Revolt against Maintenance of Certification Makes Legislative Gains

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A physician rebellion against maintenance of certification (MOC) is spreading nationwide, with legislation introduced in a dozen states and laws that limit the use of MOC in licensure, hospital privileges, and insurance reimbursement enacted in Texas and Georgia.

Bills similar to, or more limited than, the laws enacted in Texas and Georgia have been introduced in a dozen states, with varying levels of success. The process often starts with a resolution from the state medical society, and the legislation is often introduced by a legislator who is a physician. The movement has been spurred by doctors who say the MOC process is dominated by the member boards of the American Board of Medical Specialties (ABMS), with an overemphasis on high-stakes tests every 10 years that impose too great a burden in time and money in a process that has not been proven to improve patient outcomes. They seek alternative methods—such as state requirements for continuing medical education (CME)—to show that physicians are keeping up with current evidence and best practices.

At the national level, the June 2017 American Medical Association (AMA) meeting in Chicago featured a panel of physicians from different states who shared their experiences working to pass legislation. And the House of Delegates held a contentious hearing on a resolution that called for greater AMA involvement in state efforts to rein in MOC.

Georgia moves forward; support and opposition in Texas

Enacted in May 2017, the Georgia law will prevent the use of MOC as a condition of licensure, for employment by a state medical facility, for participation in insurance panels, or for malpractice insurance, according to the Medical Association of Georgia website.

The Texas law is similar, but had some amendments added to assuage the Texas Hospital Association in a process that illustrates the fault lines the movement has exposed—often pitting physicians against hospital organizations, health insurers, and ABMS.

The effort began with a unanimous resolution by the Texas Medical Association in support of a bill that would ensure that MOC “does not allow the [specialty] boards to prevent licensure, credentialing, employment, or contracts for insurance,” said Ray Callas, MD, an anesthesiologist in private practice in Beaumont who headed the medical association’s council on legislation. Introduced by a physician-legislator, the bill sailed through the Texas Senate, but “right before the bill went to the floor of the House, lobbyists were coming out of the woodwork. The ABMS was the biggest one trying to stop legislation,” Callas told Kidney News. “The Texas Hospital Association didn’t like it at all.”

One physician-legislator objected to “state legislation getting in the way of physicians making decisions on maintenance of certification,” Callas said, so the bill was amended to say that hospital “medical staff have to be the ones to decide [whether a facility would] opt in or opt out of maintenance of certification.” Other exceptions were made for level one trauma centers and advanced cancer centers like MD Anderson, Callas said.

These kinds of amendments made the legislation acceptable to the Texas Hospital Association, according to Lance Lunsford, the association’s vice president for strategic communications.

But ABMS remained firm in opposition: “The American Board of Medical Specialties believes that such legislation lowers the standards for medical specialty care, undermines professional accountability for medical specialty practice, and interferes with the right of medical staffs to set their own quality standards. It is bad for the profession and bad for patient care,” according to a statement supplied by Susan Morris, ABMS director of communications.

After a frenetic amendment process at the end of the session, the bill passed. Given the state’s size, the Texas law could have a significant impact on the debate.

Oklahoma trips on a technicality

The Texas Medical Association’s approach benefited from the experience in Oklahoma, the first state to adopt similar legislation, in 2016. Jack Beller, MD, an orthopedic surgeon in Norman and former president of the Oklahoma State Medical Association, said that a bill passed aimed at forbidding the use of MOC for condition of licensure, reimbursement, employment, or hospital admitting privileges. But hospitals in the state claimed that a technicality in the wording and the title in state codes meant the law did not apply to them.

The state medical association returned this year with clarifying legislation, but that legislation ran into a buzzsaw of opposition from the Oklahoma Hospital Association (OHA), Oklahoma Association of Health Plans, and ABMS.

“We got caught by surprise that ABMS hired four powerful lobbyists to fight it,” said the bill’s sponsor, family practice physician and Republican legislator Mike Ritze, DO.

“OHA opposed the bill because it interferes with a hospital’s right to contract with a physician and set appropriate conditions,” said Susie Wallace, OHA’s director of communications.

“The hospitals came out big time against it,” said Beller. “It is not our intention to take the granting of hospital privileges away from the medical staff. We think that if the medical staff wants to require recertification then that is their prerogative. Our problem is the hospital entities requiring recertification without input from the hospital staff.”

Michigan scales back

The Michigan State Medical Society has been pursuing similar legislation and framing the effort as a “Right2Care” campaign because, as its website puts it: “a bureaucratic nightmare known as ‘Maintenance of Certification’ … could cut off patients’ access to the physicians they know and trust!”

This year, the society is backing two bills. One prohibits the use of MOC in licensure. Another prohibits insurers and health maintenance organizations from requiring certifications not specifically required for licensure. The bills’ sponsor, Republican Rep. Edward Canfield, DO, a retired family physician, said that the second bill focuses on insurers because it would be “too heavy a lift” to also include hospitals, and perhaps raise their opposition. He notes that doctors can affect hospital bylaws to influence MOC requirements.

AMA: action or inaction

Those supporting the MOC-limiting legislation often give the impression that physicians are united in supporting their efforts, but the outcome at the recent AMA meeting reveals the uncertainty the issue presents to the medical community. A group that included the delegations of the large states of California, Florida, New York, Pennsylvania, and Texas; American College of Radiation Oncology; and American Society of Interventional Pain Physicians presented a resolution on “Action Steps Regarding Maintenance of Certification” to the House of Delegates to increase the association’s activism on the issue.

