ABIM Leaders Say They Are Revamping MOC Requirements

Marcia Frellick

November 30, 2016

Leaders of the American Board of Internal Medicine (ABIM), the governing body for Maintenance of Certification (MOC) requirements, are responding to strong criticism with proposed changes to the system.

"The world has unquestionably changed since 1979, and so must our thinking about certification," write Richard J. Baron, MD, president and chief executive officer of ABIM, and Clarence Braddock, MD, MPH, chair of ABIM's board of directors, in a perspective piece published online Wednesday in the New England Journal of Medicine.

Alternatives to 10-Year Test

One of the biggest changes planned is an alternative path to recertification. For most physicians, that would mean they would not have to take the long-form test every 10 years, but instead would have a series of more frequent, but less onerous, assessments. Consequences would increase with each unsatisfactory performance on an assessment.

For those who perform below standard on this new series of tests, or those who have lost certification and want to regain it, the 10-year test schedule would remain in place.

The authors say they have changed ABIM's internal structure and are "reimagining our relationship with practicing physicians to align with these changes."

To do that, they are using methods such as crowd-sourcing to determine what knowledge is essential for various physicians and what is most relevant to their practices.

In an effort to make the assessment results more meaningful, ABIM is also changing the format for scores so that physicians get more detailed feedback.

However, the ABIM leaders maintain that the MOC is still the best way to ensure physicians are keeping up with the changing knowledge of their specialties, and cite evidence that it can affect health outcomes.

"Despite critics' claims to the contrary," the authors write, "we believe the evidence is convincing, albeit incomplete, that certain outcomes are better for patients treated by board-certified physicians."

Among the evidence of benefit they cite is that the "cost of care for Medicare beneficiaries is 2.5% lower among physicians who were obliged to complete MOC than among those who were not."

Paul Teirstein, MD, chief of cardiology and the director of interventional cardiology at Scripps Clinic in La Jolla, California, takes issue with the 2.5%, which comes from a 2014 study published in JAMA. That number reflects the reduction in the growth differences in cost, which is much smaller than the 2.5% lower cost the authors claim, he notes.

That same study also shows an increase in emergency room use for patients treated by MOC-required physicians, he added.

"There's no evidence that MOC, recertification or take-home computer modules improve patient outcomes," he told Medscape Medical News. "This is a money-making operation for [ABIM]. It's a tollbooth, and there's no evidence that it helps anybody, and it takes a ton of time."

He said ABIM's removal of the practice improvement modules this year was a positive step, but noted that the changes the organization is currently proposing generally offer little. He maintains that the entire system should be scrapped in favor of a system of continuing medical education requirements.

To that point, the authors write that ABIM is partnering with the Accreditation Council for Continuing Medical Education to find ways that more continuing medical education offerings can count toward MOC credit, and to make claiming that credit easier.

Most physicians agree with Dr Teirstein that the MOC process is burdensome. In a study published in October by Cook et al in Mayo Clinic Proceedings, reported by Medscape Medical News, 81% of physician respondents considered MOC a burden, and only 12% said "MOC activities were well-integrated into their daily routine."

ABFM Chief: Changes Are Important Step

James C. Puffer, MD, president and chief executive officer of the American Board of Family Medicine, takes a different view of what the ABIM is proposing, calling the changes "an important step."

He told Medscape Medical News in an email that the article "underscores the important role that continuing certification plays in the self-regulation of the profession."

"Given that 81% of the physicians surveyed in the recently published Cook study felt that participation in this process was a burden, and 88% felt the process was not well-integrated into their daily activities, the challenge for certifying boards is to create efficient programs that are meaningful to the physicians that they certify while maintaining the value and integrity that the certificate represents to the public."

"The changes under way at the American Board of Internal Medicine are an important step in that direction," he said.

Dr Baron reports personal fees from the American Board of Internal Medicine outside the submitted work. Dr Teirstein, Dr Puffer, and Dr Braddock have disclosed no relevant financial relationships.

N Engl J Med. Published online November 30, 2016.

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