MOC: Debate intensifies as Medicare penalties loom

If you want to spark a debate, just ask a physician about maintenance of certification (MOC) requirements. The reaction often is visceral. The rules are designed to create a culture of continuous improvement in practice, but they can be confusing, costly, and time-consuming. In 2015, Medicare penalties are on the way for not participating in the Physician Quality Reporting System (PQRS). MOC is included in PQRS.

Today, many physicians are fighting the requirements, with one medical group going so far as to file a federal lawsuit (see sidebar: Maintenance of Certification spurs federal lawsuit), while many others are trying to make the best of it, looking for ways to make the experience easier and more valuable to them. Medical Economics recently asked a variety of experts on the subject for their advice on how physicians can make that goal a reality.

Working with your medical society, partnering with colleagues when appropriate, looking for ways to piggyback data collection onto projects you are already doing, and taking the time to really understand the requirements associated with MOC were among the top suggestions.

Strength in numbers

Eric Holmboe, MD, chief medical officer for the American Board of Internal Medicine (ABIM), suggests that in addition to availing themselves of the many ABIM online modules, physicians take advantage of the numerous opportunities offered by their medical societies to complete Part II assessments. Organizations such as the American College of Physicians and the American College of Cardiology are incorporating modules that meet Part II requirements at their annual meetings.

“Physicians can often complete questions online right after attending one of these sessions,” he says.

Some societies present the ABIM modules in a setting in which a group goes over the materials with an expert and they discuss the questions together, then go on the ABIM portal to enter them, he says. Similarly, the members of a group practice can work on the modules together, he adds.

Robert Phillips, MD, MSPH, vice president of research and policy at the American Board of Family Medicine (ABFM), says ABFM is working closely with state family medicine chapters, supporting their efforts to help members work together on self-assessment modules and quality improvement measures, at annual meetings and throughout the year.

“Physicians in these pilot programs have enjoyed it a lot more and do not feel so alone,” he says. “This also draws more attendees to the state meetings, which is an added bonus.”

Study up on the exam

For Part III, the exam, Holmboe suggests physicians avail themselves of the board preparation materials that makes the most sense for their learning style and needs.

He also recommends that physicians review the “blueprints” of the exams that are posted on the ABIM Web site for each specialty. These blueprints show how much of each content area is represented on the exam. Having this information may help a physician decide where to focus his or her studying efforts.

Make it a team effort

For Part IV, practice performance assessments, Holmboe says the principle of working with others applies here as well when using the ABIM’s Web-based practice improvement modules (PIMs).

“There is no reason a physician has to enter all of the data,” he says. “Staff members can do it too. Most questions collect primary data, such as blood pressure readings, so it is not too complicated to enter much of the data into the PIMs, but it does take time.”

He also recommends working with colleagues if you are in a group practice. “This makes it easier for the practice to incorporate the practice improvements that are discussed,” Holmboe says. “Quality improvement really is a team sport.”

Doing the performance improvement modules as a group also cuts down on the number of charts required per physician, he adds.

Interpreting data received from the module can be overwhelming at first, Holmboe says. Again, working with an experienced peer who can coach you through the process can be a big help.

Mark Malangoni, MD, associate executive director of the American Board of Surgery, agrees. 

“If patient care activities are provided by a team, it may make sense to look at outcomes as a group,” he says. “It is not about assigning blame, but about finding ways to improve patient care.”

Don’t be repetitive

Holmboe notes that Part IV isn’t limited to practice improvement modules. If your practice already receives performance data from a health plan or other validated source, it can be used to meet MOC requirements and trigger a quality improvement metric as well.

“If you have already gathered data like this in the past 2 years, you can leverage it to complete your project more efficiently,” Holmboe says.

Accepted Quality Improvement Pathways are another option. If your institution has submitted an approved project, a physician can attest that he or she was involved in it and get MOC credit. This is most commonly seen in a large practice or hospital setting, he says.

Many societies also offer registries that physicians can join to make the process easier, Holmboe says.

“Our goal is to align activities and reduce redundancy and let physicians do things that are meaningful and relevant to their practice,” he says.

Help is coming

Holmboe notes that in 2014 the ABIM is changing its MOC program to make it easier for physicians to know what they need to do to be current at any time. Starting in January, each physician will have a customized Web portal available that clearly explains his or her status.

“This portal will know you and will lead you to ways to complete MOC in your discipline,” he says.

Phillips says ABFM is working to align MOC requirements with other programs so that physicians face less repetition in reporting.

“ABMS (the American Board of Medical Specialties) is a Physician Quality Reporting System (PQRS)-certified registry, and we are trying to let MOC efforts qualify physicians for the PQRS bonus payments. This means reviewing 30 charts instead of 10, because Medicare requires 30 and the Board requires 10 for the quality improvement (Part IV) MOC requirement. This helps physicians meet both reporting needs with one effort and makes quality improvement easier,” he says.

Assistance with achieving Meaningful Use

Phillips also says ABFM is trying to help members achieve meaningful use by identifying ways to gather the data they need from their electronic health records (EHRs) so that they do not need to extract and report it multiple ways, multiple times, for multiple reasons. ABFM has set aside $2 million to build and find tools to help physicians turn their EHR data into information that helps them improve patient care and can reduce their quality reporting burdens.

