By PL JETER
The MOC controversy is a David v. Goliath story that may be the most significant corruption story ever uncovered in the history of U.S. medical education....Westby Fisher, a cardiac electrophysiologist from Illinois and author of the popular "Dr. Wes" blog.
Physicians are outraged about plans by the American Board of Medical Specialties (ABMS) and its 24 specialty boards to overhaul once again the Maintenance of Certification (MOC) requirements they say have already become too time-consuming, expensive and clinically irrelevant.
"The MOC controversy is a David v. Goliath story that may be the most significant corruption story ever uncovered in the history of U.S. medical education," said Westby Fisher, MD, a cardiac electrophysiologist from Illinois and author of the "Dr. Wes" blog.
Under ABMS's MOC requirements, physicians are assessed every other year, and must pass a re-certification exam in their specialty every 10 years. Here's the rub: MOC is legally considered voluntary and not a requirement to practice medicine in the U.S.
The ABMS, doctors insist, has an unfair near-monopoly on the MOC recertification process based on long-term partnerships with insurance companies and hospitals, who often mandate MOC recertification, a brewing problem for the swelling number of hospital-employed physicians. Medicare, the standard bearer for coverage in the American healthcare system, does not.
"I've seen the forensic accounting on this ... it would stop your heart," said Marni J. Carey, executive director of Orlando-based Association of Independent Doctors (AID). But "then you might need a cardiologist, who won't be available because (of) studying for recertification. MOC is a hoax and needs to stop."
In a grassroots rebellion against unfair MOC mandates, AID is among many organizations across the country, including the American Association of Physicians and Surgeons (AAPS), Practicing Physicians of America (PPA), and the recently physician-formed National Board of Physicians and Surgeons (NBPAS), that oppose the ABMS initiative launched Sept. 25. A month before the announcement, 33 national medical societies and 41 state medical societies sent the umbrella organization a letter proposing a meeting with certifying medical boards to address their concerns "regarding the usefulness of high-stakes exams, the exorbitant costs of the MOC process, and the lack of transparent communication from certifying boards (that have led to) damaging the MOC brand, and creating state-level attacks on the MOC process." The societies also want participation in planning a solution.
The ABMS initiative, "Continuing Board Certification: Vision for the Future," was launched anyway. ABMS CEO Lois Nora, MD, insisted the concept had been brewing for months, noting that "concerns ... stimulated our thinking about the commission."
"The best step the ABMS can take is to assure us that MOC is voluntary," said AAPS spokesperson Jane Orient, MD. "We need options."
The seismic shift of MOC from lifetime to time-limited board certification has been a major cash influx to non-profit ABMS member boards. For example, the American Board of Internal Medicine (ABIM), the largest of the member boards, reported $27 million in MOC fees on their IRS form 990 three years ago.
The MOC re-certification process began innocently enough. The program was originally created when the (ABIM) and the American College of Physicians (ACP) were searching for clever ways to perpetually fund their activities and member salaries. In the late 1970s, the ABIM tried on for size a voluntary ongoing physician recognition program, "Continuous Professional Development," as an additional board certification. The plan failed because physicians didn't find the CPD valuable to their practices.
Taking a page from the playbook of the American Board of Family Medicine (ABFM) that only offered time-limited board certification, ABIM leaders implemented a similar program, reasoning that physicians "needed to keep up" or face "uncertain circumstances," noted Fisher.
"Before 1990, ABMS's 'board certification' was a well-respected voluntary lifetime physician credential that served as a practical assessment of a physician's adequacy to practice their specialty following residency training," Fisher explained.
In the 1990s, the ABMS board implemented a MOC program requiring doctors under a certain age to obtain re-certification throughout their careers. The move appeased older physicians, who were grandfathered in via previous lifetime certification guidelines. As the "grandfathers" retire, MOC fees just for ABIM "will certainly top $50 million," said Paul Teirstein, MD, who formed the physician-led National Board of Physicians and Surgeons (NBPAS) in 2015 to create a competing recertification program.
In a bold move to ensure their place at the table, the ABMS trademarked MOC in 2005. To sell MOC to the public, ABMS promoted the process as showing how doctors are staying abreast of their specialty while also honing their clinical skills. Over the next nine years, while doctors were distracted by ever-increasing federal government mandates, the ABMS quietly increased its coffers.
By 2014, MOC costs had increased 244 percent since 1999. MOC fees average $3,000 or more, excluding calculation for time lost caring for patients. An independent study showed that MOC-related fees add nearly $6 billion every decade to the already burdened American healthcare system.
That's not the only fallout. According to ABIM, 13 percent of physicians fail their initial MOC exam, an outcome doctors say is unfair to an unproven system and is "especially inappropriate when doctors are already in short supply and suffering from record levels of burnout and suicide," noted Fisher.
The creation of NBPAS (NBPAS.org), which has gained 6,000 members in less than two years and is on target to hit the 10,000 mark by the end of 2018, was in response to unreasonable MOC mandates. The argument: ABMS lacks significant evidence to support their reasoning of increased public safety to increase MOC mandates.
"We've been lobbying for change for over two years, but the ABMS member boards still require physicians (to) prepare for tests that have little relevance to their practice and result in well over $100 million in fees to board members," said Teirstein.
In an analysis of 33 MOC studies determining whether re-certification improves patient safety and outcomes, roughly half reported a significant association between certification and positive outcomes while nearly half found no association. Three surveys found a negative association.
"There's no evidence to support their claim to this end," said Judith Thompson, MD, a general surgeon from Houston. "Never has a patient outcome been related to the MOC product. Where's the public outcry for recertification? Show us the data."
