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.

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!