A Letter to the State Senator from a physician who holds a time-unlimited certificate

"I am writing with regard to the requirement for physician Maintenance of Certification (MOC) which is included as a frequent component of healthcare legislation.  Language chosen for this mandate has resulted in significant anger and dismay in the community of medical providers.

As a doctor near the end of my medical career this issue has no great importance to my personal practice though it may accelerate my retirement. My interest largely stems from the fact that my son is just approaching the completion of his residency and from the concerns expressed to me by younger physicians, a number of whom I have trained.

Traditionally, certification has been the end point in various paths of medical training.  Tests are administered to demonstrate that the trainee has acquired an acceptable level of knowledge and is entitled to practice in a medical specialty or subspecialty. Recently, the poorly documented concern that knowledge may fade over time with an increase in adverse outcomes has resulted in requirements for recertification. In the past this has been at ten year intervals. This has been unpopular but accepted. With the passage of the Affordable Care Act a requirement for nearly continuous evaluation has been created. This process is termed “Maintenance of Certification”. The legislative language used creates a strict definition that produces a near monopoly for the organizations that perform initial certification.  Subsequent legislation has continued to refer to the importance of maintenance of certification (H.R. 1470).

This requirement has been greeted as unfair and arbitrary. Particular concern has arisen because the organization that certifies many medical subspecialties, The American Board of Internal Medicine, has come under scrutiny for its efficacy, methods and motives. These concerns are reviewed in two Newsweek articles authored by Kurt Eichenwald (http://www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html and http://www.newsweek.com/certified-medical-controversy-320495). In brief, the argument is made that the certifying organization lobbied to manipulate legislative requirements to promote the growth of a profitable industry that they will largely control. The process that they have created is expensive, extraordinarily time consuming and often requires extensive efforts in areas that have no relationship to a physician’s actual practice. Most importantly, the process has no demonstrated value in terms of improving outcomes. The burden of this process is considered so onerous that many physicians in private conversations express the possibility of leaving practice rather than submitting.

I think, when considering this issue, that it is worthwhile to try to shift terms. Certification is the process of determining that a practitioner has received adequate training to be considered a specialist or subspecialist. What society is actually concerned about is whether these practitioners continue to perform in a competent manner. Other countries, which have better outcomes than the United States, have consistently accepted participation in well designed, ongoing educational programs as sufficient to infer meaningful efforts in the maintenance of competence. Almost all subspecialty groups have such ongoing educational programs designed to promote knowledge in areas that are relevant to the pattern of a physician’s practice.  Participation in these or similar activities in addition to tracking outcomes in an individual physician’s practice with processes such as the Physician Quality Reporting System (PQRS) seem to be a more than reasonable requirements for demonstration of ongoing physician competence.

I strongly urge you to make efforts to remove language from legislation that refers to “Maintenance of Certification”. This term promotes a bias among payers with regard to using methods proposed by organizations such as the American Board of Internal Medicine (ABIM) as the best and possibly only approach to assuring continued physician competence. Efforts directed toward demonstration of competence should be minimally burdensome and certainly flexible enough to strengthen the knowledge and skills that a physician requires in their unique practice.

I would be happy to discuss this with you further if you would find it useful.  I would also be happy to refer you to physicians who have spent considerably more time and effort than I analyzing and addressing this issue.

Thank you for your consideration."

Request ASN to Disassociate KSAP from MOC

Dear fellow Nephrologists,

ASN recently launched KSAP in addition to its NephSAP as another self-assessment study tool. As we appreciate the effort and welcome the new product, it is concerning that KSAP is based on ABIM's "examination blueprints" and have MOC points tied to it. I have asked ASN to untie KSAP to MOC in the following email 3/2015:

"It is great to have a question bank offered by the ASN to help fellows, as well as practicing Nephrologists, for testing our knowledge.  This tool was unavailable when I graduated from my fellowship. The efforts the ASN and the question writers and reviewers have put forth, is very much appreciated. However, I feel strongly that there should be no association between KSAP and MOC.
 

As you are no doubt aware, there have recently been escalating controversies with MOC.  In particular,

·        Newsweek article by Kurt Einchenwald
·        The BMJ blog post by Dr. Elisabeth Loder
·        A debate from the National Board of Physicians and Surgeons by Dr. Teirstein

In addition, ABIM’s financial transparency has continue to be questioned. Needless to say, myself and many others believe that the ABIM and its MOC are in trouble from an ever widening credibility gap.

