ASN’s Options for Helping Nephrologists Maintain Career Excellence

For nearly 50 years, the American Society of Nephrology (ASN) has supported the American Board of Internal Medicine’s (ABIM’s) efforts to certify nephrologists. Championing every aspect of certification—including continuing medical education, continuous professional development, and lifelong learning—ASN is committed to ensuring nephrologists provide the highest-quality care possible throughout their careers.

ASN dedicates intellectual capital, member and staff time, and financial resources to making sure every aspect of certification is meaningful for nephrologists and improves care for the more than 20 million Americans with kidney diseases. This commitment includes supporting nephrology fellowship programs, extending free membership to fellows, offering an in-training examination, holding a board review course, providing the Nephrology Self-Assessment Program (NephSAP) as a free benefit to ASN’s nearly 16,000 members, launching the Kidney Self-Assessment Program (KSAP) earlier this year, and developing two practice improvement modules.

On behalf of the broader kidney community, however, ASN must now join much of internal medicine—particularly professional societies that represent internal medicine specialists—in questioning ABIM’s ability to meet its mission: “To enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care” (112).

In response to growing criticisms of the 2014 changes to the Maintenance of Certification (MOC) program, ABIM suspended its Practice Assessment, Patient Voice, and Patient Safety MOC requirements earlier this year. ASN supports this decision, even though it rendered the society’s two practice improvement modules mostly obsolete. ASN will terminate these modules on December 31, 2015.

Additionally, ABIM in 2015 released “A Vision for Certification in Internal Medicine in 2020,” a report developed by the Assessment 2020 Task Force. The task force recommended ABIM replace its 10-year secure exam with more frequent assessments (with the potential for some portion to be open book), focus MOC on cognitive and technical skills, recognize specialization, and consider certification in specialized areas without requiring maintenance of underlying certificates (13). Supporting these recommendations—which the ABIM leadership is still considering—ASN requests that ABIM also address the fact that more internists (including specialists, such as nephrologists) than ever before are failing the MOC examination the first time they take it (14).

Beyond the uncertainty surrounding MOC, changes to the practice environment and the proliferation of institutional quality improvement programs have raised questions about the need for a recertification process. The Medicare Access and CHIP Reauthorization Act (PL 114-10) created the Merit-Based Incentive Payment System (MIPS) in addition to repealing the Sustainable Growth Rate (SGR). Increasing the relationship between assessment and payment, the mandatory MIPS will integrate several government programs (Meaningful Use, the Physician Quality Reporting System, and the Value Based Payment Modifier).

To help implement the new law, ASN provided guidance to the Centers for Medicare & Medicaid Services regarding the practice improvement activities that Medicare should incorporate into MIPS and encourage as part of outcomes-based alternative payment models. ASN strongly supports the concept that physicians should receive credit for meeting existing requirements, such as the forthcoming MIPS for MOC or vice versa.

In fact, the kidney community is ahead of other specialties in this arena, because nephrologists must navigate bundled payment, a quality incentive program, other federal mandates (such as Quality Assurance and Performance Improvement in dialysis units), and a “model” evaluating a specialty-specific accountable care organization (15, 16). Besides increasing the regulatory burden on nephrologists, these programs often shift assessment from individual physicians to health care institutions, making much of MOC duplicative.

An additional challenge occurred when ABIM ended a 25-year-old commitment to lifetime certificate holders. Starting with the 1990 examination, ABIM implemented a certificate that was “time limited” for 10 years. ABIM considered all certified internists (including nephrologists) “grandfathers” or “grandmothers,” allowing each to remain certified as long as he or she maintained a valid medical license. With little feedback from the internal medicine community, ABIM last year tried to change the lexicon describing time-limited certificate holders to either “meeting” or “not meeting” MOC requirements. Responding to protests from internists certified before 1990, ABIM revised the terminology this year to “participating” or “not participating” in MOC.

