MOC Deadline Looms Anew, as Resistance Mushrooms

Shelley Wood

April 25, 2014

PHILADELPHIA, PA (updated) — With just a few more days to register for their "maintenance of certification" (MOC), almost 9000 physicians have signed on to a cardiologist-led petition demanding that the American Board of Internal Medicine (ABIM) recall the changes it made this year to the MOC process.

After April 30, as previously reported by heartwire , the ABIM will begin publicly reporting that physicians who are not registered are "not meeting MOC requirements."

The petition, created by Dr Paul Teirstein (Scripps Clinic, La Jolla, CA) on March 10, gathered 200 signatures in the first day, and support has mushroomed.

"The changes in the MOC requirements have upset a large number of cardiologists," Teirstein told heartwire . "It seems that pretty much everyone I speak with is against these changes, and the main arguments against the changes I received are that they don't create value for physician—ie, they do not have significant educational value—and they take considerable time and increased expense."

Dr Richard Baron, president and CEO of the ABIM, speaking with heartwire , took exception to both arguments. He pointed out that most physicians are already doing most of the activities for which they can accrue points towards their MOC requirements. Baron cited an opening address given by Dr Steven E Weinberger, executive vice president and CEO of the American College of Physicians, at an ACP meeting who pointed out that physicians attending could rack up half of the points needed within the two-year window at that single meeting. "Survey data say that people spend five to 20 hours per year on MOC, and I'm saying that for people who are saying this is a lot of 'burden,' there are many ways this can be done and many are things people are already doing, and one of our strategies for reducing burden has been to be sure we can give credit for high-value things that people are already doing," Baron said.

Moreover, he adds, "For people who are doing the really high stakes activity that is patient care, I think that's not an unreasonable amount of time to trying to keep up with your profession, and there are lots of pathways people can [take] to achieve that."

As for the costs of MOC activities, Baron points out that the ABIM is 100% transparent about its finances, and the amounts it charges for exams is "competitive" across the 23 medical boards. An additional point: 100% of the money used for educational activity comes from doctors.

A Groundswell of Concern

The idea for a petition grew out of the email-based discussion group led by Dr Morton Kern (University of Irvine, CA). Kern has been sharing questions to his now-120 members by email, mostly interventionalists and cath-lab directors, for three years. Several of the most active threads have become the meat of his popular "Conversations in Cardiology" series, published in Cath Lab Digest and Catheterization and Cardiovascular Interventions. The response to a question from Teirstein, posed to Kern's group, spurred Teirstein to launch the petition.

The petition includes a section for comments that captures the increasingly vitriolic physician reaction to what many see as unfounded distrust of their ability to practice medicine and keep up to date, plus more time and money spent on unneeded credentialing requirements.

"The ABIM claim that the public and patients are demanding this is hogwash, a complete lie and deception," says one signatory from Florida. "Doctors, you all know better."

"Board certification has never been shown to increase the quality of care . . . it just increases the financial bottom line of the board," writes another from Texas. "Many of the MOC requirements are just silly."

"Extortionate fees, dubious benefit to anyone—the ABIM has lost credibility with me," writes yet another from Virginia. "We already have precious little time to meet other demands, like, say, patient care. Not to mention the MOC activities are terrible in their own right from what I can tell so far. . . . The requirements are vacuous exercises in time-wasting."

Open Letter Sent to ABIM

Teirstein sent an open letter earlier this week to the ABIM, presenting his petition and noting its "viral" popularity.

"Most physicians believe in lifelong learning and value continuing education. However, the MOC program falls very short of its goal of continuous physician education," the letter reads. It then zeroes in on the two key problems Teirstein outlined for heartwire , saying these reflect the bulk of complaints collected online.

Many, including theheart.org on Medscape blogger Dr John Mandrola, resent the "arm-twisting tactics" that imply that doctors won't keep abreast of new information unless forced, or, as Mandrola points out, the unproven assumption that the MOC brand of medical education actually leads to improved patient outcomes.

