If there’s one constant surrounding the American Board of Internal Medicine’s (ABIM) maintenance of certification (MOC) program, it’s controversy. Physicians galvanized by the cost, time, stress, and perceived irrelevance of the requirements of ongoing certification have donated more than $290,000 to a GoFundMe campaign, sponsored by Practicing Physicians of America (PPA). The fundraiser supports three federal class action lawsuits seeking an end to MOC pending against the ABIM, the American Board of Radiology, and the American Board of Psychiatry and Neurology.
As reported by Medical Economics in December 2018, one of the suits—filed on behalf of approximately 100,000 internists—alleges that the board illegally ties its initial certification to its maintenance of certification process. The suit also claims that ABIM has used “various anti-competitive, exclusionary, and unlawful actions to promote MOC and prevent and limit the growth of competition from new providers of maintenance of certification for internists.” In January 2019, the complaint was amended to include racketeering and unjust enrichment claims.
According to Marianne Green, MD, who became chair of the ABIM’s board of directors in July 2019, “the lawsuit has no impact on fulfilling our mission.” Via email she continues, “Each and every day we strive to serve physicians and patients by developing standards that reflect the latest in medical science and the experience of physicians, as well as the means for assessing physicians in upholding these standards.”
Nonetheless, in a statement responding to the December lawsuit, the ABIM said it would “vigorously defend itself, recognizing that doing so will consume resources far better dedicated to continuous improvement of its programs.” Indeed, the ABIM filed a motion to dismiss the suit in March 2019. The plaintiff attorneys promptly opposed the motion, disputing the ABIM’s use of two franchise analogies citing Krehl v. Baskin-Robbins Ice Cream Co. to demonstrate that initial certification and MOC are not separate products.
“Physician care is not Baskin Robbins ice cream, and patient treatment is not a Subway sandwich. Hence, the notion that ABIM can force MOC on internists in service of an illusory nationwide standard unilaterally imposed by ABIM offends the free market principles that are the hallmark of medical care in this country,” the plaintiffs stated in an April 30 memorandum.
New pathways underway
In the meantime, ABIM has made some changes in response to long-standing criticism of post-1990 MOC requirements.
For example, ABIM and the American College of Cardiology announced in March an alternative option for cardiologists to maintain their board certification. The Collaborative Maintenance Pathway includes five annual performance assessments, each covering about 20 percent of the field of cardiovascular disease. The first assessments will be administered this fall, and physicians will have two chances to pass the exam.
“Over the past several years I think ABIM has done a much better job of engaging with the internal medicine community, and that work has enhanced our programs,” Green says.
“In 2020, a new option for medical oncologists, being created in collaboration with the American Society of Clinical Oncology (ASCO) will become available,” Green adds. The ABIM/ASCO Medical Oncology Learning & Assessment will replace ABIM’s Knowledge Check-In in Medical Oncology that had been planned for 2020. The new pathway will allow diplomates to take a shorter assessment every two years, with topic-focused exam modules and related educational materials provided before, during, and after exams.
Physicians will be able to select from a choice of a general medical oncology, breast cancer, or hematologic malignancies modules, with more modules slated for 2022. “These new offerings will increase choice, flexibility and relevance board certified physicians have asked for,” Green says.
Changes too slow for some
Mark Lopatin, MD, has been a vocal opponent of ABIM’s MOC process for several years, but says that these new options are similar to changes he’d like to see in his subspecialty of rheumatology. His 1986 board certification in internal medicine is still considered valid, even though he hasn’t practiced in the field for 30 years, he says. But because rheumatology boards were not available in 1989, he took and passed the exam in 1990—one year too late to achieve grandfathered status—and has gone through the MOC process every 10 years since.
He won’t be taking a fourth exam in 2020, however. “To take rheumatology boards means that I have to spend about three months preparing—at least three months—studying rote memorization of facts, esoteric stuff, trivial pursuit kinds of stuff that is not relevant to what I do on a day in, day out basis,” he says. “I’ll be 63 years old at that time, so if I took it and retired at 65, it buys me another year or two. It’s not worth it.”
While pleased to see ABIM collaborating with medical societies in some subspecialties, Lopatin says the testing component is still fundamentally flawed. “They’re still focused on that high-stress, timed exam that needs to be passed. What really needs to be measured is due diligence,” he says.
And despite his impending exit from medicine, Lopatin has already donated twice to PPA’s GoFundMe campaign. “I’ve been very outspoken about this, and this is my chance to put my money where my mouth is,” he says. “I am stopping my career because of this. To me, that’s a pretty strong statement about how I feel about what ABIM has done and is doing.”
Feedback about Knowledge Check-In
Recent changes to MOC also include an alternative to the traditional 10-year exam known as Knowledge Check-In (KCI). ABIM launched the KCI, a shorter, every-other-year online assessment option for physicians in internal medicine and nephrology in 2018. In 2019, eight more specialties were added, including gastroenterology, rheumatology, cardiovascular disease, geriatric medicine, hematology, pulmonary disease, infectious disease, and endocrinology.
“Overall, we’ve received good feedback from those who have taken it. We mostly hear that they appreciate the shorter testing experience and the convenience of being able to take it at their home, office, or test center,” Green says.
However, Lopatin argues that this option is still incongruent with the way physicians actually practice, which includes looking up information about a patient’s condition without a time limit and consulting with other physicians when necessary. “They’re more worried about people cheating than they are about providing a good educational tool,” he says.
In addition to the requirement of passing an exam every 10 or two years, physicians must also acquire 100 MOC points every five years through a combination of activities geared toward practice or quality improvement and continuing medical education (CME).
In 2015, ABIM announced a partnership with the Accreditation Council for Continuing Medical Education to expand the options available to physicians to receive MOC credit. As of June 30, 2019, 156,104 ABIM board-certified physicians had earned 13,453,817 million MOC points, Green says. To date, 27,854 activities have been registered for MOC points by 445 CME providers.
However, some physicians argue that these options are still too restrictive. Paragraph 53 of the class-action complaint notes, “Importantly, MOC differs from CME because if physicians do not see value in particular CME courses or classes they are free to purchase other CME offerings; there is no such meaningful option regarding MOC.”
Anti-MOC laws continue to spread
Theoretically, MOC is voluntary in all states. However, most hospital privileges and insurer credentialing is contingent upon a physician being board certified. As described in paragraph 39 of the original complaint, Blue Cross Blue Shield, which covers roughly one-third of Americans and contracts with 92 percent of physicians, requires physicians to participate in MOC to receive a panel of patients in their plans or be included in their networks.
Patients of internists that do not purchase MOC have been told that their physicians are no longer preferred providers, and that they should look for another primary care doctor or be subject to higher out-of-network coinsurance rates.
In 2016, Oklahoma became the first state to pass legislation preventing hospitals, licensing boards, insurance companies, and health systems from requiring MOC. The list has since grown to include Georgia, Maryland, Missouri, North Carolina, Oklahoma, Tennessee, and Texas. Bills in several other states are under consideration.
“States retain the right to set licensing requirements and other standards,” notes Green. “Physicians, patients, hospitals, and insurers see MOC as a means of conveying important information, but MOC is and has always been voluntary.”