 

I have written to ASN multiple times expressing my opposition of ASN implementation of MOC. I believe that ASN should stand firm and not solicit points for MOC before it is proven to be beneficial for Nephrologists and our practice. With ABIM’s shady image, I am disappointed to see that the ASN continues to be complacent with ABIM’s grand plan by promoting MOC. It is puzzling to me why the ASN, an organization cherished by Nephrologists for its education value, has not distanced itself from the deeply corrupted and quickly falling ABIM.  Why have we still not been formally polled about our opinion on MOC? Why does the highly anticipated KSAP have to be tied to the ABIM MOC program?

Therefore, I would like to suggest a few things for ASN to consider:

 

1.    Conduction of a poll on Nephrologists’ view on MOC, including each part of the MOC program. I think this is essential and long overdue. Following the poll, the ASN should show members the results, similar to the ACC.  I would acknowledge that other Nephrologists might have very different view from mine, which no matter the result, would prove valuable to the ASN leadership on this important issue.

2.    Disassociation of KSAP from MOC. There is no evidence that MOC equates to competency or quality of care whatsoever. Repeated “studies” conducted by ABIM board members themselves have been unable to demonstrate benefit. KSAP is embraced because of the content -- irrespective of MOC.  Tying it to ABIM MOC  forces Nephrologists to enroll in an onerous program with dubious goals. This stance is now shared by the Dermatology society which has advanced a proposed resolution to stop MOC.

3.    Develop an ASN-based certification program.  ABIM may well become irrelevant sometime in the near future, either due to upcoming investigations and/or losing credibility and faith from physicians. Both Endocrine and Cardiology societies have initiated discussions about alternate certification methods.  Case in point -- ASN already has developed a strong in-training exam for fellows.  It would be logical to partner with organizations such as NBME for the next step and develop a certification examination.  Certification by this exam could be sanctioned by a new board (see below), or ASN itself.

4.    I have sent you the information on the new board, the National Board of Physicians and Surgeons, and would continue to ask if it is possible for the ASN to work with NBPAS to facilitate new certification and MOC goals for nephrologists. "

Help needed! Professional societies, are you in?

It is certainly a sobering process for every physician going from initially hoping that ABIM will listen to us, modify their MOC program, to finally realizing that our wishes are the complete opposite to ABIM's hidden interests. After a few days of "listening", ABIM is not even pretending anymore. The G+ group was shut, and the "Transforming ABIM" blog has deleted every single comment physicians left there, all happened while ABIM sent out a letter claiming that there is "more listening", "really listen" and "keeping-up". Despite support from major media, major journal, several bills with mandatory MOC written in them quietly passed. The war on American's doctors continues.

Will our grassroots effort succeed? Being pessimistic, I doubt it, at least not without the support from our professional societies.

I have urged our professional society to take a stand and help (see the letter below). Not showing in this email are suggestions such as working with alternative board certification entities, which was communicated in previous emails.

ABIM has scheduled an Internal Medicine Summit on Sunday, April 12, 2015. EVERY specialty society will be there. Doctors, please email your specialty leaders and tell them your opinion on MOC. It is time for all professional societies to act on behalf of their members, to say No to MOC, to stop the abuse, to break ABMS/ABIM's monopoly, to restore the sanity, and to fight to give us back the time with patients.   

***********

Dear ASN,

 

I am sure at this point you have read the new report on how the ABIM has been applying creative accounting and deceptive lobbying practices to coerce additional funding by mandating physicians into the yet-to-be-proven-effective MOC.  

I hope the outrage, frustration and helplessness of all physicians in this situation will not be overlooked by the ASN and other societies. The facts uncovered by the Newsweek editorial should put yet another nail in the coffin of the ABIM, further eroding its credibility and trust with physicians.  On this basis, it is imprudent to continue working with ABIM on any MOC activity. 