“We are working to give them a way to identify the patients they need to work with,” he says. “It’s not just about giving data to the board or Medicare; it is about helping unlock their EHR data for their use. Even meaningful-use certified EHRs don’t always have the tools to do this. We are trying to find a way to help the doctors that will be low or no cost to them.”

Think of the money and outcomes

Malangoni encourages physicians to view MOC as a fact of life, especially as it has become increasingly tied to financial incentives, he says. The Centers for Medicare and Medicaid Services (CMS) is paying bonuses to physicians who participate in MOC in 2013. Those reverse and become penalties for failure to participate in 2015.

“This makes participation exceedingly important,” he says. “It is affecting multiple disciplines, from MDs to DOs, as well as podiatrists.”

He adds that physicians who are board-certified perform better in practice and are less likely to be involved in a malpractice lawsuit. MOC is simply changing certification from being a “snapshot in time” to being an ongoing process, he says.

“Physicians now need to document in four areas that they have stayed involved in learning activities between examinations,” Malangoni says. “All you are doing is documenting that you have met your board requirements for lifelong learning and practice performance improvement, nothing more.”

Know the specifics of what’s required

Malangoni encourages physicians who are feeling overwhelmed about MOC to thoroughly educate themselves about their boards’ requirements. “Much of the anxiety about this relates to misinformation and confusion. Familiarizing yourself with the specifics is one of the most important things you can do,” he says.

“Often when we are frustrated, we spend a lot of time and energy figuring out how to get out of doing what we will end up having to do anyway. Don’t risk letting your certification lapse. Learn the requirements. Ask your colleagues what they do,” he says.

All of the boards have help available, via phone or email, or on their Web sites, as do many specialty organizations, he adds.

Each board has its own approach to the Part IV requirements (practice performance improvement), he says. For example, many surgical boards have registries into which physicians can enter their data and get comparative results back.

“The idea isn’t just to enter information.  It is to get this information back and analyze ways to improve your practice, make changes, and re-analyze the updated data,” Malangoni says. “It becomes a continuous quality improvement loop that is extremely important.

“The real principle is that by doing these types of activities, physicians will better stay abreast of changes in care that can be slow to reach them. It also links lifelong learning to practice improvement,” he says.

It is important to customize your MOC experiences, he says, particularly continuing medical education attendance, to match what you do in your practice. Don’t waste your time at classes that cover an area in which you do not practice, he says.

Maintenance of Certification spurs federal lawsuit

Many physicians dislike maintenance of certification (MOC) requirements, but one group has made its objections more official, suing in federal court.

The Association of American Physicians and Surgeons (AAPS) filed a lawsuit in Trenton, New Jersey, on April 26 against the American Board of Medical Specialties (ABMS), claiming that ABMS and its 24 member boards violate antitrust laws and misrepresent the medical skills of physicians who decline to purchase and spend time on their program.

“The boards invite patients to go online to see if their physicians are enrolled in MOC, as if they can prove that this has any bearing on their clinical skills or ability to care for their patients,” AAPS says.

“These boards regulate themselves with no outside oversight. Physicians cannot see where they made mistakes on the test and have no way to appeal or to verify the accuracy of the grading. The tests are pass-fail and designed to have a certain failure rate, which could be 20% or more, depending on the board. Many a physician has lost his ability to practice medicine in his current location because of MOC – even though he has been doing an excellent job for his patients,” the AAPS says in a statement.

AAPS President Alieta Eck, MD, told Medical Economics that her group’s goal is to get ABMS to “stop requiring MOC and stop misrepresenting the idea that MOC makes for better physicians.”

ABMS, she says, has convinced medical insurance plans and hospitals that participation in its programs is necessary to ensure they are offering quality care, and many are now requiring their physicians to enroll in MOC programs.

“What was once considered a mark of excellence, board certification, has turned into a mark of competence, something that has never been proven,” she says.

“We believe in maintenance of knowledge and want to keep up with our field. CME classes are already required in most states. But you can’t measure things like clinical judgment or bedside manner with a test,” she says. “The best way we continue to learn is by reading, consulting with our colleagues, and actually caring for our patients. Each patient we see is a test of our skills.”

Certification by a group that is monopolistic, that is possessive of its questions, and that strongly pushes physicians to take its classes all go against the concept of learning, she says. AAPS instead advocates for shared information and open book tests, which it says more accurately replicates life in practice.

Eck also says that predetermined fail rates have led to some good physicians being forced off a staff. “Patients are losing access to their physician at a time when we are hiring more nurse practitioners to see patients,” she says.

AAPS asserts that the boards are primarily motivated by the profit they earn from MOC testing and classes, pointing out that some board executives have compensation packages nearing $1 million.

Eck believes AAPS will prevail in its legal action. “We will diminish the power of these huge groups,” she predicts. “No other profession is as over-regulated and, frankly, exploited as the medical profession.”

When asked to comment on the lawsuit, the ABMS described the claims as being without merit.

