Writing My Legislators About MOC

I got a message from one of the medical students alerting me to the latest Newsweek MOC article. That’s right–I said “medical student,” which isn’t so surprising because he rotated through the psychiatry consultation service while I was on duty staffing it as faculty. He got an earful from me about MOC and how it will affect his career as a doctor. He and other medical students often tell me that the first time they hear about this aspect of the health care system is from me.  I also saw an interesting piece about the new approach in medical education as well. It mentioned “absurdities in the system” and I would call MOC one of those absurdities.

I never thought much about the SGR “Doc Fix Legislation” that the Senate will consider next week–until lately. Little did I know that the American Board of Medical Specialties (ABMS) has been influencing this legislation.

I’m as eager as any doctor to get rid of the SGR, but I thank Drs. Westby Fisher and Paul Kempen for opening my eyes to the curious goings-on between the U.S. government and the ABMS. The link to the letter from ABMS lobbying congress is tough to find but it’s public. Head under “Initiatives,” navigate to “Promoting Excellence in Specialty Care” and click “Advocacy”  in the menu at left and then click the link “federal quality reporting requirements” (preceded by Learn what ABMS has had to say about–believe it or not!) in the body of the main text in the center of the page. Scroll down to the letter dated June 12, 2013.

I don’t contact my legislators as often as I should, but my letter to my congressmen (Chuck Grassley-R and Dave Loebsack-D of Iowa) is below with the important links included.

My letter is simpler than Dr. Fisher’s simply because I’m more confident talking about the MOC than any other political nicety, but you can also use the templates provided by Dr. Wes. You can read more about the SGR “Doc Fix Legislation” here. It looks like it’s “on track” according to one reporter. That didn’t stop me.

“Dear Senator,

As a practicing physician in the state of Iowa, I am writing to express my concern about the Medicare Access and CHIP Reauthorization Act (HR 2) which is up for vote by the Senate. Organized medicine heavily lobbied for this “fix” of the SGR formula, a telling example of which I recently discovered in the ABMS letter to congress in 2013, see link http://www.abms.org/media/1327/20130612_cl_energyandcommerce_sgr.pdf

The part of this bill which concerns me most is that which appears to contain language reflective of the ABMS influence in its attempt to propose its controversial Maintenance of Certification (MOC) be codified into the bill (See page 28, line 24 and pages 32-39 in the pdf form). The bill’s complicated formula seems to involve shifting to complex Merit-Based Incentive Plans which relies heavily on the MOC system for “quality” indicators.

MOC programs are not evidence-based because they have not been shown to materially improve patient care outcomes or even to impact health care cost substantially [1, 2]. Why they are being touted to congress as useful tools in the creation of quality indicators is unclear.

As the SGR “Doc Fix Legislation” goes to the Senate, thousands of physicians register their outrage (as they have for years) over MOC, which finally hit mainstream news in the Newsweek opinion pieces recently published, http://www.newsweek.com/certified-medical-controversy-320495?piano_t=1 (see link to the revealing  first piece also by Kurt Eichenwald, “The Ugly Civil War in American Medicine”.

MOC has elicited a great deal of hostility from rank-and-file doctors in America for the ABMS and many of its member specialty certification boards. Major organizations such as the American Psychiatric Association (APA) and the American Academy of Neurology (AAN) recommend eliminating the most controversial and non-evidence based component (Part IV which include the Performance in Practice or PIP module, to which HR 2 alludes).

Even the American Board of Psychiatry and Neurology (ABPN) has sent a letter to the ABMS suggesting that Part IV be made optional (while saying to board diplomates that only the ABMS has the authority to approve this measure), to which the ABMS has replied that it remains committed to Part IV yet seems to pass the buck back indicating that ABPN has the discretion on how the MOC standards (including Part IV) should be implemented.

This state of affairs regarding the conflict among ABMS and member boards, individual doctors, state medical societies (many of which have adopted resolutions opposing MOC), and large physician organizations like the APA would be comical if it were not so damaging to the physician-patient relationship and to the public image of the medical profession. Frankly the whole business is embarrassing to me as a physician.

Given the stormy political climate which the MOC debate fuels in this country, it begs the question, at least in my mind, of why the legislature would approve HR 2 with the MOC piece included.

Therefore, I suggest that HR 2 language be amended so as to clearly convey that participation in MOC and other incentive programs should be purely voluntary and non-participation in unproven programs should not be penalized.

You’ll find many thousands of physicians including me who support the principle of lifelong learning but who also oppose MOC.  Please remove any vestige of it from the HR 2 bill.