Therefore, I would suggest that the ASN consider the following actions:

1. Stop any MOC program currently initiated by ABIM.
1. It is a perfect example of “conflict of interest”:  the ABIM is a credentialing organization that is promoting more testing. As the editorial so eloquently describes, MOC is merely a fig leaf to conceal their spending extravaganzas, creative accounting tricks, and deplorable state of their finances.
2. MOC has never been proven to be beneficial, even by ABIM’s own “study”. There is no difference in the care delivered by grandfathered physicians and those with time-limited certificates. At least 10 countries have better healthcare with better outcomes, lower costs, and, yes, no requirements for MOC.  Thus, there is no ground for mandating MOC in the name of “competency”,  and furthermore it is a waste of resources to continue to collect more data on the putative utility of MOC.   I would urge you to stop saying that “more data is needed” and recognize that no further studies are indicated. We must stop MOC NOW.
2. Distance the ASN from ABIM
1. ABIM has become a corrupted organization that might be subject to further investigation.
2. ABIM has been distancing itself from physicians. The fact that they state and they are “listening” while all comments left on their blog has been completely deleted says it all. They lied to physicians about its spending and its intentions behind MOC. As a result they have lost the respect and trust of rank-and-file physicians.
3. ABIM should not be setting standards for quality, value, or professionalism. It is completely inappropriate that only the ABIM has set MOC as the single standard for physician competency, and appalling that the ABIM MOC program has turned physicians into easy targets as an explanation for our dysfunctional health care system. In a sense, ABIM, ACP, and the AMA have all failed physicians as our representatives.
3. ASN should take over the role of certifying and educating Nephrologists.
1. Initial certification plus yearly high quality CME should be sufficient.
2. ASN already has strong education programs available.
3. Patient care is the best all-around way of self-education and improvement
4. CME is a continuous process with wide varieties to meet physician needs. If the same CME works for physicians from other countries, the problem is not CME. There is absolutely no need to “create” a “continuous MOC”.
4. Please work on removing mandatory MOC from every bill or law, the ACA, the Interstate medical licensure compact, HR 2, etc. The national and political encirclement of these legislative bodies by the ABIM is deplorable, and underscores the extents to which the organization has gone to protect its economic interests.

 

The disappeared ABIM "Bonus Payment Program Template"

While I was telling other doctors about how ABIM attempted to force us into doing their MOC, I mentioned that they put out a "Bonus payment program" template for insurance companies. However, the link does not work anymore. I do not know when that first happened. Just post it here for future reference.

http://www.abim.org/doc/Bonus-Payment-Program-Template.doc     

Bonus Payment Program Template

 

[Insert Plan Name] would like to inform our network internists and internal medicine subspecialists, who are actively participating in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program, of our bonus payment initiative, [Insert Bonus Payment Initiative Name]. MOC promotes lifelong learning and enhancement of the clinical judgment and skills essential for quality patient care. 

Upon completion of an ABIM PIM Practice Improvement Module® as part of ABIM's Maintenance of Certification program, network internists and subspecialists will be eligible to earn a $[Insert Amount] bonus payment through [Insert Plan Name]'s [Insert Bonus Payment Initiative]. By aligning this financial incentive with ABIM's MOC requirements, [Insert Plan Name] and ABIM can work together to help you reduce the redundancy of data collection and measurement.  

Bonus payments are earned for completing one PIM [Choose “annually” OR “every two years”] during your MOC cycle. To earn the bonus payment of $[Insert Amount], you must: 

• Be an active [Insert Plan] provider as an internist or internal medicine subspecialist in full compliance with [Insert Plan Name]'s credentialing process;
• Be enrolled in ABIM's MOC program;
• Complete an ABIM PIM [Indicate Specific Time Period (e.g., Annually, Every Two Years, etc.)]. PIMs can be completed individually or as a group with other physicians in your practice (including physicians certified by the American Board of Family Medicine); and
• Authorize ABIM to provide electronic notification of your ABIM PIM completion status to [Insert Plan Name] through ABIM's web site (www.abim.org/submit-PIM).

 

If you have completed an ABIM PIM since [Insert Specific Date] and would like to authorize ABIM to provide [Insert Plan Name] with electronic notification of your PIM completion, please visit www.abim.org/submit-PIM. A step-by-step guide on how to submit a completed PIM to our plan is [Attached and/or Available on our Website at________]. 

[Insert Plan Name] encourages all internists, including those holding time-limited certification and those with certifications that are valid indefinitely, to participate in ABIM's Maintenance of Certification program. If you have not yet enrolled in MOC and would like to do so, please visit www.abim.org/moc. 

Please visit [Insert Plan Website] for information related to eligibility and participation in [Insert Plan Name]'s [Insert Name of Bonus Payment Initiative].

