Physicians to Spend 26% More Time on MOC, Study Says

August 04, 2015

For almost 2 years, many internists and internal medicine (IM) subspecialists have bitterly complained that recent changes to their maintenance of certification (MOC) program cost them more time and money but do not make them better physicians.

The Annals of Internal Medicine published a study last week that tried to quantify the extra MOC burden imposed by the American Board of Internal Medicine (ABIM). It reported a 35% increase in fees and a 26% increase in the hours a physician will need to spend over the course of 10 years to satisfy the ABIM's recertification requirements as of February 2015.

When the dollar value of physician time, calculated as an hourly wage plus the cost of fringe benefits, is added to MOC fees, internists and IM specialists will spend, on average, $23,607 for recertification, according to the study. This cost ranges from $16,725 for general internists to $40,495 for hematologists-oncologists. Physician time, which comes to roughly 180 hours per physician over the course of 10 years, accounts for 90% of the cost totals.

As a group, internists and IM specialists will spend a grand total of $5.7 billion over the course of 10 years under the ABIM's new scheme, the study found. That compares with $4.5 billion if physicians were complying with the less rigorous MOC requirements that were in effect in 2013.

Study coauthor Dhruv Kazi, MD, calls for a rigorous evaluation of the ABIM's MOC program and its effects on patient care to justify that expense.

"Such a large investment should be driven by evidence," said Dr Kazi, an assistant professor at the University of California, San Francisco, in an interview with Medscape Medical News. "We don't see the evidence."

ABIM President and Chief Executive Officer Richard Baron, MD, counters that most physicians spend a considerable amount of time and money to keep up with their fields regardless of MOC. The ABIM's program merely provides a structure for that activity and does not necessarily create extra work, much less the 26% increase in MOC hours reported by the Annals of Internal Medicine study, Dr Baron said. He also points to another recent study showing that MOC for his specialty is reducing healthcare costs by billions of dollars per year."

Protest, Then Concessions

Before 1990, there was no MOC controversy in the ABIM, one of 24 boards making up the American Board of Medical Specialties. Certification in internal medicine and its subspecialties, once earned, lasted a lifetime. After 1990, the ABIM began certifying internists for 10-year stretches. Re-upping for another 10 years meant passing an exam and completing various training modules. By 2013, physicians had to earn 100 module points every 10 years, including 20 points in so-called practice assessment exercises, but could do that in the year before they took their recertification exam.

The ruckus kicked off in 2014, when ABIM made MOC more of a continuous process. It began requiring physicians to earn their 100 module points every 5 years and engage in some MOC activity every 2 years. There were new patient safety and patient voice modules to complete (the latter gives internists "the opportunity to incorporate the values and preferences of patients and their families when medical decisions are made," according to the ABIM). And the cost of the modules and the exam increased by almost 16%, to $1940, for internal medicine, and by 39%, to $2580, for an additional subspecialist certification.

A rebellion ensued. Internists and IM subspecialists began signing a petition — the signature count is now at almost 23,000 — demanding that the ABIM base board recertification on just an exam every 10 years. The leader of this campaign drive, cardiologist Paul Teirstein, MD, and other MOC dissidents formed a rival to the American Board of Medical Specialties called the National Board of Physicians and Surgeons (NBPAS), which promises a far easier and more meaningful path to recertification. (Disclosure: Eric Topol, MD, editor-in-chief of Medscape, is a member of the NBPAS advisory board, an unpaid position.)

In response to the blowback, an apologetic ABIM said in February that "we got it wrong" and introduced concessions. It would suspend the practice assessment, patient voice, and patient safety module requirements, which were decried by some as busy work, for 2 years. In addition, the ABIM would recognize most forms of continuing medical education approved by the Accreditation Council for Continuing Medical Education as credit toward training points.

The ABIM followed up with other changes. It announced in June that it would update its recertification exam beginning this fall. And in July, the ABIM said that physicians certified in nine IM subspecialties would no longer have to maintain underlying board certifications. Those nine subspecialties are advanced heart failure and transplant cardiology, clinical cardiac electrophysiology, interventional cardiology, adult congenital disease, transplant hepatology, adolescent medicine, hospice and palliative medicine, sleep medicine, and sports medicine. A physician boarded in interventional cardiology, for example, no longer needs to be recertified in cardiovascular disease.

Methodological Dispute

Study coauthor Dr Kazi told Medscape Medical News that his analysis of the ABIM's new requirements for MOC include the changes announced through February. Accordingly, the study assumes that 25% of continuing medical education activities that physicians undertake to satisfy state licensing requirements will earn MOC credit.

The ABIM's Dr Baron said he cannot make sense of this assumption because a physician could easily satisfy 100%, not just 25%, of MOC training requirements through CME. "There are a huge number of pathways in which a doctor could fulfil that," said Dr Baron.

In response to Dr Kazi's call for MOC to demonstrate its value, Dr Baron said a study published in JAMA last December did just that. It compared the healthcare outcomes of Medicare beneficiaries treated in 2001 by two groups of internists. One group had lifelong board certification earned in 1989. The other group, initially certified in 1991, had to get recertified in 2001. The authors found that annual healthcare costs rose at a lower rate in the following years for Medicare patients treated by the recertified internists compared with the cost of care for patients seen by MOC-grandfathered internists. Put another way, MOC reduced per beneficiary spending by 2.5%.

With total Medicare spending per year topping $550 billion, this 2.5% cost savings approaches $15 billion a year, said Dr Baron. So MOC pays off, he said.

ABIM funded the JAMA study, and four of its eight authors are affiliated with the organization.

Dr Kazi said he views the JAMA study as a proof of concept — MOC may pay off — but not as any vindication of the changes introduced in 2014. Extrapolating the effects of an older version of MOC on healthcare to 2015 is an apples-to-oranges analysis. More studies are needed, given the projected $5.7 billion investment that internists and IM specialists will make over the course of the next 10 years to get recertified, said Dr Kazi. He noted that the MOC changes announced in July, which were not analyzed in his study, could knock that figure down.

MOC dissident Dr Teirstein told Medscape Medical News that Dr Kazi's study confirms what he and others have been saying all along, although he thinks the projected 26% increase in MOC hours is too low.

"It justifies some of the feelings we have, that this is an outrageous amount of time, energy, and money we have to spend on a process that has not been proven to add a benefit to patients or physician practices," said Dr Teirstein.

His colleagues, he added, are not complaining about spending a certain number of hours keeping up with their medical field.

"Our complaint is that most physicians don't equate MOC with keeping up," he said. "We equate MOC with busy work."

The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online July 28, 2015. Abstract

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