Minutes on the Maintenance of Certification (MOC) session in ASN kidney week 2014

ABIM has added new requirements for Maintenance of Certification (MOC). Comparing with what used to be a every-10-year recertification test plus yearly CME credits, the workload is now more than doubled, not to mention the expense. Many physicians, as well as subspecialty societies such as AACE, ACC, AGA, AASM, etc. have expressed concerns about this significant change in the accreditation rules. However, the American Society of Nephrology (ASN) has not made any public statement on this important issue.

On Nov 15, 2014 a special session on MOC was held during ASN kidney week in Philadelphia.  The meeting was based on requests by several of ASN members who are deeply concerned about this abrupt change in accreditation policy.  Unfortunately, the session was not included in the formal conference program guide or the conference app, thus the attendance was extremely low. As one of the three who attended the session, I want to let you know what happened, and what might be our next steps in restoring some sanity to the whole MOC debacle.

The Meeting

Participants:

• ABIM panel: Drs. R Baron (CEO of ABIM), S Linas (Nephrologist and treasurer of ABIM Board of Directors)
• ASN education committee panel: Drs. J Berns, E Lederer, S Linas, M Rosenburg, S Wartnick
• ASN staff, including Mr. P Kokemueller, Chief Learning Officer
• ASN members: Drs. M Azar, L Huber, E O’Shaughnessy

Concerns/comments presented by ASN members:

1. There is insufficient evidence to support the benefit of MOC.

• After 20 years of implementing re-certification, there has been no study showing the benefit of re-certification, such as comparing outcomes of “grandfathered-in” physicians vs. physicians who take re-certification every 10 years.
• Note: new studies were published after this meeting. JAMA will host a discussion on these new data on 12/17/2014, Wed at 12N. Please attend if you could.
• No study has compared the MOC requirements with other methods of keeping up-to-date, such as self-directed education, attending conferences, preparing presentations.
• No study has shown that the current system (every 10-year re-certification + yearly CME) failed. Many countries using initial certification ONLY + yearly CME WITHOUT any re-certification are having superior patient outcomes.

2. Personal experiences from ASN members have proved that the MOC process is onerous, expensive, redundant and irrelevant

• It requires a major time commitment, detracting significantly from patient care.
• The every 2-year, every 5-year scheme is arbitrary, lacks scientific evidence and is impractical.
• Many MOC modules are irrelevant.
• Although new, some MOC content might not have sufficient time to be validated, and testing based on these new studies might be premature.
• It is a significant financial burden. 
• The PIM (performance improvement module) and patient survey are potentially associated with selection bias.
• Most hospitals conduct patient surveys regularly. If being done at the local level, there is no need for ABIM oversight.

3. Mandatory MOC will affect the future of medicine and physicians unfavorably

• The ABIM is a proprietary organization in the business of credentialing. They should not speak for our scientific or clinical societies. The legitimacy of ABIM promoting more credentialing process such as MOC is questionable and raises significant financial conflict.
• Constantly implementing unproven new regulations adds distrust towards our profession.
• Many physicians have to surrender their hard-earned multiple board certifications due to the egregious time and financial burdens imposed by the new MOC requirements mandated for each board certification. This is contrary to the goal of life-long learning.
• Mandating these radical changes in MOC requirements without input from practicing physicians sends a negative message to all hard working physicians and trainees.  Furthermore, the ABIM continues to not address concerns raised by petitions from several groups and an ongoing lawsuit.

Comments by Dr. Baron/ABIM

• CMS PQRS (Physician Quality Reporting System) showed that the quality of care is inconsistently provided. More regulations may come from other sources if we do not police ourselves. ABIM is trying to help all physicians.
• The fee for MOC is justified because of the high expenses related to preparing the test questions, setting up tests, staff, etc.
• Increased revenue of ABIM is all from membership fee and is transparent.
• If physicians decide not to maintain some of their board certifications, it is their choice.
• There is a lawsuit initiated by AAPS (Association of American Physicians and Surgeons), and the recent hearing was postponed. Everyone is free to support any group. However, the AAPS is a radical group with views not shared by the mainstream medical community.
• ABIM cannot set the criteria for hospital credentialing, CMS requirements or insurance company mandates.

Post-meeting Assessment:

1.      Tremendous amount of work will be needed to completely recall these MOC requirements. A more practical goal may be to modify it so it can be more manageable.

2.     There is the possibility that the ASN could take a position about MOC if we can align the membership toward a goal for the members and the organization. Several ASN panel members sympathized with our plight, and expressed some willingness to help. They stated that ASN will work to avoid regulations from other organizations while trying to simplify the MOC requirements.

3.      ABIM so far does not acknowledge the burden MOC imposes on physicians.

4.      ABIM is not addressing the issues raised by different voices; rather it is focusing on discrediting the opponent. 

5.      While Dr. Baron was stating that ABIM cannot set the criteria for hospital credentialing or insurance company mandates, ABIM has put on an online bonus payment program template for insurance companies to give incentives for enrolling in MOC.

6.      While Dr. Baron was stating that ABIM cannot set the criteria for hospital credentialing or insurance company mandates, ABIM has already ruled that “you will be board certified contingent upon "Meeting MOC Requirements" each year”.

7.      While Dr. Baron was stating that ABIM cannot set the criteria for hospital credentialing or insurance company mandates, ABIM has already ruled that “Fall behind in payments, your certification status may change."

 Proposals to ASN:

1.      Without any clear evidence, any promotion of MOC is unjustified. ASN should take a stand, as other subspecialty societies to minimize the burden of unnecessary regulations.

2.      Any change that will be applied to thousands of physicians needs to be tested first in pilot studies with meaningful and measurable outcomes.

3.      Any change that will be applied widely should be voted on by members.

4.      The ABIM board members should be more representative of the demographics of our physicians.

5.      In addition to meeting the ABIM goal, the ASN should take the opinions of the membership into account regarding the recertification process. A first step would be to survey members on their view of the new MOC requirements.

6.      ABIM should develop a process to allow subspecialty societies, including the ASN, to create specialty-specific MOC products without the need to have each vetted by ABIM.

7.      Nephrology is a subspecialty with its quality assessment highly monitored and deeply regulated by both CMS and industry. Practice improvement and reporting is also being performed regularly at the local level. There is no need to involve the ABIM. The current practice assessment components of MOC are unnecessary and need to be reconsidered.

8.      If the ultimate goal of MOC is to satisfy the quality requirement of CMS, it should only be mandatory for providers who do not meet the quality standard.  For providers who consistently meet the standard, every 10-year recertification plus yearly CME should be sufficient.

9.      Recertification should NOT be universally contingent on MOC.

Proposals to everyone:

1.      For everyone whose re-certification is due after 2015, let’s stop enrolling in further MOC programs until our requests are answered and concerns are addressed.

2.      Please encourage every Nephrologist you know to join the fight. Enough on just voicing your concerns. Nothing will change without action! From the low attendance of this session, it is obvious that either the importance of this issue is not realized, or it was assumed that someone else was going to be there. Again, nothing will change without action from everyone!

3.      It will be helpful to have some prominent figure in Nephrology to join us. If you know someone, please spread the words and ask for help!

4.      Ideas are needed on how to pressure ABIM to reconsider these requirements before it is too late. You can tweet to #ABIMMOC or leave message here to share your thoughts!