Dermatologists Are Taking Action in Their Fight Against MOC
Maintenance of Certification (MOC) continues to be a thorny topic for some medical practitioners— and that may be stating the case mildly.
On its face, maintenance of certification (MOC), the program that provides physicians an opportunity to keep their coveted board certification status, has all the makings of a quality improvement initiative that serves patients’ best interests. The American Board of Medical Specialties (ABMS), the umbrella organization for the 24 specialty member boards and the chief arbiter of physician certification, describes MOC as “a system of ongoing professional development and practice assessment and improvement” that “challenges physicians to focus on the continuous development of their skill set, especially those skills that enable them to function effectively in interprofessional teams, integrated systems of care, and community settings.”
The ABMS contends that MOC helps physicians achieve a “higher standard of care” and perpetuates “professional development as well as improvements to patient care.” As a testament to the success of its program, the ABMS claims that, “Many hospitals have independently made the decision to use board certification by an ABMS Member Board as part of the criteria for staff privileges.”
To some in the medical community, however, the ABMS’ assertions about MOC and its value to the public ring hollow, and the fact that employers may require MOC is potentially troublesome, if not illegal. In some circles, discussions of MOC evoke strong reactions from doctors who see the program as an affront to physician autonomy, or worse, an exercise of questionable value invoked by institutions that are out of touch with the actual practice of medicine.
Prior to 2000, board certification was granted as a lifetime status (see What is Maintenance of Certification?). New rules instituted at the time, however, placed a 10-year time limit on board certification, leading to the creation of the MOC program as a way for doctors to retest and maintain board status.
Yet, to some, the cost of recertifying, measured in time and resources, undermines its value. Despite claims from the ABMS that MOC is steeped in evidence-based practices, critics of the program point to a lack of validated studies demonstrating that MOC has any impact on patient care or quality of care delivery.
Moreover, anti-MOC critics say, the grandfather clause, which allows older physicians to maintain lifetime board status, seems contradictory to the underlying premise of MOC: that physicians need to stay current with changing techniques and new approaches to medicine to deliver quality care. But if that were true, wouldn’t it make sense to ask older doctors, who are further away in years from their formal training, to recertify?
“MOC has not been proven to be clinically effective at all,” says Jeanine Downie, MD, a dermatologist in Montclair, NJ, and a leading voice in the anti-MOC movement. “It’s just a frightful, untested, unproven strategy that just lifts money out of younger physicians.”
A Question of Priorities
According to Dr. Downie and others, the MOC program is a classic example of a solution in search of a problem. While there is certainly a need for doctors to stay current with the practice of medicine, she says, there may not have been need to change the status quo, especially when the program that was implemented does not truly test one’s competency in his/her chosen field.
Dr. Downie says that several colleagues who have gone through MOC have described the process as an exercise in regurgitating facts. In several cases, she said, the questions on the test related to general concepts of dermatology that may have little value to someone who has subspecialized—and to add insult to injury, the pictures used for identification of skin diseases were grainy and hard to decipher.
“CME is the way it was done for years until they figured out they could do a lot more, and take a lot more money from the younger doctors—all in the name of medicine and education and keeping us updated,” says Dr. Downie.
CME, Dr. Downie continues, is at least a validated and studied entity in the medical community. On the other hand, some studies have found no difference in care performance measures between physicians with time-limited certification versus those with time-unlimited certification.1 Meanwhile, despite that MOC lacks proper validation, participation in the program comes at a significant cost: By some estimates, physicians will spend an average of $23,607 over 10 years to stay current with their board certification.2
The money generated via MOC by the various ABMS member boards has led some to question their ability to objectively evaluate the worthiness of time-limited certification. For instance, Dr. Downie points out that the American Board of Dermatology (ABD) reported revenue of $2.3 million for tax year 2015 against the same in expenses. But the distribution of those funds does not seem to align with the objectives of member dermatologists. For instance, she asks, why is the ABD waiting until 2020 to launch studies into the effectiveness of MOC when they seem to have the financial means to start that process today?
