Maintenance of Certification: An Update from the ASN Recertification Task Force

Recertification is a significant and evolving issue for practicing nephrologists. In response to physician complaints, the American Board of Internal Medicine (ABIM) has proposed a number of recent modifications to its Maintenance of Certification (MOC) program. The latest change released in August 2016 was an update of the MOC examination blueprint in nephrology informed by input of over 400 nephrologists in order for questions to better reflect what is seen in practice (http://goo.gl/f05DQX).

Other recent developments include a decision to award MOC points to physicians who participate in Quality Assurance and Performance Improvement (QAPI) programs managed by the Centers for Medicare & Medicaid Services (CMS) and a proposal to award points to residency and fellowship program directors (and other educational faculty) for resident and fellowship quality improvement and patient safety activities.

Additionally, ABIM announced in May 2016 a plan to offer physicians alternative MOC assessment options (beginning January 2018) including shorter assessments that can be taken from personal or office computers more frequently than every 10 years, and a potential testing out option eliminating the need to take a high stakes examination every 10 years. Planning to offer this option initially to general internal medicine and two specialties, ABIM has not indicated when nephrologists would be eligible.

Despite these recent developments, ABIM and MOC remain controversial and the subject of much criticism. Concerns with the current MOC process include relevance to practice, redundancy with other required practice improvement activities, the time and cost required to complete MOC requirements, the lack of evidence to support the inherent benefit of current MOC activities, and the perception of accountability issues with ABIM.

ASN has been actively engaged in these MOC issues at every possible level. For example, ASN leaders and staff have met regularly with ABIM leadership to express the concerns of nephrologists. The society has communicated through letters to members and Kidney News articles about MOC developments (Table 1), and ASN has collaborated with other specialty societies to address MOC issues, including sending a letter to ABIM leadership asking for clarification of the vision and future strategy for MOC. ASN has also surveyed the society’s membership about certification, recertification, and ABIM (http://goo.gl/DApw0V) with varied results on the importance of MOC and the activities that should count for MOC credit.

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In light of the high stakes nature of MOC to nephrologists and the controversies surrounding both ABIM and the MOC process, ASN formed a Recertification Task Force to define an ideal pathway to recertification (Tables 2 and 3). The task force met six times by conference call between May 10, and July 20, 2016. The purpose of this article is to inform ASN members and the broader kidney community about the deliberations of the task force, to outline principles and initial recommendations stemming from these deliberations to highlight areas where consensus has not been reached, and to encourage feedback from the society’s members concerning the progress of the task force’s (admittedly still evolving) recommendations.

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The task force developed a set of principles to provide a foundation for its final recommendations:

I. ASN supports a commitment to lifelong learning for all nephrologists.

The goal of any recertification program should be to reinforce the commitment to continuously staying updated in relevant areas of knowledge related to the practice of nephrology to deliver the highest quality patient care throughout the career of the nephrologist. There was consensus among the task force with this principle.

II. A recertification credential should be a voluntary demonstration to all stakeholders of a nephrologist’s commitment to lifelong learning.

The task force agreed that it was important to reconfirm that recertification is voluntary (not required for licensure, for example) but to recognize that recertification is required in many instances for hospital privileges and payer reimbursement.

III. The focus of any recertification activity should be on facilitating learning.

There was general agreement that the process for recertification should be user friendly and as simple as possible to ensure the majority of physician effort is spent on learning and not on trying to work through the logistics of how to accomplish recertification. Physicians should want to participate in recertification and not bear an undue burden in maintaining their status.

IV. Materials should use established adult learning theory in the design and execution of Continuing Medical Education (CME)/MOC activities and assessments.

An extensive evidence base exists on how to make learning more efficient and durable. There was general agreement that any recertification program should incorporate adult learning theory to enhance the quality and retention of information.

V. Financial transparency and accountability are a critical component of any recertification activity.

The task force agreed that it was important to have financial accountability as a core principle behind the recertification process. This belief includes identification and management of any real and perceived conflict(s) of interest.

VI. ASN should play a major role in the design of educational content for nephrologists.

ASN should continue to produce educational content that adds value to each nephrologist’s practice. The task force agreed that the role of ASN and other professional societies should be focused on developing high-quality educational content.

