Board Games: NBPAS, ABIM, and Maintenance of Certification

The American Board of Internal Medicine (ABIM) maintenance of certification (MOC) program has generated controversy since its introduction in 2014. Physicians have expressed frustration with a process many find burdensome, costly, and irrelevant to their everyday practice.

Dissatisfaction with the new certification requirements led ABIM to suspend and revise parts of the initiative in February, but not before several leading physicians introduced an alternative to MOC. The National Board of Physicians and Surgeons (NBPAS) offers American Board of Medical Specialties (ABMS) board–certified physicians a choice for ongoing certification and lifelong learning. These developments have altered the landscape physicians must navigate to maintain their board certification and consequently their ability to practice.

No MOC and NBPAS

Designed to improve upon continuing medical education (CME), MOC was adopted by ABMS and their member boards in 2000. The program focuses on six core competencies—medical knowledge, patient care, professionalism, interpersonal communication, and personal and system improvement. In addition to the 10-year recertification exam requirement, ABIM’s implementation added patient survey and patient safety modules, and public reporting of physician participation in MOC activities.

“Many physicians are upset about the recent changes to the MOC process, which we believe are onerous, time consuming, time wasting, and expensive,” NBPAS President Paul Teirstein, MD, told ASN Kidney News. “The main reason why doctors care about certification is because hospitals, and some payers, require it for them to practice.”

Teirstein, a leading interventional cardiologist, started an online petition—http://nomoc.org/—which became a rallying point, garnering more than 19,000 signatories. Sensing the demand for an alternative, he joined with other leaders in academic medicine to create NBPAS, a not-for-profit organization providing ongoing physician certification. “Why should the ABMS have a monopoly on continuing certification?” he asked. “There have to be different ways and people have different needs.”

NBPAS ensures physicians are staying current with medical advances, have valid licensure, and have no outstanding issues, such as loss of hospital privileges. Instead of patient surveys and other MOC practice quality improvement activities, physicians have to complete 50 hours of CME every 24 months, as evidence of lifelong learning, to receive a 2-year NBPAS certification.

Both sides of the MOC divide point to evidence in the literature to support their positions—pro (ABMS [1] and ABIM [2]) and con (Teirstein [3, 4])—on MOC and the adequacy of CME for lifelong learning. Teirstein cites meta-analyses that show little correlation between actual MOC activities and improved patient outcomes, and points to potential conflicts of interest in ABMS’s research. “We’ve looked carefully at the entire certification process and are trying to come up with a more reasonable and meaningful method of ensuring lifelong learning,” he said.

A serious point of contention is the 10-year recertification exam, which Teirstein believes is meaningless. “It makes you study for things you don’t know, and the reason you don’t know them is that you don’t need to know them.”

Other MOC activities, such as the medical knowledge modules, may not be clinically relevant to an individual’s practice. Still others, such as modules for patient safety, are redundant for physicians practicing in hospitals or other institutional settings.

“CME has tightened up quite a bit in the last decade,” said Teirstein. Still, he believes there’s room for improvement to ensure physician engagement and comprehension.

The American Medical Association (AMA) and other physician organizations have expressed concern about MOC’s cost ($1940 for a 10-year ABIM certification in internal medicine, $2560 for any specialty) and have called on ABMS to ensure MOC “doesn’t lead to unintentional economic hardships.” Teirstein noted that NBPAS isn’t focused on making money. “None of the doctors are getting paid and we’re trying to charge very reasonable fees ($169 for a 2-year certification for all specialties).”

The path to acceptance

Yet acceptance of the new credentialing organization will take time. “This is a multi-month process,” said Teirstein, “that requires physician champions at every hospital to push this through.”

Because most hospitals require ABMS board certification, recognition of NBPAS certification necessitates changing the bylaws. Credentialing or medical executive committees must approve the change, before final approval from the board of trustees. Since committees usually only meet once a month, it can take several months to gain approval. Teirstein added it was still ongoing at his own institution.

At press time, NBPAS was set to announce eight hospitals had approved NBPAS certification for admitting privileges. “I expect to see a lot more hospitals approve it over the next couple of months and I think it will snowball from there,” he added. However, it may take longer for payers to come on board. Blue Cross Blue Shield of Michigan recently announced it “does not intend to recognize NBPAS as a qualified board that meets our current standards for network participation.”

“We got it wrong, and we’re sorry.”