So far, 17 states have proposed legislation to ban mandatory MOC requirements, but powerful industry lobbyists quashed Oklahoma's anti-MOC legislation passed in 2016. The Right-to-Care law, the first of its kind in the nation, intended to eliminate MOC as a stipulation for physicians to receive hospital privileges and licenses. But various loopholes in the language allowed hospitals to mandate MOC as a requirement.
In Tennessee, lawmakers were only able to remove MOC requirements for medical licenses. Aggressive anti-MOC bills in Arizona, Kentucky and Michigan legislatures died quietly.
In the 2017 session, a Florida anti-MOC bill languished in committee. The move was expected, since Gov. Rick Scott made millions as a hospital industry executive and was tied to Columbia/HCA, which eventually became the nation's largest private for-profit healthcare company. However, on Oct. 25, Sen. Denise Grimsley (R-26th District), a registered nurse, filed Senate Bill 628, "prohibiting the Boards of Medicine and Osteopathic Medicine, respectively, the Department of Health, certain healthcare facilities, and insurers from requiring physicians and osteopathic physicians to maintain certification or obtain recertification as a condition of licensure, reimbursement or admitting privileges."
Other states are making headway on the MOC issue. In an Oct. 11 hearing, Fisher, who has 17,000 Twitter followers, testified to the Ohio Health Committee that "hundreds of Tweets and emails I receive each year speak to the reality of the tremendous negative effect (MOC has) on decent, highly respected colleagues too embarrassed to go public with their failure, many of whom quietly leave medicine."
Georgians embraced the first successful state-implemented MOC legislation. In May, lawmakers successfully removed MOC mandates at some hospitals for doctor privileges, medical licensure and payer membership.
"The battle in state legislatures is an effective first step, but could be side-stepped if ABMS (et al) 'rebrands' the MOC program to a new product. As such, the most effective deterrent will be a ruling by the Federal Trade Commission (FTC) that (their MOC program) is a monopoly and violates anti-trust laws," said Fisher, noting the American Medical Society (AMA) has lobbied since 2015 to keep at bay an anti-trust lawsuit filed in the Northern District of Illinois.
"ABMS is now desperate to rebrand the MOC® program that funds as much as 47 percent of some ABMS member-board annual revenues in an attempt to pivot to a new, clever revenue stream that'll still permit cash to flow to this consortium of unaccountable private non-profit corporations to continue," said Fisher.
To compile a commission of roughly two dozen members to manage MOC changes, the ABMS has said it will include a diversity of industry representatives. When asked if the commission would include physicians, including representation from unpaid NBPAS members, Nora dodged the question, adding that members appointed to the commission will be determined by the ABMS planning committee.
"Physicians should insist their hospital Medical Executive Committee recognize NBPAS as an equal alternative to participation in MOC," said Fisher. "Both boards require initial board certification, but NBPAS recognizes the Accreditation Council on Continuing Medical Education (ACCME), vetted Continuing Medical Education credits, as valid for documentation of ongoing lifetime certification without having to commit to signing a HIPAA business agreement."
National Board of Physicians and Surgeons Offers Alternative
Physicians are jumping on the bandwagon of the newly formed National Board of Physicians and Surgeons (NBPAS), which offers an alternative MOC certification program. The San Diego, Calif.-based organization has accrued 6,000 members since its inception in 2015, and is on target to reach 10,000 members in 2018.
According to the NBPAS.org website, here's the most common question physicians have about the organization:
Is NBPAS accepted or recognized by hospitals, insurance companies, and state medical boards?
It's important to understand what "accepted" or "recognized" means with respect to these types of organizations.
For hospitals, NBPAS acceptance usually means the hospital's Board of Directors will accept NBPAS certification instead of ABMS member board (or AOA) certification for hospital privileges. The process for gaining acceptance usually starts with an interested physician making a presentation to the hospital's Medical Executive Committee (MEC), where they vote to recommend the hospital's Board of Directors accept NBPAS as an alternative. There are currently over 60 U.S. hospitals that either accept NPBAS certification for privileges or have eliminated MOC requirements from their bylaws. We are fighting to increase hospital acceptance/recognition by: providing advocacy materials on the Advocacy Center tab of our website, engaging our 400-volunteer physician Advocacy Committee, lobbying (within the limits allowed by law) state legislators to pass anti-MOC bills, and meeting with the Federal Trade Commission to consider the anti-competitive aspects of MOC.
For payers (insurance companies), NBPAS acceptance means the insurer will contract with physicians whose ABMS or AOA certification has expired but who have current NBPAS certification. Acceptance by payers is critical for widespread growth of NBPAS, and no insurer that we know of currently accepts NBPAS. It has been very difficult to get the attention of insurance company's management on this issue. While currently frustrating, we believe our continued growth and political activity will win over the payers. We especially believe passing anti-MOC bills in many states will be very helpful to our goal of gaining acceptance by insurers.
For state medical boards, acceptance is usually irrelevant. State medical boards do not require board certification or MOC as a requirement for initial licensure or MOL (maintenance of licensure). One important function of NBPAS is to bring awareness of this controversy to the state medical boards, which will help deter any efforts to make MOC a requirement for MOL in the future. However, there is one caveat we are aware of. A few states, including California and Texas, have laws requiring ABMS (or AOA) member board, or equivalent certification if a physician advertises they are a "board-certified specialist." These laws define "equivalent" very restrictively, so as the laws currently stand, NBPAS would not qualify. As NBPAS gains more widespread growth, we believe these laws will be changed.