While supporting this revised terminology, ASN is disappointed that ABIM withdrew its pledge to certificate holders with so little input from the community. ASN also rejects the argument that ABIM was forced by the American Board of Medical Societies (ABMS) to make this change, because ABIM certifies nearly 25% of the physicians in the United States and ABIM revised the terminology earlier this year without first consulting ABMS (17).

With virtually no feedback from the internal medicine community, ABIM fundamentally changed its governance structure in 2014. Previously, the ABIM Board of Directors comprised the chairs of each test-writing committee (including nephrology) and other selected leaders, such as internal medicine department chairs or chief executive officers of health care systems. This structure guaranteed every internal medicine specialty was represented on the ABIM leadership and resulted in a reasonable balance among general internists, hospitalists, geriatricians, and specialists.

Today, ABIM’s Board of Directors is much smaller with representation from fewer specialties; no nephrologist currently serves on the board of directors, but the Chair of the Nephrology Specialty Board is a member of a recently formed ABIM Council that includes the chairs of all of the specialty boards. The charges to, purposes of, and relationships among the ABIM Board of Directors, Council, specialty boards, and test-writing committees are unclear, as is the link between these entities and the many internal medicine professional societies, including ASN.

Confusion surrounds the specialty boards. What is their charge? Does this charge encompass the entire mission of ABIM or just MOC? Should each specialty board have the same charge, have parallel memberships, and function similarly? How are the specialty boards supposed to relate to the professional societies?

This lack of clarity has left societies such as ASN unsure of how to interact effectively with ABIM. Due to a combination of uninspired agendas and choreographed meetings, the ABIM Liaison Committee for Certification and Recertification is currently not a meaningful forum for dialogue between ABIM and the internal medicine community. Even though ABIM held three summits with internal medicine leaders during the past 18 months, these discussions have failed to accomplish much. ABIM scheduled the third such summit the day before ASN Kidney Week 2015, virtually guaranteeing no nephrologist would participate in the discussion.

Recently, the ABIM Nephrology Specialty Board approached the directors of the US nephrology fellowship training programs about fundamentally changing the documentation requirements for fellows regarding procedures, including recording the number of inpatient dialysis orders and outpatient home dialysis encounters. The fact that the nephrology specialty board could consider this proposal raises troubling boundary questions about the responsibilities of ABIM, the Accreditation Council for Graduate Medical Education (ACGME), and the kidney community (as represented by ASN in this situation).

These boundary questions highlight the fact that members of the specialty boards brandish remarkable power in their fields, despite the fact that they were appointed and not elected by a broad membership, unlike the leaders of societies such as ASN. In light of the firestorm over MOC, concerns about the changes to ABIM’s governance, and lack of clarity concerning the role of the specialty boards, ASN currently lacks confidence in ABIM’s direction, focus, and leadership.

Finally, investigative journalist Kurt Eichenwald has questioned the organizational relationship between ABIM and the ABIM Foundation, the transfer of reserves from ABIM to the Foundation, ABIM’s approach to estimating deferred revenue, and ABIM’s dependence on future revenue from MOC (1820). Given the gravity of these accusations, ASN has been deeply disappointed with ABIM’s response. ABIM’s reaction reduced trust across internal medicine, including in the kidney community.

ABIM has invited ASN and other professional societies to “co-create” a meaningful MOC program that supports lifelong learning and practice improvement while achieving public accountability. ASN will continue to address the multiple concerns raised by the society’s members, along with much of organized medicine, regarding the direction, focus, and leadership of ABIM, with a particular focus on MOC reform.