Then there are the costs and the revenue that the new MOC requirements is generating for the ABIM, something many critics see as the final straw. The latest publicly available IRS 990 statements for the ABIM, provided to heartwire , show that the annual budget for the organization was over $50 million, with the CEO making $800 000 in 2010.

Prominent blogger and electrophysiologist Dr Westby Fisher, an outspoken opponent of the new requirements, has pointed out that "since the advent of MOC recertification, the financial reserves of the ABIM and ABIM Foundation have increased substantially; in 2006 and 2007, the ABIM transferred $13 million to its 'foundation.' "

After the announcement of the new requirements one year ago, the Association of American Physicians and Surgeons (AAPS) launched a lawsuit against the American Board of Medical Specialties (ABMS) "for restraining trade and causing a reduction in access by patients to their physicians." The AAPS also alleges that the MOC program will bring in "tens of millions of dollars in revenue" to the ABMS and 24 allied corporations, "which then pay prodigious salaries to their executives."

Addressing concerns about salaries, Baron points out that, as with all nonprofits, salaries are determined by boards who work with compensation consultants. "They ask, if they were trying to hire somebody to do this job, what other job would they be doing and what would people in comparable organizations be paid?"

The ABIM is a now $55-$60 million-a-year organization, he added. "If you want to hire a Chief Operating Office for an organization of that size, there is a salary that goes with that."

"A Silly Waste of Time"

It's been several years since the ABIM introduced mandatory recertification every 10 years. Then, in 2014, new MOC requirements were introduced with shorter deadlines, the idea being to ensure physician education remains continuous. Physicians must register before April 30, then demonstrate that they've accrued 10 "points" of accredited education modules within two years and a total of 100 points every five years.

Even cardiologists who were "grandfathered" within the ABIM requirements for having been board-certified prior to 1990 will now need to participate in MOC or otherwise face being listed as "certified, not meeting MOC requirements." After registering, physicians have until December 1, 2015 to complete at least one MOC activity to avoid being labeled as not meeting the requirements.

In addition to participating in MOC activities, physicians also need to complete a "patient safety and patient survey" module every five years that involves a review of their own patient data and "supports the implementation of and/or reporting on a quality-improvement plan for their practice."

This component in particular, Teirstein said, "was a silly waste of time. The people designing these things are clearly not busy practicing physicians."

Cardiology Organizations React

Cardiology specialty organizations are also wading into the fray. The Society for Cardiovascular Angiography and Interventions (SCAI) recently sent a letter to members announcing that it has formed an internal, physician-led MOC working group "whose initial task is to work with ABIM to address our MOC needs, both from an advocacy and a practical, day-to-day perspective."

The group aims to help members with the tools needed to "fulfill the MOC requirements in ways that are meaningful and quality-driven but not burdensome" and "engage with the ABIM to help them shape more relevant MOC process improvement."

Back in March, on the day of the earlier MOC registration deadline, ACC president-elect Dr Kim Williams (Wayne State University School of Medicine, Detroit, MI) also acknowledged the controversy over the MOC in an interview with heartwire .

"The ACC is committed to serving its members," Williams said at the time. "In this regard, we are not the drivers of MOC, but we believe in lifelong learning, however that's done, and to that extent that MOC is a process that is being required we will help our members obtain the MOC credits."

Asked what direction this contentious discussion has been heading in, Baron said that "physicians, historically, have been proud of their board certification."

His hope is that physicians will come around again to the belief that hospitals and practices need accreditation and certification to best judge who they should hire, and that process is best done by a physician-run board.

"People are struggling with lots of change. There is change at the federal level, there's electronic health records, and there is change in the ABIM program because medicine itself is changing. I think and I hope that the way we will sort this out is, we will recognize a collective [value] in demonstrating to our colleagues, to our institutions, and to the public that we do have special knowledge and skills, and we are keeping up. And that's what this is about."

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