MOC Shock: ABIM Program Signs Up Most Docs

June 04, 2014

New and tougher maintenance of certification (MOC) requirements set by the American Board of Internal Medicine (ABIM) have been widely derided as busy work, but most boarded internal medicine physicians and subspecialists nevertheless enrolled in the program by the May 1 deadline.

How much the numbers reflect fear of noncompliance or faith in MOC is an open question.

Almost 150,000 physicians signed up as of May 1 for MOC out of a possible 200,000 to 220,000 who hold some form of certification, which includes lifetime and time-limited, according to ABIM president and chief executive officer Richard Baron, MD. The fact that some physicians hold both lifetime and time-limited certification, Dr. Baron said, makes it hard to say precisely how many were confronted by the new MOC requirements.

Before 2014, physicians with time-limited certification were subject to recertification every 10 years. This has meant exercises in lifelong learning and self-assessment, testing, and analyzing their practice performance to find room for improvement. Recertification was not a requirement for physicians boarded by the ABIM and its subspecialty boards for cardiology, gastroenterology, oncology, and 17 other fields prior to 1990, when certification was a one-time event.

The rules have changed in 2014. The recertification process has sped up, forcing physicians, for example, to accrue 10 points for accredited education modules over 2 years and 100 points every 5 years. Physicians boarded before 1990 will keep their lifetime certification regardless of whether they participate in MOC, but the ABIM has found a way to pressure them to enroll nonetheless. This year, these grandfathered physicians will be listed as "certified, not meeting MOC requirements" if they don't get with the new program. The ABIM will apply the same label to nonparticipating physicians who received time-limited certification before 2014, but they will remain certified until their 10 years are up.

Physicians with time-limited certification have fallen in line. The ABIM reported that 77% of this cadre enrolled in MOC by May 1, with the participation rate exceeding 80% for gastroenterologists, endocrinologists, oncologists, and cardiologists. In contrast, only 21% of grandfathered physicians enrolled, but this was a considerable jump from a 2% rate before 2014.

The ABIM touts MOC — and its latest reiteration — as a way for physicians to demonstrate to everyone from patients to hospitals that they are keeping up with their field and trying to sharpen their performance.

Almost 16,000 physicians are on record at last count as disagreeing. They signed a petition earlier this spring promoted by cardiologist Paul Teirstein, MD, in La Jolla, California, stating that "MOC activities are complex, have questionable value, and detract from more worthwhile pursuits including patient care and other educational activities." The petitioners called on the ABIM to undo the changes in MOC and revert back to recertification every 10 years.

In another backlash, the Association of American Physicians and Surgeons has sued the American Board of Medical Specialties, consisting of the ABIM and 23 other member boards, for allegedly restraining trade and imposing enormous burdens on clinicians through its organizationwide MOC program.

A Number That Can't Be Ignored

Dr. Teirstein attributes MOC's high enrollment numbers to fear. "It's not that 150,000 physicians are loving MOC," Dr. Teirstein told Medscape Medical News.

Younger physicians with time-limited certification are worried about losing their hospital staff appointments if they sidestep MOC, he noted. The penalty is even more onerous for physicians first boarded in 2013 and beyond. Their certification, which is neither time-limited nor lifetime, hinges on MOC enrollment beginning this year.

"Grandfathered physicians are not as scared," noted Dr. Teirstein. "You're not concerned about losing your admitting privileges or licensure, or people disrespecting you."

The ABIM's Dr. Baron said he does not characterize the number of enrollees as a vindication of the MOC program.

"Some people who enrolled expressed frustration that they had to," Dr. Baron said in an interview with Medscape Medical News. "We know there are concerns, and changes we have to make.

"But I wouldn’t ignore [the figure of 150,000] either," he said. "We know some people enrolled because they believed it's a way they can signal to patients and colleagues that they support voluntary self-regulation."

Dr. Baron said MOC is winning over some grandfathered physicians who had been under the widespread and erroneous impression that they could risk losing their lifetime status if they participated. They are discovering, he said, that MOC gives them "a lot of credit for many if not most things they already do" in the way of self-improvement, such as attending medical conferences and participating in quality improvement programs at their hospitals.

To Dr. Teirstein, however, converting non-ABIM activities into MOC credits "takes considerable extra time." Plus, physicians essentially pay ABIM to accept this evidence of lifelong learning in the form of yearly fees, said Dr. Teirstein. Many MOC critics take umbrage at these fees — $200 to $400 per year for most physicians — which they say are too high, and unnecessarily enriching the ABIM.

Dr. Baron, in turn, calls the fees reasonable and invites skeptics to inspect the ABIM's financial statements on its Web site.

Fine-tuning MOC

Even as the ABIM defends MOC, it is redesigning some of the elements in response to physician complaints.

Dr. Baron said that the ABIM is trying to broaden the types of physician professional development that can translate into MOC credit. For example, discussions are under way to recognize continuing medical education (CME) conducted under the auspices of the Accreditation Council for Continuing Medical Education that hasn't been independently reviewed by the ABIM. Right now, such CME doesn't count unless the ABIM signs off on it.

Change also is in the works for MOC's practice-improvement modules. Dr. Baron said they will become less data-intensive.

"We have heard very clearly that doctors consider the modules busy work," he said. "They involve a great amount of data entry. We don't think that's a good use of their time."

That said, the ABIM is not returning to a simpler era when physicians could merely declare that they had expertise and competence, and that was that, he said. "Those days are long behind us."

The ABIM "has a clear obligation to make board certification as unburdensome as we can, with meaningful work and realistic standards, but we need to set standards," he said. "Most internists want us to do that."

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