Time to Scrub MOC

It’s time to scrub Maintenance of Certification (MOC). I see the American Psychiatric Association (APA) candidates for President (Dr. Rahn Kennedy Bailey, M.D.) and Secretary (Dr. Brian Crowley, M.D.) are running for office based partly on platforms that promise to “abolish MOC.” I’ve inquired about their specific plan for doing so. My question to both are below, in case it doesn’t get past moderation:

I’m a psychiatrist at The University of Iowa Hospitals & Clinics and have been a conscientious objector to MOC for several years. I’m speaking as an individual and not as a representative of my employer. I support the principle of lifelong learning.

I remember Dr. Renee Binder running for APA President in 2014 and she too was publicly opposed to MOC. After she was elected, I didn’t hear much from her on how specifically she would abolish MOC as it’s currently configured. Both you and Dr. Brian Crowley, who is running for APA Secretary, are running for APA offices based on a commitment to abolishing MOC. How specifically would you accomplish that?

I was pretty disappointed in APA after 2014 and, as a consequence of the lukewarm commitment to opposing MOC and supporting llfelong learning, I did not renew my membership. That doesn’t mean that I think APA has done nothing about changing MOC. The APA has formally asked the ABPN to eliminate Part IV, but ABPN has not done so. The APA has not yet asked the ABPN to eliminate self-assessment or the examination.

What is your plan?

I would like to hear something else besides campaign promises. So far, the only reply I’ve received is from Dr. Crowley, “If elected we will move to abolish MOC and appoint a very short term work group to detail the strategy; it has been done by other specialties in medicine. Could have to change boards if needed.” He may be referring to NBPAS, to which I sent some questions:

1. Why does NBPAS certification require previous ABMS member board certification? Doesn’t this requirement keep us dependent on the ABMS? How would new medical school graduates avoid ABMS member board certification, which requires MOC participation? Wouldn’t the requirement for previous ABMS certification be a disincentive to certify with NBPAS, since that requires paying for two certifications?
2. And what happens to the NBPAS certification holder when the ABMS certification expires? Does that mean the NBPAS certification also expires? When I presented the case supporting NBPAS at a faculty meeting, this issue was raised by one of my colleagues.
3. If certain private insurance payers require MOC participation, how does NBPAS compete with ABMS?
4. Is the goal of NBPAS to provide a practical alternative to ABMS, or to somehow persuade the ABMS to change?

I just sent the message and I don’t yet have answers to these questions yet. However, pursuant to the 3rd question, Dr. Paul Mathew, M.D. F.A.A.N., F.A.H.S., who is a volunteer board member of NBPAS:

“WHAT DO PRIVATE PAYERS GAIN FROM REQUIRING MOC?

As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements.—from Dr. Wes blog “Will Fraud Investigators Read the New England Journal of Medicine?” by Westby G. Fisher, MD, FACC, originally posted Jan 4, 2017, accessed January 29, 2017.

According to Trent Holmberg, M.D., who moderated the MOC debate at the recent 47th Annual Meeting of the American Academy of Psychiatry and the Law that was held in Portland, Oregon, “The audience response data were very clear and do represent a mandate for change. 97% favored a requirement for 30 hours of CME annually, yet 70% favored abolishing the “Self-Assessment” requirement (Part II). An emphatic 92% favored abolishing the high-stakes cognitive examination (Part III) every 10 years, and 91% favored abolishing the “Performance in Practice” requirement (Part IV). Both the APA and the AAN have already formally asked the ABPN to eliminate Part IV, but ABPN has not done so. Neither the APA nor the AAN has yet asked the ABPN to eliminate self-assessment or the examination, but the AMA passed Resolution 309 several months ago calling for “the immediate end” of recertification examinations.” –from Psychiatric Times “Maintenance of Certification and Self-Mortification” by James L. Knoll IV, M.D., and Dan Cotoman, M.D., published December 08, 2016 and accessed January 29, 2017, comment section, Resolution 309 summarized is:

RESOLVED, That our American Medical Association call for the immediate end of any mandatory, secured recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process for all those specialties that still require a secure, high-stakes recertification examination.

Further, AMA policy states:

Any changes to the MOC process should not result in significantly increased cost or burden to physician participants (such as systems that mandate continuous documentation or require annual milestones).

The MOC program should not be a mandated requirement for state licensure, credentialing, reimbursement, insurance panel participation, medical staff membership, or employment.

According to Dr. Karen Sullivan Sibert, M.D., from her blog A Penned Point, “The Boards Have Exceeded Their Bounds,” posted January, 16, 2017, accessed January 29, 2017:

Many physicians have rebelled against compulsory MOC and have succeeded in getting the attention of their state legislatures. The state of Oklahoma passed a law in April, 2016, stating that nothing in its laws concerning medical practice shall be construed to make MOC “a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state.” Kentucky’s governor signed a more limited measure that forbids making MOC a condition of state licensure. Other states are considering joining Oklahoma as “Right to Care” states.

I can tell you that the ABPN has essentially eliminated the Performance in Practice (PIP) component of Part IV of the MOC, which ironically undercut the contribution and acceptance of the PIP Clinical Module for Improvement in the Assessment and Management of Delirium, and I’m giving you the link to it because it’s otherwise almost impossible to find. One of the psychiatry residents and I worked on that module, which the ABPN took a full year to approve.