But an even larger issues looms with the mandate of the ABD to advance the practice of dermatology and to protect the public. According to Dr. Downie, neither the ABD nor the American Academy of Dermatology (AAD) has taken any kind of meaningful stance against the rising tide of non-dermatologists offering aesthetic and cosmetic services.
“We have charlatans and beauticians saying they’re doctors, we have internal medicine doctors saying they are dermatologists. We have podiatrists who are acting like they’re just as equally qualified to do dermatology as if they’ve taken dermatology residency. But the AAD does not do anything to protect us against them and neither does the ABD. So how are they protecting the public?” asks Dr. Downie.
A constant theme among those active in the anti-MOC camp is that they have been given little recourse to voice their objections. According to Dr. Downie, the issue has been raised to AAD and ABD leadership on numerous occasions, but it seems they cannot even gain an audience.
Taking matters into her own hands, Dr. Downie recently worked with a lawyer to draft a resolution to the ABD that would restore time-unlimited certification, abolish the 10-year time limit, and mandate that dermatologists satisfy an annual quota of CME credits. Most of all, the resolution would align the ABD with other ABMS member boards that, “have determined that the MOC requirements following the successful completion of board certification exams, are unreasonable and overly burdensome, and have decided to eliminate the MOC requirements, except for reasonable CME requirements.”
Citing the rising incidence of melanoma skin cancer as one area where dermatologists’ time would be better spent, the resolution essentially argues that MOC requirements are not just a burden on physicians’ personal lives, they are also a distraction from the important work of seeing patients
Dr. Downie added two other objectives in the resolution: a call to poll member dermatologists to gauge their perspective on MOC and to change procedural rules in the ABD so that representatives are elected and not selected.
“The board of directors of the ABD right now is selected, but they’re not selected by any of us. They’re not elected. If those were elected positions, then they would be somewhat accountable to the people who elected them,” Dr. Downie contends.
The issue of proper representation is familiar to H. L. Greenberg, MD, a Las Vegas based dermatologist and vocal critic of MOC. Dr. Greenberg has made several attempts to introduce policy changes with respect to MOC, only to be shut down at every turn. The fundamental problem, he says, is that the Board of Directors of both the AAD and ABD are entrenched, rooted in their own self interest.
“We have to change the [MOC] advisory board so that they will then allow a vote,” Dr. Greenberg said, “except the problem is that in order to get on the advisory board, you have to be a selected or slated candidate, and there’s a nominating committee that chooses who gets to be a slated candidate.”
Dr. Greenberg’s anti-MOC activities actually go back a few years. He said he introduced a resolution to the advisory board in 2015 that was summarily rejected without explanation. Following that, he worked with the AAD on a more formal bylaw resolution, which he submitted to the AAD Bylaw Committee for submission to the AAD Board of Directors. However, despite garnering 400 signatures at the behest of the AAD, the AAD Board of Directors rejected a vote on the proposal, claiming it was tantamount to a policy statement, and as such, conflicted with other sections of the bylaws.
What is Maintenance of Certification?
According to the ABMS website,1 the concept of board certification emerged from a meeting of members from the pioneering medical boards representing dermatology; obstetrics and gynecology; otolaryngology; and ophthalmology that was held in June 1933. The American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS) formed in 1939 to offer similar credentialing to doctors of osteopathic medicine. Much later, in 1993, the American Osteopathic Association (AOA) assumed responsibility for and oversight of certification for osteopaths through its designated agency, the Bureau of Osteopathic Specialists.
Over the years, each organization has tweaked its model for achieving certification as medicine has evolved and as the healthcare environment became increasingly more sophisticated. Historically, there has been little pushback from the physician community on the criteria the specialty boards have used to determine eligibility for board certification.