References:

  1. Gray, B. M., et al. (2014). “Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.” JAMA 312(22): 2348-2357.
  1. Hayes, J., et al. (2014). “Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality.” JAMA 312(22): 2358-2363.”
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Comments

  1. SEE:
    http://drwes.blogspot.com/2015/04/medicare-sgr-replacement-bill.html
    and especially
    http://www.modernhealthcare.com/article/20150411/MAGAZINE/304119983/an-unwarranted-role-for-physician-specialty-boards
    and I quote:
    “The special role given physician specialty boards in the SGR replacement bill heightens the stakes in the recent controversy swirling around the costly and complicated recertification process at the American Board of Internal Medicine, one of the largest boards in the nation. A rival group is seeking to substitute continuing medical education credits for recertification test-taking, which the ABIM and patient and consumer advocacy groups oppose.
    The flare-up has brought some of the more unsavory and unscientific aspects of the self-regulating physician recertification process to light. A recent New England Journal of Medicine perspective by ABIM critic Dr. Paul Teirstein of the Scripps Clinic noted that the latest studies have shown no relationship between physician recertification and performance on quality measures—the very task given to certification boards in the SGR replacement bill.
    Teirstein also accused the ABIM of being “a private, self-appointed certifying organization” that charges exorbitant fees “unfettered by competition” for its products and tests. ”
    Send this to your senators in the letter!

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    • OK, now I’m not sure what to make of the American Medical Association comment on the Goozner article in Modern Healthcare, http://www.modernhealthcare.com/article/20150411/MAGAZINE/304119983/an-unwarranted-role-for-physician-specialty-boards:

      “We have reviewed the bill closely and in every instance that Goozner mentions, activities related to maintenance of certification (MOC) and the certification boards are among a list of options for demonstrating or measuring quality. There is nothing in the bill that requires physicians to take part in MOC or any certification board activities if they do not want to. The AMA is disappointed that Goozner is misleading his readers into thinking that H.R. 2 provides new power to the certifying boards when it is really focused on improving a tremendously flawed payment system that has obstructed physician efforts to invest in practice improvements and threatened patient access to care for far too long.”

      I’m not sure who to believe because somebody called “Anonymous” also made similar comments on Dr. Westby Fisher’s article, http://drwes.blogspot.com/2015/04/working-physicians-were-played-its-time.html:

      “Wes, your message here is not clear. You need to write a blog post SPECIFICALLY outlining the issue. I read your highlighted sections and there was NO mention of MOC so I’m not entirely sure what the central issue is. I read the SSA site you linked to and found the ABMS reference but the law does not mandate this…. please re-write and use examples from the H.R.2 that support your case.”

      And this one in reply to Dr. Fisher’s answer to the above, which began with “Clearly you don’t get it…”:

      “Hi Wes, with regard to my earlier post, I’m not debating the supposed value of MOC and you don’t have to sell us on why MOC is flawed. I get it. But if you’re asking us to write our Senators then we need to very clear about our concern so we can sound intelligent.

      What I asked of you was to point out EXACTLY what you think we should identify in H.R.2 and find distasteful. Again, I read all your (highlighted) links and the SSA page but do not see the mandated issue of concern. I don’t clearly see where it says MOC is mandatory. If I don’t see this then it’s likely many other people don’t see the problem. Please advise.”

      Paul, before you tell me that I don’t get it either, can you explain to me why both Anonymous and the AMA might be mistaken about the role of MOC itself in the SGR H 2 bill?

      You know I’m an old campaigner against MOC and it sounds like Anonymous is opposed to it as well. I’ll be the first to admit that I did not read the H 2 bill closely enough to debate about anything in it, including MOC. I’ll also admit that the sections I quoted (which I took from Dr. Fisher’s blog post,http://drwes.blogspot.com/2015/04/the-clever-practice-improvement-module.html) to Senators Grassley and Loebsack really don’t say MOC is mandatory, per se. However, I was concerned about the language which sounds like it’s right out of certification boards’ talking points.

      I’m going to say I could be wrong about the idea that the SGR H 2 bill makes MOC participation mandatory–and I still support the principle of lifelong learning and I still don’t believe MOC embodies the principle.

      I have to set an example for my trainees (who read my blog), which is part of that almost-impossible-to-define competency of Professionalism. If I can’t admit it when I’m wrong, then I’m no better than the board leaders I’m criticizing for being unable to do likewise.

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  2. Please also consider sending an email message to your state medical and psychiatric societies about the upcoming ABIM summit meeting about MOC coming up on April 12, 2015; see link for details, http://nephtangles.blogspot.com/2015/04/help-needed-professional-societies-are.html

    State medical societies still might also be able to send an email to the address at link https://www.asn-online.org/membership/BlastEmails/files/asn%20moc%20update.pdf which is email@asn-online.org to register their views on MOC.

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