I suspect that the incentive for using it might be lukewarm now that the ABPN has changed the rules about the clinical module requirement. While they haven’t actually gotten rid of Part IV, they almost have. No one who doesn’t want to work on the PIP Clinical Module actually has to because they can substitute a Feedback Module. Most front line doctors don’t have time to fiddle with the PIP Clinical Modules on the ABPN MOC web site because so many of us are subspecialized it’s virtually impossible to find one which would be meaningful and worth taking time away from our practice for. That’s why we call the PIP Clinical Modules “busywork.” The Delirium Clinical Module is pertinent but why would anyone bother now?

The ABPN technically doesn’t violate the American Board of Medical Specialties (ABMS) insistence on retaining Part IV because Part IV itself remains intact. On the other hand, psychiatrists are probably getting a break from the burdensome and wasteful PIP Clinical Module because, while Part IV is not optional–the PIP Clinical Module is. As of February 18, 2016, the American Board of Psychiatry and Neurology, Inc. (ABPN) has expanded the options for diplomates for their one required Improvement in Medical Practice (PIP) activity every three years to include any Clinical Module OR Feedback Module activity listed on the ABPN website.

What this looks like is the ABPN’s work-around way of implementing a suggestion to make Part IV itself optional (“Based upon the feedback we have received from the AAN and the APA, the ABPN has respectfully asked the ABMS to consider modifying its 2015 MOC Standards so that Part IV is an optional component of MOC.” The ABMS of course rejected it. Although the ABPN change doesn’t go that far, it accomplishes almost the same goal. No one who doesn’t want to work on the PIP Clinical Module actually has to because they can substitute a Feedback Module. But that doesn’t mean we should simply go along to get along with the MOC.

Dr. Holmberg goes on to say, “The ABPN is rapidly approaching $100,000,000 in assets and will probably have exceeded that number in 2016. They collect roughly $15,000,000 a year in fees from psychiatrists and neurologists, including over $500,000 in late fees alone.” It’s for this reason that the MOC has been dismissed as a “money grab” by diplomates.

And I haven’t even mentioned the trouble with the American Board of Internal Medicine (ABIM), which commits the most egregious injustices to our diplomates, including our combined internal medicine-psychiatry graduates. According to Charles Cutler, M.D., M.A.C.P., in the winter 2016-17 issue of Philadelphia Medicine, Philadelphia County Medical Society, in an issue entitled “Is The ABIM Too Broken to Fix?” article “A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires,” reforms should include:

• “Reign in the wild spending.
• Stop turning staff into millionaires; get salaries in line with the market. Stop relying on consultants who feed into higher and higher salaries.
• Eliminate the retreats, the resorts, and the plush accommodations. Require coach travel.
• Close the ABIM-Foundation. Return the money to diplomates.
• Insist that charitable donations are made from the ABIM directors’ own pockets not from diplomates’ fees.
• Ban real estate ventures.
• Establish a basic benefits package in line with community standard. Eliminate deferred compensation. Investigate an internet report that the ABIM’s retirement contribution is 18% while the industry standard is 5%.
• End mission creep and return to the original role of the ABIM (i.e. set standard for a medical specialty).”

And take note of the APA Board of Trustees message to ABPN President Larry Faulkner, M.D way back in 2015 (by the way, he earned over $900,000 in 2014 according to IRS Form 990):
• “APA does not agree that there should be an exam every 10 years for MOC.
• Certification of lifelong learning should be an integrated, ongoing process relevant to actual practice.
• APA is willing to work with the ABPN to improve the MOC process.
• For subspecialists taking a recertification exam, the ABPN should ensure that the exam primarily consists of questions related to the diplomates’ subspecialty. Any general psychiatry questions that are included should be relevant to the diplomates’ practice.
• No psychiatrist should be forced to maintain her/his underlying general and subspecialty certification through more than one certification process.”

I appreciate the direction in which the ABPN is moving. It needs to move more swiftly and with greater resolve. The political nature of the relationship between the ABMS and specialty certification boards like the ABPN is one thing. But the danger of scaring new scholars from pursuing careers in medicine at a time when physician shortages are at an all time historical high is another.

Given the sustained opposition to MOC across the country, isn’t it well past time to scrub the MOC?

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Comments

  1. It IS well past the time.

    I only vote for ABOLISH MOC candidates. I don’t buy the “we will look into it” attitude. There has also been a splitting effect on the profession. Many younger physicians who have been forced to comply with MOC by their medical groups are resentful toward the grandfathered in crowd. Some of that reaction has mysteriously been: “They need to go through what we are forced to go through.”

    For some reason – their reaction has been short sighted and they do not realize that nearly 100% of the grandfathered in physicians see no point at all in MOC and want to see it trashed.

    I don’t care if it brings down the ABMS and all of the specialty boards.

    The coalition with the NCQA is as corrosive as any managed care initiative against physicians. They will have a very docile and obedient profession when their business tactics infiltrate examinations and professionalism. There will be no end to hoop jumping and of course very little time to complain against the typically incompetent business managers.

    George Dawson, MD, DFAPA

    Liked by 1 person

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