As part of this process, ASN will request that ABIM:

  1. Suspend all MOC-related activities until the ABIM implements a completely new approach to MOC that is far less onerous to physicians. The entire internal medicine community must fully vet and approve this new direction. Pausing MOC would allow the community to work with ABIM to co-create an ideal approach to continuous professional development.
  2. Include in its new approach to MOC recommendations outlined by the ABIM Assessment 2020 Task Force that have already been embraced by the internal medicine community. These recommendations include replacing the 10-year secure exam with more frequent assessments (with the potential for some portion to be open book), focusing MOC on cognitive and technical skills, recognizing specialization, and considering certification in specialized areas without requiring maintenance of underlying certificates.
  3. Return its governance structure to the previous model, eliminate the specialty boards, and name “sponsors” (such as the Alliance for Academic Internal Medicine, the American College of Physicians, and the specialty societies) to increase organizational oversight.
  4. Allow ASN’s leaders and auditor to meet with ABIM Chief Financial Officer Vincent J. Mandes to review the finances of both ABIM and the ABIM Foundation in light of Mr. Eichenwald’s accusations. ASN thanks ABIM President and Chief Executive Officer Richard J. Baron, MD, for extending this offer to ASN shortly before press time.

While continuing to address these issues and reinvent every aspect of MOC, ASN has a responsibility to its members to explore at least four other pathways in 2016 to ensure nephrologists have the tools to continue to provide high-quality care to the more than 20 million Americans with kidney diseases.

Option 1: ASN could request that ABMS create two boards. The first board (ABIM) would focus solely on general internal medicine, hospital medicine, and geriatrics; the second board (the proposed American Board of Specialty Medicine) would focus on specialty internal medicine, including nephrology. Some may argue ABIM is “too big to fail,” but the nation’s 9,771 urologists, 9,320 otolaryngologists, and 8,832 dermatologists each have independent boards. The 9,394 nephrologists in the United States are massed into ABIM along with more than 200,000 generalists, hospitalists, geriatricians, and other specialists (21).

Option 2: ASN could promote competition by partnering with ABIM, the National Board of Physicians and Surgeons (NBPAS), and any other qualified entity to certify nephrologists and provide continuous professional development. Ideally, this option would result in improving coordination among the myriad entities that assess physicians and institutions. It should also eliminate the unacceptable variability among ABMS’s 24 specialty-specific boards.

Option 3: ASN could sever ties with ABIM (and ABMS) and partner with NBPAS or any other qualified entity to certify nephrologists and provide continuous professional development. This option is tricky, because the approximately $9,500,000,000 annually in Medicare funding for graduate medical education (including nephrology fellowship programs) has two criteria. First, the residency or fellowship program must be accredited by ACGME. Second, the training program’s residents or fellows must be eligible to take an ABMS-sanctioned certification examination.

Option 4: ASN could recognize that changes to the practice environment eliminate the need for ABIM/ABMS MOC. Under this option, ABIM/ABMS could focus on initial certification while the specialty societies provided continuous professional development. ASN commends the American Gastroenterological Association (AGA) for beginning to explore this possibility in the Gastroenterologist: Accountable Professionalism in Practice (G-APP) Pathway (22). In theory, societies like ASN and AGA could band together to provide lifelong learning.

Committed to ensuring nephrologists provide the highest quality care possible throughout their careers, ASN will consider every aspect of certification and continuous professional development in 2016. (To suggest other potential approaches, please contact ASN at education@asn-online.org by January 31, 2016.) During this assessment—which will include a survey of US nephrologists—ASN will determine the future of its relationship with ABIM, ABMS, NBPAS, and other entities. ASN will continue to do what is best for patients, for the relationship between patients and their physicians, and for ensuring nephrologists maintain excellence throughout their careers.

References

1. 

Williams, KA, Shor R. The American College of Cardiology and Maintenance of Certification: The Path Forward. J Am Coll Cardiol 2015; 65:2564–2565.

2. 

O’Gara PT, Oetgen WJ. The American College of Cardiology’s response to the American Board of Internal Medicine’s Maintenance of Certification requirements. J Am Coll Cardiol 2014; 64:526–527.

3. 

