It's Time for Change! Conversations About Maintenance of Certification

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Michigan Medicine - January/February 2016

Conversations About Maintenance of Certification 

Maintenance of Certification brings up one consistent question among Michigan physicians: Why? 

  • Why are we paying thousands of dollars to bring zero value to our patients? 
  • Why are we subjected to redundant, non-specialized modules and procedures? 
  • Why is MOC continuing to be regulated?

In this issue of Michigan Medicine, we talk to three physicians about their frustrations with MOC and how this bureaucratic requirement is affecting their practice and patients. Their stories and many others are fueling change and inspiring advocacy campaigns such as Michigan State Medical Society’s recent Right 2 Care initiative, which aims to eliminate unnecessary requirements in Michigan. 

Michigan Patients have a right to high quality health care from a physician of their choice.

Michigan Physicians have a right and a responsibility to deliver high quality care to their patients.

Those rights are at risk because of a bureaucratic nightmare known as “Maintenance of Certification,” and a reckless new health insurance company plan that could cut off patients’ access to the physicians they know and trust!

That’s not just a hassle- that’s dangerous. 

What is Maintenance of Certification?

As physicians’ careers advance, they take part in continuing medical education programs that help them keep current with advancements in medicine and patient care. The costs of this testing and training are paid by each physician, and are necessary to allow them to practice in Michigan.

Here’s the problem: the American Board of Internal Medicine, or ABIM, devised a way to make huge profits through regular, additional, duplicative and unnecessary Maintenance of Certification (MOC).

Now, some health plans and insurance companies in Michigan are threatening to cut off patients’ access to their highly trained, highly qualified physicians unless those physicians jump through bureaucratic hoops.

How does Maintenance of Certification Hurt Patients and Physicians?

Physicians already maintain education requirements to keep their licenses to practice medicine and have the right to deliver high quality health care to their patients, but:

  • Maintenance of Certification is an out-of-state scheme that drives up the cost of health care while limiting physicians’ time with their patients. 
  • A new health insurance company plan may use MOC to force some patients to leave the physicians they’ve grown to know and trust.

Defending Michigan Patients Right 2 Care.

Patients deserve access to high quality health care. New legislation in Lansing would make sure they get it. 

Senate Bills 608 and 609 and House Bills 5090 and 5091 will protect and defend:

  • A patient’s right to the health care and support they need from the physician they choose. 
  • A physician’s right to provide quality care to patients without costly, troublesome “pay to play” requirements. 
  • A state’s right to create a health care system that works for everyone.

 

Megan M. Edison, MD
Pediatrician, Brookville Pediatric and Internal Medicine

Q: When did you begin advocating against MOC and why? 

A: Like many pediatricians, my concerns with MOC started in 2010 when the American Board of Pediatrics again revised their program to a more expensive and ongoing MOC program, without any evidence these changes would improve patient care. Pediatricians tried to voice our concerns, but we felt alone and easily intimidated in the fight.

It really wasn’t until the past two to three years when American Board of Internal Medicine tried to force these same continuous MOC programs on the internists that this issue really gained attention. Since then, we’ve all come together as physicians to speak out against this MOC scheme affecting us all. 

I am a young pediatrician, with 25 years left in my career. In just eight years, I’ve watched the ‘mission creep’ of MOC go from an open book every seven years, to a secure exam every seven, to the five year cycles of secure testing, online testing and practice improvement modules it is now. The American Board of Pediatrics is already starting discussion of weekly testing and direct access to our charts for research data. At a certain point, we have to get involved in the process, and say ‘enough.’

Q: Tell me about a situation when MOC clearly affected your practice and/or one of your co-workers’ practice.

A: In Michigan, the issue of MOC is more pressing for our physicians than for doctors in other states because Blue Cross Blue Shield of Michigan (BCBSM) requires board certification and MOC to participate. In other states, doctors can simply choose not to participate in MOC without consequence. In Michigan, doing so will result in loss of insurance participation.

This isn’t just an idle threat by BCBSM. This year, one of my partners was a few weeks late turning in data for a ‘hand washing module’, where patients rate our hand washing and the data is sent to the American Board of Pediatrics. He was immediately notified by BCBSM that he could no longer see his BCBSM patients until he complied with MOC. This means these out-of-state board corporations with their ever-changing MOC requirements have incredible power to end relationships between doctors and patients.  

Q: Tell me about your involvement in the Right 2 Care campaign and why you feel that this campaign will help bring change.

A: My involvement in the Right 2 Care issue dates back to helping write the very first anti-MOC resolutions at the 2013 House of Delegates, and then sitting on committees in the 2014 and 2015 House of Delegates listening to my colleagues present their anti-MOC resolutions. The passion and unity of physicians around MOC is simply unprecedented. It’s exciting to be part of the process where physician concerns become resolutions, resolutions become MSMS policy and now hopefully MSMS policy becomes state law. 

If Michigan becomes the first ‘Right 2 Care’ state, meaning MOC would not be required for a medical license, insurance participation or hospital privileges, many positive transformative changes would happen for doctors and our patients. Michigan doctors would be free to choose continuing medical education that best suits our needs and our unique patient populations, rather than the limited proprietary products from the boards. We would be free to pursue relevant clinical research and novel practice improvement projects, rather than the irrelevant projects chosen by the boards. 

Right 2 Care legislation would improve medical access and patient choice, as doctors won’t be dropped from insurances for not participating in MOC and our more experienced doctors won’t be considering early retirement to avoid another costly and time consuming MOC cycle.