Stop talking and start taking ACTIONS on MOC

It is exciting when there is the appearance of progress. The publication of articles that raise doubt about the utility of MOC brings hope. These have appeared in the New York Times, NEJM, JAMA, etc. The original petition is a success, having collected more than 21,000 signatures. The excesses of the ABIM have been revealed and its integrity questioned. Progress has been made with launch of an alternative board, the NBPAS.

In reality, there has been little progress. The threat posed by MOC and resistance to MOC remains unchanged. The other petition, “a pledge of non-compliance with ABIM’s MOC”, has only gathered a little more than 7,000 signatures. The disappearing 14,000 signatures is nothing but “when idealism meets realism”. Noncompliance risks the loss of income, collapse of career, theft of our freedom and years of work, control of our lives, and the stifling of our passion and dreams. Unfortunately, there has been no modification of the requirements for MOC. The ABIM remains inflexible. The only change is that the poorly designed PIM now has a new name–“patient voice”.  

Doctors, it is time to stop talking. It is time to take more aggressive efforts!

First, we need clear goals. Do they include modifying current ABIM MOC proposals, abolishing ABIM MOC, creating an alternative MOC, or stopping the requirement for recertification? What would be the priority? What would be the most achievable? What would be the most ideal? Importantly, what would be our bottom line? What is our plan if the line is crossed?

I do not believe that our goals can be achieved by working with the ABIM. It is clear the ABIM was central in the design of ACA MOC requirements given the similarity of language in ACA and ABIM documents. Thanks again for Dr. Wes’ extraordinary work. WE are being naïve if we still put all our hope on ABIM, who definitely benefits from these MOC tests.  

Therefore, we do not have much choice but relying on an alternative pathway. The NBPAS is new and inexperienced, but I have hope that we can work with it to bring about change, if we act together and stay united.

These are my proposals:

1.      Let’s all apply for NBPAS certificate, no matter how many years your ABIM certificate is valid for. This is to support the new board and to send strong message to everyone.

2.      All of us should start to advocate for NBPAS Certificate as an alternative to the ABIM immediately. We must develop a plan to educate everyone on this issue. Edit this letter and send it to our credentialing committees, state medical societies, Chiefs of Staff, and insurers. Talk to everyone on the committee at every opportunity. This will be a difficult fight. However, if we can achieve acceptance of NBPAS certification, ABIM monopoly will break. ABIM MOC and recertification will become irrelevant.

3.      NBPAS should work to address the ACA requirements (see red and blue squares) ASAP. I believe that ACA requirements can be met by an alternative MOC program (see green squares).  There needs to be a program but not necessarily ABIM MOC, and there is definitely no mandate for repeated testing. We could push for using the hospital surveys that are already in place. If we have to do a required PIM at 10 years, it will painful but tolerable.

Screen shot of The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.

4.      We need recognized, respected, influential physicians of other specialties to be on the NBPAS board and subspecialty board. Methods to ensure and facilitate practical and meaningful lifelong learning are to be developed. Please volunteer! It is not just for your colleagues, it is for yourself as well. We have a lot of such wonderful people. Do not underestimate yourself. Look at our Surgeon General!

5.      Because NBPAS is still new, we can be more involved and help constructing it into a organized and approachable structure, one that remains responsive to the needs of practicing physicians. Legal and financial expertise will be needed during this process.

 

I want to remind you again to stop wasting time on ABIM and its subspecialty societies. Most do not care. They have no motivation to resist MOC. To this day, they are still promoting MOC despite the outcry of thousands of physicians! It is time to move forward deliberately. Let us start taking steps.

P.S. some extra info provided by another physician:
The ACA sections that deal with MOC:  They are so specific that for practical purposes MOC as sold and promoted by ABMS and ABIM and member boards is enforcing the LAW. NBPAS will have no choice but to do the same.
Go to the PPACA as passed:
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Then go to page 844 approximately:

SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM. 
‘‘(3) AUTHORITY.—For years after 2014, if the Secretary
of Health and Human Services determines it to be appropriate,
the Secretary may incorporate participation in a Maintenance
of Certification Program and successful completion of a qualified
Maintenance of Certification Program practice assessment into
the composite of measures of quality of care furnished pursuant
to the physician fee schedule payment modifier, as described
in section 1848(p)(2) of the Social Security Act (42 U.S.C.
1395w–4(p)(2)).’’.

Notice that the wording is the same as that of the Boards. In the last part of that section, PQRS/MOC requirements are coupled to medicare physician fee schedules. NBPAS will not be able to bypass this.