Rising Resistance to Maintenance of
Certification
Legislation passed in multiple states curtailing specialty board monopolies
Legislation passed in multiple states curtailing specialty board monopolies
Matt
Bogard, M.D.
(Dr.
Bogard practices Emergency Medicine at multiple hospitals in the area)
The
American Board of Medical Specialties (ABMS) is comprised of 24 member
boards that provide "board certification" in their
respective specialties: the American Board of Internal Medicine,
American Board of Surgery, American Board of Family Medicine, and
21 more. Each MOMS member is likely board certified by one of
the ABMS member boards and subspecialists may be double- or triple-board
certified.
Obtaining
initial board certification requires completion of a
rigorous accredited training program and passing multiple
exams beyond the three USMLE Step exams necessary to obtain a
medical license. While becoming board certified was once a voluntary sign of accomplishment and
prestige, maintaining board certification (via Maintenance of Certification
programs, or MOC) has become an ongoing process that seems to be little more than a lucrative money
maker for the boards and a drain on physician time and resources.
For many
years specialty board certification was lifelong and worthwhile – the
culmination of completing medical school, internship, residency, fellowship,
accruing cases, and taking that final big exam to prove you knew your stuff. But, beginning in 1990, most
ABMS boards moved from one-time certification to a ten-year "time limited"
certification and in following years introduced increasing numbers
of mandatory activities including computer modules, interactive
online encounters, recertification
exams and practice
improvement projects all required to "maintain
certification." Knowing this shift from lifelong certification
to decade-long blocks would never fly with established
practicing physicians, ABMS boards "grandfathered" all the physicians
who were currently certified and only applied the
changes to new, younger physicians who lacked
the time, financial means, and political clout to fight the onerous new MOC requirements. Currently, about 40% of physicians are
grandfathered. And, keep in mind,
this is often a separate process from the CME hours one must
accrue to maintain a state medical license.
As many
of us know, MOC activities not only consume precious time (when physician
burnout is at an all-time high) but also include numerous fees.
A study published in the Annals of Internal Medicine in late 2015 estimates the
average physician spends $23,000 per ten year cycle to complete MOC
activities. And it's no secret where this money is going: the American
Board of Internal Medicine (ABIM) 2014 tax form 990 shows $27 million in revenue from MOC activities. For
the American Board of Family Medicine it's $12 million - and its CEO's salary
of $641,000 is likely more than most Family Medicine physicians
earn. Collectively, ABMS boards and their foundations hold in excess
of one billion dollars in
assets.
While the
ABMS boards moved to "time limited" certification there was also
a push to mandate board certification as a condition of insurance
participation and obtaining hospital privileges, thereby forcing
physicians to participate in MOC. The National Committee for Quality
Assurance (NCQA) certifies most insurance companies in the US and assays as a "quality
metric" rates of physician MOC participation among insurance plans. The CEO of the NCQA is a former
board member of ABMS and
certainly has a conflict of interest in formulating policy at NCQA for the
benefit of ABMS.
So,
with all the younger physicians forced to participate in (and pay
for) MOC, is there data proving it worthwhile? Most
participating physicians surveyed report learning very little from the required
activities. Not a single study has clearly demonstrated
improvement in patient outcomes by MOC compliance. Multiple
published articles claim slight advantages but these are fraught with
concern: authors with significant conflicts of interest, research
funded by the specialty boards, insignificant p-values in the outcomes,
and data subsets showing negative outcomes ignored.
Physicians
around the country are increasingly fed up. The AMA House of
Delegates has adopted
multiple resolutions calling for changes to MOC. Grassroots
resistance led to the founding of the National Board of Physicians and Surgeons
(nbpas.org) as an alternative board certification agency and the
Practicing Physicians of America (practicingphysician.org) is fundraising
to bring antitrust litigation against the ABIM. Furthermore, nine states
have passed legislation prohibiting hospitals and insurance companies from
requiring participation in MOC as a condition of obtaining privileges or
contracting with insurers. Locally, Iowa bill HF2010 did not make it
out of committee this year and legislation has yet to be introduced in
Nebraska.
I
think nearly all of us are advocates of keeping up with changes
in our specialties and few balk at the CME requirements to maintain our medical
licenses. Obtaining initial board certification is a reasonable step
at the end of training. But current MOC requirements are onerous, not
meaningful, unnecessarily expensive, have no demonstrable benefits, and
waste significant time.
If you're among the 60% of physicians stuck participating in this fiasco,
consider advocating for meaningful change.
Published in the Metro Omaha Medical Society Physicians Bulletin Magazine,
July/August 2018
References:
LinkedIn
Profile: https://www.linkedin.com/in/matthewbogard/
*** Dr. Matthew Bogard is an emergency medicine doctor primarily at the Lucas County Health Center in Chariton, Iowa. Presently, he is Board Certified in Family Medicine by the National Board of Physicians and Surgeons and the American Academy of Family Physicians.