Although the AMA affirmed the resolution’s provision of “lifelong learning” as “a fundamental obligation of physicians” that is “best achieved by ongoing participation in a program of high-quality CME,” the most contentious provisions of the resolution were held in deference to existing policy or for future consideration. Among the measures sent back to Council for future consideration was that AMA “join with state medical associations and specialty societies in directly lobbying state licensing boards, hospital associations, and healthcare insurers to accept the satisfactory demonstration of lifelong learning through high-quality CME … for credentialing,” instead of “the ABMS-sponsored MOC process using … high-stakes testing.”

The snowballing state efforts and recent AMA House of Delegates debate about MOC raise questions about physician self-regulation versus turning over control of recertification to state regulators.

Norman Kahn Jr., MD, CEO, of the Council of Medical Specialty Societies, said he does not want state regulation to supplant the profession’s own efforts. Dr. Kahn, a family physician, said it is understandable that physicians can feel overwhelmed by the demands and burdens placed on them, but this legislative approach may be “self-destructive in the long run” because physicians have a responsibility to self-regulate the profession: “It’s a part of professional self-regulation, and if it’s not right, it’s our responsibility to fix it.”

Objections to MOC

The objections to MOC are well-known in the medical community: The tests are an outsized burden in terms of money and time; the thousands of doctors grandfathered in are performing well without being subjected to the tests; and MOC has not been shown to improve patient outcomes or quality measures. A recent study in the Journal of the American Medical Association found that almost a third of questions on the ABIM Maintenance of Certification (IM-MOC) examination were not relevant to general practice during the 2010–2013 testing period.

Texas’ Callas notes that the challenge is not against certification: “We 100% agree that ABMS or any board is very important to make sure that we have standardization and specialization related to getting board-certified.”

But recertification is a different matter, said Oklahoma’s Beller: “The problem is that all of these doctors have gotten their board certification, and now they are having to spend days and thousands and thousands of dollars every 10 years to maintain that certification. It has just become such a financial burden and a time burden out of their practices.” He notes that he is exempt from the testing because he is grandfathered in, and CME has proven sufficient for him and his peers.

“There isn’t data that shows [that MOC] improves patient outcomes,” said Megan Edison, MD, a Grand Rapids, Mich., pediatrician who has been a prominent MOC critic. “Continuing education has been shown to improve patient outcomes, but … ABMS’ education product has not been shown to do it. [CME] has worked pretty well for grandfathered doctors. Over half of doctors … passed their boards once, and then they do continuing education. Every state has their own requirements.”

Kevin McFatridge, director of marketing, communications, and public relations at the Michigan State Medical Society, said his organization agrees with this perspective: “The MOC requirement is not increasing the quality of care at all, and there are many studies that prove that. Michigan is one of the states that have the most CME hours required by law for physicians to complete for their [licensure]. So, for a health plan to tack on the MOC process is duplicative.”

Of course, it was the perception among many specialty boards that CME is too passive and not effective enough that led to the increase in MOC requirements, said Kahn of the Council of Medical Specialty Societies.

And ABMS disagrees strongly about MOC’s utility: “There is evidence that board certification and MOC are associated with higher standards, better quality care, and improved patient outcomes. There is evidence that physicians participating in MOC provide care at lower cost, mostly by ordering fewer tests and more efficient patient management.”

Alternative path?

One response to dissatisfaction with ABMS has been the establishment of a continued certification program by the National Board of Physicians and Surgeons that is less costly and requires a fraction of the time of the ABMS program. The organization’s website says it is “currently accepting applications for all ABMS and American Osteopathic Association specialties.”

Dissatisfied with the pace of change at ABIM, the American Association of Clinical Endocrinologists sent a letter to its members in 2015 inviting them to explore this alternative path to MOC.

At least one other professional organization is also pushing ABIM to reform its MOC process. The American Gastroenterological Association has proposed an alternative to the “high-stakes, every 10-year exam,” which the organization opposes, according to its website. The Gastroenterologist-Accountable Professionalism in Practice (G-APP) Pathway would replace the test with “active, adaptive, self-directed learning modules that allow for continuous feedback.”

Boards respond with changes

For their part, ABMS and its member boards are responding to physician concerns and complaints about the burden of MOC by proposing and implementing changes. Last year, ABIM said it would begin offering a second option in addition to the exam taken every 10 years.

The new option would allow physicians to take more frequent, shorter assessments on their personal or office computers. The process, which would allow ABIM’s diplomates to use an open-book resource, “would provide feedback on important knowledge gap areas so physicians can better plan their learning,” according to an ABIM press release. ABIM plans to pilot this two-year option in internal medicine and nephrology starting in spring 2018.

The American Board of Anesthesiology has already dropped its 10-year test and replaced it with an online test and learning modules.

“An overwhelming majority of our diplomates are actively using the tool, which means they are continuously engaging in building and retaining their medical knowledge,” said Deborah J. Culley, MD, secretary of the American Board of Anesthesiology. “They’ve told us we’re moving in the right direction. Since longitudinal assessment is a new approach to physician assessment, we have had a few challenges. For instance, diplomates have told us some questions were not relevant, poorly written, or repeated too often. We’ve revised or pulled questions based on this feedback, and continue to develop new items to build our question bank.”

“I give ABA very big credit, because they listened to their anesthesiologists,” said Callas, the anesthesiologist and MOC critic from Texas. “They did away with the high stakes test. We have to answer 30 questions every quarter, and we are not scored in a negative or derogatory way. They give you the answer at the end after you assess your question, and you read about it. They try to make sure that we maintain a high level of care, and they also try to gear the questions toward your type of practice.”

The anesthesiology board is often cited as a leader in exploring this new approach to physician education and re-assessment. As other specialty boards adapt to the shifting landscape, the pace of their innovations could determine how much they are challenged by dissatisfied physicians pushing legislation to force change.

July 2017 (Vol. 9, Number 6)