
At a meeting in December 2009 between leaders of the Los Angeles County Medical Association and the Young Physicians Organization over 70 physicians raised concerns about the time commitment requirements to complete the Recertification process while already having to keep up-to-date with mandatory CME responsibilities and other related requirements.
Almost all the attendees agreed that the current Board Recertification process requires a time commitment of typically 6 months for completing all the components.
As one YPO Board member asked at that December 10, 2009 meeting in Beverly Hills, "How can we make sure this process leads to better patient care when right now it appears entirely unnecessary and completely irrelevant to our daily practice of medicine?" Another member said, " The Board Recertification process requires unnecessary, unreasonable and irrelevant demands which ultimately detracts from Patient Care."
One result of this meeting was that another informal gathering was held on March 3, 2010 between members of the Youngphysicians.org, Los Angeles County Medical Association and leadership of the American Board of Internal Medicine which addressed critical issues related to the efficacy and fairness of the Maintenance of Certification program.
The discussion centered around controversies and misconceptions with the examination process as incoming ABIM Chair Dr. David Reuben addressed several concerns and ideas for reform. He opened with a brief presentation about the use of the examination process and candidly answered inquires related to costs, administration expenditures and standards of evaluation.
Many of the physicians in attendance at the March 3 program echoed concerns raised in the December meeting. "This MOC process is discriminatory, costly, time consuming and of questionable relevance to our daily practice of medicine." "The process does not make one a better physician, does not improve ones ability to take care of patients or make for better patient safety. This process requires reform not just for doctors, but for our patients".
As Dr. Reuben addressed each topic and inquiry, he made a point to say that opportunities for improvement of the process would be addressed by the ABIM Board as a result of this meeting. He mentioned that the fact that not every doctor is taking the examination would be reviewed and that the Board would look into making the process more efficient for physicians as well as continuing to ensure that testing is relevant to todays physician practice.
Since that time, none of our concerns or recommendations have been acknowledged by the ABIM.
Better Care for patients?
Doctors at that special meeting reiterated a common theme among all physicians: "How does all of this lead to helping my patients?" The resounding consensus was that it doesn't in any way at all.
While issues of fees and time away from patient care are important concerns for physicians, the Change Board Recertification community of physicians is committed to providing a dialogue and process to help reform the entire process.
Does the Recertification process help doctors improve their skills? Is it a predictive measure of one's ability as a doctor? And perhaps most importantly, does it help physicians provide better care for their patients?
A growing number of physician leaders across the country are passionate about this issue and are determined to voice their concerns. In fact, physicians have been interviewed and have expressed that in previous attempts to point out their concerns, their efforts were strictly rejected without any recourse or further action. As a result, physicians across the country are determined to push for changes in the Board Recertification procedures and requirements.
Better for physicians?
From the House of Delegates Report of the Council on Medical Education, Update of the American Board of Medical Specialties, Program on Maintenance of Certification: "CME Report 7 (A-02) established new AMA policy H-275.932 (AMA Policy Database) which opposes the use of recertification or Maintenance of Certification as a condition of employment, licensure or reimbursement. In fact, the ABMS does not endorse the use of certification, recertification or MOC for employment, licensure or reimbursement and has specific policy that opposes the use of board certification for the delineation of clinical privileges, as well as for the initial state licensure and licensure re-registration."
From the HOD Resolution 323 (A-08) adopted as amended, as introduced by the Young Physicians Section on Improvements to the Maintenance of Certification Process: "The MOC process can be onerous for physicians in terms of costs, inconvenience and time away from practice...Whereas, MOC increasingly used by hospitals as criterion for maintaining staff privileges..."
It is clear that the initial policy which opposes the use of recertification or MOC as conditions for employment, licensure or reimbursements are being challenged if not directly contradicted. Staff privileges are in jeopardy if a physician doesn't comply by doing the MOC program.
And there is documentation from the ABIM informing that they are now collaborating with health plans with regard to MOC.
From that ABIM announcement:
"Earn rewards and/or recognition from many health plans for completing an ABIM PIMsm Practice Improvement Module."
"Reward programs facilitate the quality improvement process by offering monetary compensation to physicians who complete a PIM".
"In a Physician Directory, a completed PIM designation will show patients that a physician's quality improvement work distinguishes him/her from other network providers".
Clearly, this is in direct opposition to the AMA policy and due to grandfathering qualifies as unfair business practice.