Despite changes this year to make the maintenance of certification (MOC) process easier on internists, the American Board of Internal Medicine (ABIM) still faces strong opposition to the program. In May, South Carolina became the 12th state to pass an “anti-maintenance of certification” law. Legislation has been introduced in more than a dozen other states, according to press reports.
The MOC requirements for internists have become controversial in recent years. Some physicians complained about the cost, the time required to study for and take the exam, testing questions that didn’t apply to their work. On top of that, there is heavy pressure to pass and prevent the loss of certification, which can mean losing insurance panel participation, hospital privileges and sometimes employment.
Physicians have also complained about the monopoly that the ABIM and other specialty boards have on doctors’ ability to practice medicine.
In 2015, some physicians formed the National Board of Physicians and Surgeons (NBPAS) as an alternative certification for physicians to provide to hospitals and insurance panels. Some hospitals now accept NBPAS certification in addition to ABIM and other board certifications, but acceptance isn’t widespread, and insurance panels currently do not accept it.
In response to physician complaints about the MOC process, as of June internists and nephrologists were allowed to start taking a shorter “knowledge check-in” every two years instead of one longer test every 10 years. The option of the shorter exam will be rolled out to other ABIM specialties in 2019 and 2020. But these changes don’t appear sufficient to appease critics and slow the momentum for additional anti-MOC legislation.
“Physicians are pushing legislation on the state level because they don’t trust the ABMS [American Board of Medical Specialties] and its financial conflicts of interest,” says Paul Mathew, MD, a volunteer board member of the NBPAS in Cambridge, Mass. “Many feel the only way to declaw the tiger is legislative action due to insurance companies and academic institutions having no reason to change their pro-MOC policies.” The ABMS oversees MOC for its 24 boards.
The newer option allows for an online test with 90 questions in one sitting, taken at the physician’s convenience and his or her own computer. It’s expected to take two to three hours. Physicians may consult UpToDate, a clinical decision support tool, as a reference during the exam, unlike the traditional test where no resources are allowed.
Both exams result in recertification if passed. Doctors will still be able to test every 10 years if they prefer.
The MOC process vs the legislative process
Physicians interviewed say that anti-MOC legislative actions are unrelated to any modifications of the certification process.
While these doctors argue that they’re strongly in favor of continuing education, which is already required for state licensure, they say MOC has essentially become mandatory. In states where doing so is not banned by law, many hospitals require board certification for admitting privileges or hiring, and insurance companies require it for inclusion on panels.
The bills are a way to bring the issue to a larger audience. “Continued knowledge is always a goal, but you have an exam used for outside purposes. We want to make sure that doesn’t happen,” says Mishael Azam, COO and senior manager of legislative affairs at the Medical Society of New Jersey.
New Jersey’s anti-MOC bill was introduced in the state Senate in June 2017 but died in committee. It forbade board certification as a condition of licensure, reimbursement, employment, or admitting privileges at hospitals in the state. “Even if not signed into law ever, it’s still an important tool to continue our conversation with the [ABMS] board, just them knowing that there’s legislation introduced. They probably don’t want to deal with legislation state by state,” Azam says.
In March Washington state passed what MOC proponents consider a weak bill, as it only mandates that certification cannot be a condition of state licensure. That was a preemptive strike, since MOC isn’t required for state licensure in any state, and there are no current efforts to change that, says Paul S. Teirstein, MD, founder and president of the NBPAS and chief of cardiology for Scripps Clinic in La Jolla, Calif.
The bill was structured that way based partly on “some of the pragmatic concerns of what we could get passed through the legislature,” and partly on members’ primary concern of not having MOC tied to maintaining licensure, says Denny Maher, MD, JD, general counsel and director of legal affairs at the Washington State Medical Association in Seattle. While bill passage solves one potential problem, says Maher, it does not alleviate member concerns about MOC cost and relevance.
Some states, like Washington, begin with a “starter bill” to introduce the concept to legislators, says Maher. Then, if passed, legislators might introduce a subsequent bill with more teeth. This was the case in Tennessee. That state’s bill prevents healthcare facilities from requiring MOC activities of a licensed physician as a condition of employment or staff privileges.