Based on these principles, the task force has formulated initial recommendations. Some of the recommendations are straightforward, but others remain controversial and without complete consensus among task force members. At this time, the task force’s recommendations include:

1. Continue discussion with ASN members and other stakeholders regarding the pathway for remaining certified. This discussion involves two unconcluded questions: 1) Should ASN support recertification? and 2) Should ASN support a single recertification entity or process with accountability to nephrologists and kidney professional organizations versus continue to support all options for recertification?

This recommendation was the most controversial topic among task force members with views ranging from continuing to work with ABIM as the single recertifying entity to establishing a separate recertification entity housed within a professional society, such as ASN. This lack of consensus was driven largely by a loss of confidence in ABIM as an organization that could effectively manage a recertification process. On the other hand, support for ABIM was based on an effort by ABIM to reach out to the community, admit mistakes, and make corrections, such as the suspension of the MOC Part 4 requirements and the recent MOC initiatives, including proposed alternatives to the 10-year examination.

The task force agreed that a need exists for independent research to establish an evidence base that MOC enhances patient outcomes and improves practice. Other considerations include conducting a feasibility study of ASN serving as or supporting an independent recertification entity. At this point, no consensus has been reached among task force members that is consistent with the ASN member survey data (http://goo.gl/DApw0V), particularly the question “Is ABIM the appropriate organization to recertify nephrologists?” to which only 42% of respondents answered yes.

2. Establish an independent recertification oversight committee comprised of nephrology professional organizations and other key stakeholders to advise and approve ABIM recertification policies and activities if ASN were to accept ABIM as the single recertifying entity.

Given the controversies surrounding ABIM and MOC, and the past history of ABIM initiatives that have not been fully vetted by the physician community, the task force felt strongly that there should be an oversight committee comprised of nephrology professional organizations and other stakeholders to advise, and also to approve, any changes in recertification requirements. This oversight committee would be independent of ABIM and the newly established ABIM Nephrology Specialty Board. Oversight would primarily be around process and financial implications of any changes in MOC.

3. Permanently eliminate Practice Assessment, Patient Voice, and Patient Safety requirements for MOC (Part 4).

ABIM has suspended the requirement for Practice Assessment, Patient Voice, and Patient Safety in its MOC program through December 31, 2018. Physicians may still choose to earn MOC points for these areas but they are not mandatory. It was the recommendation of the task force that these areas should not be part of the ABIM MOC requirements to avoid redundancy. Quality improvement and patient safety (QI/PS) activities occur within practices, dialysis units, and health systems and will be a component of the clinical practice improvement component of the CMS Merit-Based Incentive Payment System (MIPS) that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

4. High-quality, relevant educational activities (approved CME and MOC) should be the foundation for obtaining recertification credentials.

There was general agreement within the task force that recertification should be based on completing accredited CME programs, many of which can now be registered for MOC medical knowledge self-assessment points, if certain conditions are met, including a comprehensive evaluation component. These activities could be combined with low-stakes examinations that could be used as part of self-assessment of knowledge gaps allowing the physician to target CME activities to their practice needs.

5. Eliminate the high stakes examination and move to more frequent low-stakes assessments (assessment for learning, not of learning).

In general, the task force agreed with this recommendation. This position is consistent with the ABIM Assessment 2020 report (http://transforming.abim.org/assessment-2020-report/) informing ongoing design of the ABIM MOC program. The ABIM announcement in May 2016 discussed above is also moving in this direction, proposing low-stakes exams and a potential test-out option. The task force felt that the timeline for elimination of the every 10-year examination should be accelerated.

6. Simplify any web-based information concerning CME/MOC activities for lifelong learning available to nephrologists with more complete information (requirements, cost, other) and transparency.

The task force agreed, in general, that this recommendation was important to make needed information more accessible to physicians.

7. Have the task force present at a Recertification Forum at ASN Kidney Week 2016 on Thursday, November 17, 2016, from 10:30 am to 12:30 pm.

The task force looks forward to discussing MOC, recertification, and the principles and recommendations discussed in this article with Kidney Week participants at this session. Each member of the task force is very interested in more immediate feedback after members have read this article. Together, we will start a conversation about recertification issues on ASN Communities (http://community.asn-online.org/home). While ASN continues in these discussions, please forward your comments or concerns related to certification, recertification, ABIM, and related issues to the main ASN email address (email@asn-online.org) and use the subject line “MOC.”