“We stand by ABMS MOC as an important voluntary program of lifelong learning, self-assessment, and quality improvement for physicians that offers value to the patients, families, and communities served by those physicians,” it said in a statement.

Practice performance added to Osteopathic Continuous Certification

According to Stephen Scheinthal, DO, chair of the Bureau of Osteopathic Specialists, the Osteopathic Continuous Certification (OCC) requirements are not a major change from the previous osteopathic recertification process. The only difference is the addition of a practice performance assessment, he says.

“Osteopathic physicians have always needed to hold an unrestricted license to practice medicine, to complete 50 hours of specialty continuing medical education (CME) credits, to take a cognitive test, and to maintain membership in the (American Osteopathic Association [AOA]),”he says.

“OCC added a practice performance module, making a four-step process into a five-step process,” Scheinthal says. “The idea is for the physicians to compare how they are performing against national benchmarks.”

There are a variety of ways a physician can do this, he says, and options are available for osteopathic physicians who work primarily in a specific, limited area, such as research or administrative roles. “They can pick and choose the content that best is most relevant to them,” he says.

For example, he is a geriatric psychiatrist, so he notifies the board that all of his patients are over 55, and he only completes modules relating to that patient population.

He notes that OCC is a fluid concept, and it is constantly monitored and modified based on feedback from members. It was developed over a 6-year period, and implemented January 1 by all 18 osteopathic boards. It is not mandatory for all osteopathic physicians, just the ones who have time-limited certificates. It is hoped that osteopathic physicians on non-time-limited certificates will voluntarily participate in OCC, he says.

Many osteopathic physicians are under the mistaken impression that they have to submit their charts as part of completing this new fifth step. In fact, he says, they only have to submit data off the charts and it is entirely up to the physician to decide which patients he or she wants to use.

He stresses that data gathered in this way is owned entirely by the AOA and is used only to improve physician performance. It is not shared or published.

For greater success on the exam component, he suggests that osteopathic physicians attend their specialty meetings whenever possible as many of the osteopathic boards select questions from information presented at recent meetings.

Also, each osteopathic board has a great deal of information about OCC on its individual Web site that can help de-mystify the process, he adds.

“There is naturally some apprehension about anything that is new and unknown but the feedback we are getting is that the process is really quite smooth. We are hearing that it takes a little more time, but the feedback it provides is valuable and is helping the OCC process evolve.”

Unlike the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM), which recommend physicians work together on maintenance of certification (MOC), Scheinthal says the AOA does not recommend a group approach to OCC.

“We want to gather non-aggregated data to create a helpful, unique experience for each physician,” he says.

The components of maintaining certification

American Board of Medical Specialties

Part I:
Licensure and Professional Standings

Medical specialists must hold a valid, unrestricted medical license in at least one state or jurisdiction in the United States, its territories, or Canada.

 Part II:
Lifelong learning and self assessments

Physicians participate in educational and self-assessment programs that meet specialty-specific standards that are set by their member board.

 Part III:
Cognitive Expertise

Physicians demonstrate, through formalized examination, that they have the fundamental, practice-related and practice environment-related knowledge to provide quality care in their specialty.

 Part IV:
Practice Performance Assessment

Physicians are evaluated in their clinical practice according to specialty-specific standards for patient care. They are asked to demonstrate that they can assess the quality of care they provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up assessments.

Osteopathic continuous certification

Component 1:

Unrestricted Licensure

Requires that osteopathic physicians who are board-certified by the American Osteopathic Association (AOA) hold a valid, unrestricted license to practice medicine in one of the 50 states. In addition, these physicians are required to adhere to the AOA’s Code of Ethics.

 Component 2:

Lifelong Learning/Continuing Medical Education

Requires all recertifying physicians to fulfill a minimum of 120 hours of continuing medical education (CME) credit during each 3-year CME cycle–though some certifying boards have higher requirements. Of these 120+ CME credit hours, a minimum of 50 credit hours must be in the specialty area of certification. Self-assessment activities will be designated by the specialty certifying boards.

 Component 3:

Cognitive Assessment

Requires provision of one (or more) psychometrically valid and proctored examinations that assess a physician’s specialty medical knowledge, as well as core competencies in the provision of healthcare.

 Component 4:

Practice Performance Assessment and Improvement

Requires physicians to engage in continuous quality improvement through comparison of personal practice performance measured against national standards for the medical specialty.

 Component 5:

Continuous AOA Membership

Membership in good standing through the AOA serves to establish your foundation of commitment to lifelong learning through basic CME requirements. In addition, certified members participate in relevant specialty-specific educational activities. Membership also demonstrates your dedication to the ethical practice of osteopathic medicine through adherence to the AOA’s Code of Ethics.

Additional resources

In the article headlined “Viewpoint: Maintenance of certification has value for physicians and their patients,” the president of the American Board of Medical Specialties defends the MOC process.

In the article headlined “Author’s view of MOC unrealistic,” a few Medical Economics readers share their frustrations with MOC.

The article “Where do you stand on maintenance of certification?” examines both sides of the controversy around MOC, with one disillusioned physician incredulously asking, “I have to spend time and money being told to wash my hands?”