A year after launching MOC, ABIM President and CEO Richard Baron, MD, announced major changes to the program, noting “ABIM clearly got it wrong,” in a February 3, 2015, statement. These included suspending the Practice Assessment, Patient Voice, and Patient Safety requirements for at least 2 years; changing language reporting a diplomate’s MOC status; updating the internal medicine MOC exam; and maintaining enrollment fees at or below the 2014 levels for 3 years.

ABIM recently released the new internal medicine exam blueprint to be administered fall 2015 (http://www.abim.org/pdf/blueprint/im_moc.pdf). Developed with community input, the blueprint provides granular details on exam content designed to be more relevant for internists. In addition, ABIM announced plans to provide improved feedback on exam performance to physicians.

As controversy around its MOC implementation grew, ABIM became a target of public scrutiny. A series of Newsweek articles by Kurt Eichenwald (5) raised questions about the organization’s finances and alleged ABIM held a monopoly on certification. While nothing has been substantiated, some of ABIM’s statements during this period have provoked discussion.

In his March 11, 2015, response to the Newsweek article, ABIM Board Chair David H. Johnson, MD, said physicians had “… a choice among certifying boards that certify physicians in internal medicine and its subspecialties.” However, until NBPAS’ formation in January, nephrologists had only two choices for maintaining specialty certification—ABIM and its osteopathic analogue the American Osteopathic Board of Internal Medicine (the American Board of Physician Specialties certifies internal medicine only).

In the wake of MOC, the AMA recently called for ABMS to develop “fiduciary standards” for member boards, and for full transparency for MOC costs.

ASN and lifelong learning

Throughout the MOC process, ASN has listened to members’ concerns and conveyed them directly to the ABIM leadership. Over a series of meetings with ABIM, ASN also discussed issues surrounding ABIM governance, the new ABIM Nephrology Board, and potential effects related to conflicts of interest and commitment.

“ASN is taking a leadership role in addressing issues related to MOC,” said ASN President Jonathan Himmelfarb, MD, FASN. “This includes making sure our members have access to information about alternatives to the ABIM process—including information about NBPAS—as well as opportunities for lifelong learning and the necessary tools to make MOC as painless as is possible.”

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“We strongly support the importance of ongoing physician education to ensure best patient care, and to support professional development,” Himmelfarb told Kidney News. “ASN remains committed to helping our members navigate these complex issues.”

The road ahead

Despite ABIM’s decision to suspend some MOC activities, the program remains in effect, although it does not affect maintenance of licensure (MOL). The Federation of State Medical Boards (FSMB) has stated MOC is not required for MOL, and has emphasized the independence of each system. The Interstate Medical Licensure Compact, an FSMB initiative passed in seven states to date, also makes no reference to MOC because no state requires MOC as a condition of licensure.

The controversy surrounding MOC has been focused on standards to ensure physicians remain current with the latest medical advances. However, the implications of lifelong learning are wide reaching—involving every nexus in health care and affecting public trust in physicians and their ability to provide optimal patient care—which is why MOC remains a top priority for ASN and other physician organizations.

“We’re at a tipping point now,” said Teirstein. “We’re looking to organizations such as ASN to help propel the movement to take back some control over the onerous requirements physicians have had to comply with.”

ASN will host a Board Certification Forum special session on Friday, November 6, at 10:30 am PST at ASN Kidney Week 2015 in San Diego, CA. Teirstein will address the forum, which will be chaired by ASN leadership and give ASN members another opportunity to voice their concerns and opinions about the controversies in board certification and recertification.

Listen to the ASN Kidney News Podcast with Dr. Teirstein and ASN Executive Director Tod Ibrahim at https://www.asn-online.org/media/podcast.aspx. For more information, view ASN’s comparison of certifying bodies (https://www.asn-online.org/education/moc/Certifying_Boards.pdf), and visit the ASN (https://www.asn-online.org/education/moc/), NBPAS (https://nbpas.org/), and ABIM (http://www.abim.org/) websites.

References

1. 

Irons MB, Nora LM. Maintenance of certification 2.0 — strong start, continued evolution. N Engl J Med 2015; 372:104–106.

2. 

Baron RJ. Professional self-regulation in a changing world: Old problems need new approaches. JAMA 2015; 313:1807–1808.

3. 

Teirstein PS, Topol EJ. The role of maintenance of certification programs in governance and professionalism. JAMA 2015; 313:1809–1810.

4. 

Teirstein PS. Boarded to death—why maintenance of certification is bad for doctors and patients. N Engl J Med 2015; 372:106–108.

5. 

Eichenwald K. The ugly civil war in American medicine. Newsweek. March 10, 2015. http://www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html