Four additional states—Texas, Oklahoma, Georgia and South Carolina—have passed comprehensive legislation, generally prohibiting use of MOC as a factor in hospitals privileges, insurance payments, and state licensure.
Washington, Arizona, North Carolina, Kentucky, Missouri, Maine, and Maryland have passed starter legislation. And other states have introduced legislation that is currently pending or has expired. New Hampshire’s House of Representatives passed a proposed law this year, which is currently awaiting action from the New Hampshire Senate. “I think the political activity is pretty impressive, that it’s still going strong despite the changes the boards have made,” says Teirstein.
It’s a difficult process, Teirstein notes, because physicians lobby legislators as volunteers, taking time away from their practices and going up against what he says are highly paid and articulate ABMS and ABIM lobbyists. Sometimes specialty societies, which sell certification review courses and thus have a financial stake, lobby alongside the boards as well. Legislators may not understand the nuances and interests of all involved parties, making it more difficult for physicians to sway them.
ABIM did not respond to interview requests. But Tom Granatir, senior vice president for policy and external relations spokesman for the ABMS, said in an emailed statement: “These physicians may continue to press for legislation that will prevent the need to recertify. We remain committed to an independent program of assessment and will continue to oppose legislation that denies hospitals, health systems, insurers, and patients the assurance that their physician’s knowledge and skills are current and up to date, even as the boards work to improve their continuing certification process.”
What internists think of the MOC changes
Along with a continued legislative push, “There’s still a tremendous amount of momentum for maintenance of certification reform,” says Teirstein. He sees the testing changes as a step in the right direction. Other critics say the ABIM is not addressing their underlying test concerns.
“Their proposal of testing us more frequently is not meaningful,” says Scott Shapiro, MD, a cardiologist in Abington, Penn., and past president of the Pennsylvania Medical Society. The shorter tests are not substantively different than the longer test, and the questions aren’t directly applicable to what the physicians do in practice, says Shapiro. “It’s infuriating to the physicians who wouldn’t mind being tested more frequently, if it’s a process more relevant to our practice, and tailored to how we see patients.”
A concern for rheumatologist Mark Lopatin, MD, FACP, based in Willow Grove, Penn., is that the changes don’t address physicians’ complaints about the exam itself. “They have advertised it as open book, but physicians will have access to only one resource, UpToDate, and it appears that the ABIM has not allowed enough time during the exam for physicians to use that resource the way we do in practice,” says Lopatin.
The test also requires preparation time, which will take physicians out of the office every two years. “The shorter exam does not reduce the amount of time necessary to prepare for it, nor the stress associated with it,” he says.
The ABMS contends that physicians are happy with the new system. “Changes made by the boards in many disciplines have received very positive feedback from diplomates who believe the boards are listening to their concerns and making a sincere effort to make the program more relevant, valuable, convenient, and less costly,” says the ABMS’s Granatir.
ABMS considers additional changes
In January, the ABMS launched an initiative to further review the MOC process and plans to release a report in early 2019 with recommendations for ABMS boards to use in developing future continuing certification programs.
Labeled the “Vision for the Future,” the initiative “offers an independent and objective analysis of ABMS Member Boards’ approach to continuing certification today, and how it can be optimized for physicians in the future,” say co-chairs Christopher Colenda, MD, MPH, and William J. Scanlon, Ph.D., in an emailed statement to Medical Economics. The Vision Initiative commission is comprised of 27 members, including physicians and representatives of health systems, state medical associations, and specialty medical societies.
The NBPAS’s Mathew spoke at a recent Visions Initiative meeting. “I thought it would be like Hillary Clinton getting invited to speak at an RNC [Republican National Committee] meeting,” he says, but “the ABMS officials hosting the meeting were gracious and appreciative of my commentaries on the expensive, time-consuming, onerous, and unproven nature of MOC.” Mathew says he was surprised to see a number of commission members who were opposed to MOC. “I applaud the ABMS for not filling the room with supporters,” he says.
Given the sustained level of physician resistance to the MOC process, Teirstein sees the momentum for both state legislation and exam changes continuing. “I think the ABIM is getting a very clear message that it’s not just going to go away and physicians are disgruntled,” he says.