Q: If MOC were to continue being regulated, what would you change about it to make it more reasonable and relevant for doctors

A: I don’t believe the American Board of Medical Specialties and their boards will change their highly lucrative MOC program unless doctors are given a choice to stop participating or are allowed to certify through competing boards like the National Board of Physicians and Surgeons. Only when we are given freedom to choose, will change happen.

Any MOC requirements must be straightforward, egalitarian, inexpensive, and physician-focused. After certifying, re-certifying and re-re-certifying through the American Board of Pediatrics, I have had enough. I am currently maintaining my pediatric board certification through the National Board of Physicians and Surgeons, because their requirements reflect my ideals of what MOC should be: Pass the board examination once, hold an active, unrestricted state medical license and demonstrate commitment to ongoing education through 50 hours of Continuing Medical Education (CME) every two years. That is more than adequate. 

 

Srinivas K. Janardan, MD
Gastroenterologist, Grand River Gastroenterology

Q: When did you begin advocating against MOC and why? 

A: I have been involved in the certification and recertification process for the American Board of Internal Medicine for the last 20 years. I initially took my Internal Medicine boards in 1991; in 1995, I took my gastroenterology boards. I’ve elected not to recertify in Internal Medicine. I have retaken my Gastroenterology boards in 2005 and most recently in 2015. In the last two years, I have been very disappointed with the new requirements of the MOC process. 

The high failure rate in Gastroenterology boards has made this a very stressful test. It is this that has led me to be very active in opposing the MOC requirements. When looking at the pros and cons of the MOC, it is clear that it does not add value to me as a clinician or to my care of my patients. It has become a right of insurability and paperwork. It has become a very stressful event with no significant game. I do not find it helpful as a form of education. I do not find it helpful in improvement of my practice. The endless number of practice improvement modules are worthless for gastroenterology. There is significant overlap with multiple other agencies and requirements for us as physicians. The excessive cost, time requirements and time away from family has made these MOC requirements unreasonable.

In July 2013, I was elected Chief of Staff at Mercy Health St. Mary’s (MHSM). During the same time, I have had to recertify in Gastroenterology. As Chief of Staff, I sent out a survey and fact-finding email to all of the medical staff at MHSM. Many medical staff shared my opposition to the recertification and MOC process. I received numerous emails from the medical staff in support of my efforts to overturn this process. Recently, I have been elected to the board of MHSM. In this position, I have presented this same opposition and asked for support to oppose requiring the MOC for the medical staff. It is my hope that we will get MHSM bylaws changed in the near future. Unfortunately, insurance companies such as Blue Cross Blue Shield have been unwilling to change or look for alternative certification. It is this reason that I believe state legislation will be necessary.

Q: Tell me about a situation when MOC clearly affected your practice and/or one of your co-workers’ practice.

A: I have seen high quality physicians fail the test and then be dropped from insurance reimbursement. In addition, I have seen physicians who came from abroad that are not allowed to take these tests. As such they have been excluded for participating in insurance company reimbursement. These are world experts that are excluded from practicing here in Grand Rapids. Again, for no specific reason apart from rigid requirements. In the end, our patients are losing high quality care.

Q: If MOC were to continue being regulated, what would you change about it to make it more reasonable and relevant for doctors

A: I believe the MOC process is an outdated method, even though it was just started in the last few years. It does not address how physicians practice. It does not take into account how physicians research information and collaborate with other physicians. It does not address how physicians learn as practicing physicians rather than as residents and fellows. 

The Gastroenterology associations are starting a process of continuing education that would be far superior to the MOC methodology. Our Gastrointestinal (GI) societies are going to be very active in overriding the American Board of Internal Medicine MOC. It is my hope that this will become a reality within the next one to two years. Certainly, I hope I will not have to go through the recertification and MOC process for last 15 years of my career!


Josephine P. Dhar, MD
Chief and Program Director, Internal Medicine, Central Michigan University School of Medicine; Adjunct, Internal Medicine, Wayne State University School of Medicine

Q: When did you begin advocating against MOC and why? 

A: It was through the Michigan State Medical Society (MSMS) that I originally became involved. I’m on the editorial board and I very clearly started to express my opinion on MOC and that it’s a burden on the practice. 

I’ve been in an academic setting, and so I appreciate the difference between an academic setting and a private office or community setting. We have the advantage of having training programs [at Central Michigan University School of Medicine] and so for us, it’s not as difficult. But for people that practice to start implementing these type of educational activities in their office, it’s just overly burdensome. 

When I did the MOC modules, there were no modules for Rheumatology, which I thought was silly. So in my busy academic practice, I was doing modules on cardiovascular disease and hypertension which did nothing to improve my patient care. I’m a rheumatologist and there were no rheumatology MOC modules.

Q: Tell me about a situation when MOC clearly affected your practice and/or one of your co-workers’ practice.

A: I just remember walking in to a patient’s room and saying ‘do you mind doing this questionnaire for me because I need to do it for my certification.’ It was just odd to ask them to help me get my certification. And then after that, I would still have to extract data from their chart into my questionnaire because it requires certain information. I just remember patients saying ‘Why are you doing this Doctor Dhar?’ and they always said, ‘Okay, I’ll help you.’ The patients were really nice, I think the patients are just wonderful trying to help their doctor. 

It was an imposition on the visit, and then I had to explain to the patient it wasn’t research, I had to do it for my course. It’s just awful the way you have to insert it into your practice. Not only did it not help my practice, but it interfered with the patient.

Q: If MOC were to continue being regulated, what would you change about it to make it more reasonable and relevant for doctors?

A: I don’t understand what the purpose of MOC is. We’re required to get continued education and credits every year and most of us are attending specialized meetings and so we’re already learning about our field. How is MOC different than that?