But that all changed in 2000 when the ABMS launched its most radical overhaul of the certification process to date, eliminating lifelong certification and replacing it with time-limited certification.2
According to the ABMS, the MOC program is intended to evaluate physicians’ competencies in six core areas (practice-based learning and improvement, patient care and procedural skills, systems-based practice, medical knowledge, interpersonal and communication skills, and professionalism), which are, in turn, measured in a four-part framework: Part I: Professionalism and Professional Standing; Part II: Lifelong Learning and Self-Assessment; Part III: Assessment of Knowledge, Judgment, and Skills; and Part IV: Improvement in Medical Practice.
Many who oppose the idea of time-limited certification loudly and fiercely contest that MOC demonstrates relevant competencies in one’s chosen field. One of the frequent criticisms from the anti-MOC movement is that there is insufficient evidence to support that participation in MOC has any impact on patient care, either positive or negative. Furthermore, whereas advocates of the program see MOC as an ongoing and continual emphasis on learning, opponents label it as an onerous, burdensome, and costly intrusion on their ability to put patients first—and some even contend that the “grandfather” clause allowing physicians who achieved board status prior to October 1, 1994, to keep lifelong certification is tantamount to age discrimination and perhaps even a restriction of trade.
Most troubling to some is the sense that the growing MOC movement, and the strength of its lobby, could make participation in the program compulsory. Even if MOC does not become mandatory, some physicians are concerned that they may nevertheless be compelled to participate in the interest of job security. In fact, many hospitals have taken the step of mandating board certification for employment, which some see as a move to make MOC a de rigueur condition of gaining hospital privileges. State medical boards in several states have already launched legal challenges to that requirement, and at least one state (Oklahoma) has passed legislation addressing the issue.
To some, a larger threat to physician autonomy with respect to board certification exists in efforts to link MOC with Maintenance of Licensure (MOL), a concept conceived by the Federation of State Medical Boards (FSMB). If enacted, MOL would stipulate that physicians provide evidence that they participate in continuous professional development as a condition of maintaining a medical license.3 One of the proposals on the table from the FSMB is that participation in MOC should qualify for MOL criteria. Some physicians flatly reject the idea that MOC would even be necessary in the context of MOL given that most state licensing agencies require physicians to participate in continuing medical education activities as a condition of licensure—and, therefore, MOC would be redundant.
1. http://www.abms.org/about-abms/history. Accessed July 25, 2017.
2. J Community Hosp Intern Med Perspect. 2013; 3(1): 10.3402/jchimp.v3i1.20326.
3. Federation of State Medical Boards. Maintenance of Licensure: Frequently Asked Questions. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Foundation/mol-faq.pdf. Accessed July 25, 2017
4. http://www.abms.org/board-certification/steps-toward-initial-certification-and-moc. Accessed July 25, 2017.
5. JAOA publishes statistics on Osteopathic Board Certification. Available at: https://certification.osteopathic.org/news/jaoa-publishes-statistics-on-osteopathic-board-certification. Accessed July 25, 2017.
6. 2016 Osteopathic Medical Profession Report. Available at: http://www.osteopathic.org/inside-aoa/about/aoa-annual-statistics/Documents/2016-OMP-report.pdf. Accessed July 25, 2017.
7. ABMS Releases Updated Board Certification Report. Available at: http://www.abms.org/news-events/abms-releases-updated-board-certification-report. Accessed July 25, 2017.
8. Young A, Chaudhry HJ, Pei X, et al. A Census of Actively Licensed Physicians in the United States, 2014. JOURNAL of MEDICAL REGULATION VOL 101, N O 2. Available at: https://www.fsmb.org/Media/Default/PDF/Census/2014census.pdf. Accessed July 25, 2017..
So, Dr. Greenberg tried again, this time drafting an amendment to the purposes section of the AAD bylaws to add specific language stating that part of AAD’s overall mission should be “To promote once in a lifetime board certification and to end re-certification and maintenance of certification.” For this go around, he collected 655 signatures of AAD fellows.
