By Rose M. Ramirez, MD
Maintenance of Certification
This issue of Michigan Medicine is highlighting issues related to Maintenance of Certification (MOC); however, secondarily, I would also like to share a brief update on Advance Care Planning (ACP) in Michigan.
First, a little history…The American Board of Medical Specialties (ABMS) is the parent organization of the 24 core boards and their subspecialties. Board certification began in 1917 with the American Board of Ophthalmology as the first specialty board. The American Board of Internal Medicine (ABIM) was incorporated in 1936. Forty-two years ago, the ABIM officially endorsed the principle of recertification, but decided to implement it on a voluntary, rather than mandatory basis.
By 2002, the core group of the 24 member boards of the ABMS had a firm set of shared guidelines and requirements for board certification. Over time, MOC has become a mandate rather than a recommendation.
In the April 15, 2010 issue of The New England Journal of Medicine, an article discussing the results of a poll of members regarding board recertification was published.
Specifically, many readers felt that the cost of MOC far outweighed the educational benefit and that the MOC program was essentially a money-generating activity for the ABIM. Others felt that the exercise was only marginally relevant to their day-to-day practice and that it took their time away from patients and other learning activities.
In January 2014, the ABIM substantially increased the requirements and fees for its MOC program. Internists will now incur an average of $23,607 in MOC costs over 10 years, ranging from $16,725 for general internists to $40,495 for hematologists-oncologists. Time costs account for 90% of MOC costs.
Faced with mounting criticism, the ABIM suspended certain content requirements in February 2015 but retained the increased fees and number of modules.
In 2014, when the ABIM issued the new requirements for maintaining certification, Paul Teirstein, MD, (chief of cardiology at Scripps Clinic in San Diego) and his colleagues declared “enough.” They formed a new recertification organization called the National Board of Physicians and Surgeons (NBPAS). The NBPAS fees are much, much lower than those charged by the ABIM and its board and management—all top names in medicine—work for free. The goal is to break the monopoly the ABMS has on MOC and put leadership back into the hands of practicing physicians.
Here in Michigan, another approach to the onerous and expensive requirements of MOC includes legislative proposals by Senator Peter MacGregor and Representative Edward Canfield, DO, to remove the requirement by insurers of board recertification as a prerequisite to payment for health care services. The bills are currently in the Senate and House Health Policy committees. Please visit http://right2care.org for the latest information.
The Pennsylvania Medical Society held a forum on MOC at the American Medical Association Interim meeting in November. It was well attended by practicing physicians and by leadership from many of the Specialty boards. I think ABMS and its core members are finally getting the message that MOC needs to change.
One big challenge is that 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. For 2013 and 2014, the “Quality Reporting System’ portions included requirements of MOC in the registry reporting section and gave payment incentives. In 2015, reporting on MOC was still required, but incentive payments were no longer included.
And even though the mantra from the ABMS attempts to sell MOC as a “Trusted Credential”, the ABMS uses empirical evidence to make its claim of the value MOC brings to health care and has yet to prove that the value is greater than the cost. However, because hospitals and payers want a way to show that their physicians are high quality, this is one surrogate they use. Various quality organizations and health care purchasers also use this ‘credential’ to show value.
At the recent Interim meeting, the AMA House of Delegates approved the Report 2 from the Council on Medical Education which includes the AMA principles on MOC. This report reviews and consolidates existing American Medical Association (AMA) policy on MOC, Osteopathic Continuous Certification (OCC) and Maintenance of Licensure (MOL) to ensure that these policies are current and coherent.
We will need the unified physician voice to make a change in the deeply entrenched powers that want to maintain the MOC http://right2care.org/ status quo. That’s why MSMS developed it’s campaign, ‘Right2Care’. I encourage each of you to visit http://right2care.org, where you may contact your lawmakers and contribute to fight this bureaucratic nightmare.”
Advanced Care Planning (ACP)
Before I conclude, I want to briefly discuss some of the Advance Care Planning (ACP) work going on in our state. ‘End of Life Care’ is one of our current Michigan State Medical Society (MSMS) strategic objectives and we have an opportunity to collaborate with a number of communities in our state already working on ACP and essentially following the Gunderson Lutheran Respecting Choices model. This ACP model provides an evidence-based process with a standardized approach to conversations with patients and their families about end of life care.
- First Steps: Introduce ACP and basic documentation.
- Next Steps: Discuss ACP again when chronic illnesses become more advanced.
- Final Steps: Discussions with frail, elderly or when a patient may die within next 12 months.
More complete documentation such as Physician Orders for Life Sustaining Treatment (POLST or MI-POST).
As these documents are completed, they will be uploaded to a statewide registry. While community volunteers, clergy and others can participate in First Steps, medical professionals are needed for the Final Steps. Medicare will begin to reimburse for time spent counseling patients on end of life care beginning in 2016.
Some of the components that make this program successful are the community approach, the availability of information as standard practice and education of healthcare professionals. Other components include the careful scripting of the conversations and the training of physician and other non-physician advance care planning facilitators.
Other states have used their state medical societies to promote ACP programs. The two organizations in our state working on this are “makingchoicesmichigan.org” and “honoringhealthcarechoicesmi.org”. John McKeigan, MD, was one of the founding members of RespectingChoicesMichigan, which has been mostly focused in West Michigan.
At the October 7, 2015 MSMS Board meeting, a motion was approved to “request more comprehensive information on the Gunderson Respecting Choices model and an analysis of the feasibility of our MSMS leading this initiative statewide.” The motion was passed unanimously. More information will be forthcoming!