Open Letter to Iowa Lawmakers Supporting Legislation Opposing MOC

The Iowa Medical Society (IMS) will soon be voting on a new resolution to oppose Maintenance of Certification (MOC) and preserve the principle of lifelong learning. It will entail pursuing the help of Iowa lawmakers in the pursuit of legislation toward clarifying what MOC should not be used for. I support it and acknowledge my bias as well as respect the opinions of colleagues who do not share my views on MOC. Below is my letter to my congressmen. You are free to disagree with it and should you wish to express dissenting comments, I will share them.

Dear Sirs:

I support the Iowa Medical Society (IMS) policy resolution proposal urging state legislators to introduce a bill opposing the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC). ABMS created MOC and made it a requirement for certification under their trademark and which member specialty certification boards are required to support) MOC. The IMS proposal reads as follows:

“IMS shall pursue legislation to prohibit the imposition of a requirement that a physician secure Maintenance of Certification (MOC) as a condition of licensure, hospital privileges and reimbursement from third party payers.”

The IMS will vote on the resolution at their annual meeting April 28, 2017. A similar law was passed in Oklahoma in April 2016. This legislation is being considered by 10 other states. Moreover, 20 state medical societies have adopted resolutions opposing MOC.

I submitted the original IMS proposal for supporting continued lifelong learning and opposing Maintenance of Licensure (MOL) in 2013, which was adopted into IMS Policy as H-275-019: Licensure and Discipline, Maintenance of Licensure:

“IMS supports the continued lifelong learning by physicians and the improvement to quality of practice; opposes the institution of Maintenance of Licensure for those physicians who are board certified and/or maintaining relevant CME and peer-reviewed quality of practice and/or participating in Maintenance of Certification; and opposes further Maintenance of Licensure implementation for all other physicians without sufficient supportive data demonstrating that the Maintenance of Licensure program supports patient outcomes and improves quality of care.”—IMS Policy Compendium.

I also submitted PRS 14-02 opposing Maintenance of Certification to the IMS Policy Forum in 2014, which was also adopted, PF-275.020:

“IMS opposes mandatory Maintenance of Certification (MOC) for licensure, hospital privileges, and reimbursement from third party payers. IMS supports continuing medical education and the principle of lifelong learning by physicians.”—IMS Policy Compendium.

Not everyone agrees with the IMS Policy resolution suggestion above and think pursuing legislation is the wrong way to go. Some believe that it’s the responsibility of physicians to decide on what the standards should be for medical specialty certification and that patients have a right to know whether their doctors are keeping their skills and knowledge up to date. It’s also been suggested that if physicians have problems with the structure and processes of MOC, they should simply work with the ABMS.  A paper has been cited which was written by the President and CEO of The American Board of Pediatrics in support of this position—(Nichols, D. G. (2017). “Maintenance of Certification and the Challenge of Professionalism.” Pediatrics).

I hardly think it’s an unbiased opinion, but I respect it and acknowledge my bias as well. I concede the point that physicians should set the standards and patients should know we are doing that, but I think we’re capable of doing that for ourselves.

In my opinion, rank and file physicians are turning to legislation because they don’t think the ABMS and member specialty certification boards are trustworthy. The American Board of Internal Medicine (ABIM) has been the subject of controversy for quite some time in this regard (see Dr.Wesdotblogspotdotcom). Further, 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 in fact include doing just what the title says and much more (Cutler, C., MD, MACP, A message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires, in Philadelphia Medicine: The Official Magazine of the Philadelphia County Medical Society Philadelphia Medicine 2016, Hoffmann Publishing Group, Inc.).

I realize that some specialty certification boards are making special efforts to improve the MOC process and The American Board of Pediatrics is one of them. However, MOC is controversial. Based on a recent survey of physicians, MOC is not an effective or practical way to support lifelong learning for doctors (Cook, D. A., et al. (2016). “Physician Attitudes About Maintenance of Certification.” Mayo Clinic Proceedings 91(10): 1336-1345.):



To determine physicians’ perceptions of current maintenance of certification (MOC) activities and to explore how perceptions vary across specialties, practice characteristics, and physician characteristics, including burnout.

Patients and Methods

We conducted an Internet and paper survey among a national cross-specialty random sample of licensed US physicians from September 23, 2015, through April 18, 2016. The questionnaire included 13 MOC items, 2 burnout items, and demographic variables.


Of 4583 potential respondents, we received 988 responses (response rate 21.6%) closely reflecting the distribution of US physician specialties. Twenty-four percent of physicians (200 of 842) agreed that MOC activities are relevant to their patients, and 15% (122 of 824) felt they are worth the time and effort. Although 27% (223 of 834) perceived adequate support for MOC activities, only 12% (101 of 832) perceived that they are well-integrated in their daily routine and 81% (673 of 835) believed they are a burden. Nine percent (76 of 834) believed that patients care about their MOC status. Forty percent or fewer agreed that various MOC activities contribute to their professional development. Attitudes varied statistically significantly (P<.001) across specialties, but reflected low perceived relevance and value in nearly all specialties. Thirty-eight percent of respondents met criteria for being burned out. We found no association of attitudes toward MOC with burnout, certification status, practice size, rural or urban practice location, compensation model, or time since completion of training.


Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.”

Even the American Medical Association (AMA) has a policy which reads:

“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.”

There is no compelling research evidence showing that MOC participation improves patient outcomes:

(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– Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. 

(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. — Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

The growing opposition to MOC is so deep and broad that an alternative board has been created to provide another choice for physicians who need or want board certification. This is the National Board of Physicians and Surgeons (NBPAS), which doesn’t require participation in MOC nor recertification examinations. NBPAS leadership are also making it a priority to address a particularly misguided misapplication of MOC by some private insurance payers, who are making MOC participation a condition of reimbursement. Legislators, the public, and physicians should be aware of the potential for conflict of interest issues possibly inherent in this business practice.

Dr. Paul Mathews, MD, who is a unpaid volunteer leader within NBPAS, has written about the complex relationships involved in the relationship of 3rd party insurance and physicians when it comes to imposing MOC as a restriction on reimbursement:

(NBPAS), which is a newly established alternative to the ABMS which doesn’t require MOC participation:


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” – (Mathew, P., MD (2016). MOC and Physician Burnout: Treating the Cause, Not the Symptoms. Practical Neurology).

In my opinion, physicians should have the right to simply forgo MOC or alternative certifications and pursue the continuing education which is relevant to their practice. There ought to be a genuine choice to participate in MOC or some other vehicle for fulfilling the principle of lifelong learning. Those who want MOC should be able to continue participating in it. Those who don’t should be allowed to continue using the method they’re most comfortable with for maintaining their knowledge and clinical skills, including CME and other creative methods for staying current with the medical literature. They should not be afraid they’ll not be allowed to practice medicine or not be reimbursed for their hard won knowledge. MOC is widely perceived to be at best an annoying imposition on physicians’ time. At worst, it can interfere with patient care because of the time burden which is viewed as time wasted by many physicians.

While there are some doctors who oppose the IMS policy change and the legislative efforts that it portends, there are many who support it. There are several reasons for it and some of them frustrate and sadden doctors. I agree that the IMS should represent all doctors. I think it’s too bad that this MOC controversy divides us.

Nonetheless, I support the IMS policy change suggestion as noted above and urge legislators to strongly consider supporting legislation opposing MOC.

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