In response, the AAD Board, joining with the American Academy of Dermatology Association (AADA), rejected the proposal, claiming in a letter to Dr. Greenberg that it was too “issue specific and too narrowly framed to properly be included in the Purposes sections of the AAD or AADA bylaws.” Furthermore, they wrote, the proposed amendment “would conflict with existing policies of the Internal Revenue Service (IRS) and therefore could trigger an expensive and time-consuming IRS audit and potentially jeopardize AAD’s 501(c)(3) status.”
Dr. Greenberg finds that explanation simply insufficient.
“The interesting thing is that I had a phone call with the attorney of the AAD to use that language. We had a phone call to discuss the language that should be used so that there wouldn’t be an issue with the IRS,” Dr. Greenberg said. “That was prior to submitting the resolution.”
Above and beyond the headaches of trying to lobby the board, though, Dr. Greenberg does not feel his organization actually protects the practice of dermatologists, nor its actual members. The failure of the AAD to protect against what Dr. Greenberg calls “wannabe dermatologists in the community” from offering aesthetic and cosmetic services seems at odds with the AAD’s stated purpose, “To promote the highest possible standards in clinical practice, education, and research in dermatologic medicine and surgery, and related disciplines,” and, “To promote the highest standards of patient care and promote the public interest relating to dermatology.”
In his interactions with the AAD Board, Dr. Greenberg also asked for a formal survey of members on MOC, a stipulation that the Board conceded to. But until they do that survey, he said, the AAD and ABD cannot claim that they are adequately serving their mandate to members.
“[MOC is] neither evidence-based nor member-supported,” Dr. Greenberg says. “It’s a total overreach. The AAD needs to step away from MOC and start protecting board-certified dermatologists from the community at large.”
An Alternative Path to Recertification
Despite the difficulty in broaching the topic of MOC with the ABMS and member boards, physicians are not without recourse. Some physicians are opting out of board certification altogether. State medical societies from California, Florida, Georgia, Indiana, Iowa, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Texas, Virginia, Washington, West Virginia, and Wisconsin have each proposed resolutions in opposition to MOC.3-16 Meanwhile, the Association of American Physicians & Surgeons and has opened an antitrust lawsuit against the ABMS,17 and a group of osteopathic doctors has entered into a class action lawsuit against the AOA for return of membership fees that the class feels are egregiously in excess of the actual cost of MOC.18
A group of physicians has also taken the unusual step of organizing a new certifying board called the National Board of Physicians and Surgeons (NBPAS). Outside of a small administrative staff, volunteer physicians serve as directors and oversee NBPAS operations, which they claim allows them to provide an equally valid board recertification as the ABMS but at a substantially lower cost of $169 for two years (not including the costs of acquiring mandated CME credits).
The number of hospital credentialing committees that accept NBPAS recertification is growing, a fact that some hope will at least force ABMS to reconsider its stance on MOC.
Others, however, are less optimistic about the prospects of MOC reform. When asked if any real progress has been made to overturn the tide of MOC, Dr. Downie offers a succinct, “my answer would be no.”
“My colleagues should be voting people into the American Academy of Dermatology who are anti-maintenance of certification and voting people into the American Society for Dermatologic Surgery who are anti-maintenance of certification,” Dr. Downie says. “We should be voting in people who reflect our same views so that they can put more pressure on the ABD.”
The other choice, she said, is to do nothing, in which case MOC becomes even more entrenched, and perhaps even linked to other movements, such as maintenance of licensure, making it even harder to change course.
“The risk of doing nothing is that maintenance of certification strangulates doctors and people don’t go into medicine anymore. The risk of not doing anything is that complacency will make MOC work,” Dr. Downie says.
1. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA. Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. 2014 Dec 10;312(22):2358-63.
2. Sandhu AT, Dudley RA, Kazi DS. A Cost Analysis of the American Board of Internal Medicine’s Maintenance-of-Certification Program. Ann Intern Med. 2015 Sep 15;163(6):401-8.
17. Available at: http://aapsonline.org/AAPSvABMSresponse-6-3-2014.pdf. Accessed August 29, 2016.
18. Available at: http://www.duanemorris.com/site/static/aoa_class_action_complaint.pdf. Accessed August 29, 2016.