Day JD, Youngblood JH. Heart Rhythm Society: Independent Cost Analysis of ABIM’s MOC Published in Annals of Internal Medicine. http://www.hrsonline.org/About-HRS/Heart-Rhythm-Society-Governance/A-Message-From-Our-President/Independent-Cost-Analysis-of-ABIM-s-MOC.

4. 

Endocrine Society. Advocating for You: ABIM’s MOC Program. https://www.endocrine.org/education-and-practice-management/moc/moc-advocacy.

5. 

American Association of Clinical Endocrinologists. AACE Position Statement on Lifelong Learning. https://www.aace.com/files/position-statements/lifelong-learning-moc.pdf.

6. 

American Gastroenterological Association. AGA Rallies GI Societies to Push ABIM to Change MOC. http://www.gastro.org/press_releases/2015/11/4/aga-rallies-gi-societies-to-push-abim-to-change-moc.

7. 

American Society of Hematology. Statement from ASH President David A. Williams, MD, on Need for Changes to Maintenance of Certification, Comments on Assessment 2020 Report. http://www.hematology.org/Newsroom/Press-Releases/2015/4641.aspx.

8. 

Infectious Diseases Society of America. Concerned about Changes to the ABIM MOC Program? IDSA Is Working for You. http://news.idsociety.org/idsa/issues/2015-06-10/17.html.

9. 

Vose JM. An Update from ASCO on the ABIM MOC Program. https://connection.asco.org/commentary/update-asco-abim-moc-program.

10. 

Baumann MH, Carlin BW. American College of Chest Physicians MOC Response Letter. August 22, 2014. http://www.chestnet.org/Education/Advanced-Clinical-Training/MOC-PIMs.

11. 

American College of Rheumatology. American College of Rheumatology Position Statement: Maintenance of Certification. http://www.rheumatology.org/Portals/0/Files/ACR%20MOC%20Postion%20Statement%202015.pdf.

12. 

American Board of Internal Medicine. Our Mission. http://www.abim.org/about/.

13. 

Assessment 2020 Task Force. A Vision for Certification in Internal Medicine in 2020. http://assessment2020.abim.org/wp-content/uploads/2015/09/Assessment-2020-Final-Report.pdf.

14. 

American Board of Internal Medicine. First-Time Taker Pass Rates—Maintenance of Certification. https://www.abim.org/pdf/pass-rates/moc.pdf.

15. 

Watnick S, et al. Comparing mandated health care reforms: The Affordable Care Act, Accountable Care Organizations, and the Medicare ESRD Program. Clin J Am Soc Nephrol 2012; 7:1535–1543.

16. 

Comprehensive ESRD Care (CEC) Model Request for Applications. Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Innovation. May 22, 2014.

17. 

Nora LM, Chaudhry HJ. Update on MOC and MOL. 2015 Council of Medical Specialty Societies Spring Meeting. May 8, 2015. Chicago, IL. http://www.aapmr.org/members/activities/Documents/CMSS-Spring-2015-Meeting.pdf.

18. 

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.

19. 

Eichenwald K. Medical Mystery: Making Sense of ABIM’s Financial Report. Newsweek. May 21, 2015. http://www.newsweek.com/medical-mystery-making-sense-abims-financial-report-334772.

20. 

Eichenwald K. To the Barricades! The Doctors’ Revolt Against ABIM Is Succeeding! Newsweek. September 15, 2015. http://www.newsweek.com/abim-american-board-internal-medicine-doctors-revolt-372723.

21. 

AAMC Center for Workforce Studies. 2014 Physician Specialty Data Book, Washington, DC, Association of American Medical Colleges, 2014. https://members.aamc.org/eweb/upload/Physician%20Specialty%20Databook%202014.pdf.

22. 

Rose S, et al. Introducing the Gastroenterologist-accountable Professionalism in Practice (G-APP) Pathway: Bridging the G-APP-Replacing MOC with a Model for Lifelong Learning and Accountability. Clin Gastroenterol Hepatol 2015; 13:1872–1892.