How Maintenance of Certification Rule Changes Affect Rheumatologists

Dr. Flood

As I write this column, I see almost daily a new article on Maintenance of Certification (MOC) from various sources and organizations—PolicyMed, American College of Cardiology, Annals of Internal Medicine and, oh yes, from the American Board of Internal Medicine (ABIM) as well. An eye-catching story reported that 15,000 physicians have signed a petition requesting a recall of ABIM’s new MOC requirements, and in turn, the ABIM issued a press release defending the program.^1-3

With all of the controversy swirling around the subject, I’ll offer some of my perspectives about MOC and where the American College of Rheumatology stands on the matter.

Where Do I Fit into MOC?

As most of you are aware, the ABIM changed its MOC program this year. Along with doubling the number of points required (from 100 every 10 years to 100 every five years), physician participation is being reported in a new way. Physicians who have not yet enrolled are now publically reported as “Not Meeting MOC Requirements.” I am one of those physicians. Having certified in 1983 in internal medicine and 1984 in rheumatology I hold two, time-unlimited certificates and am considered grandparented. As such, I won’t lose my certification status by not participating in MOC, but now I am faced with the ABIM listing of “Certified, Not Meeting MOC Requirements,” leaving me and others (including perhaps my patients) questioning the meaning.

I am not the only rheumatologist grand­parented but not enrolled. In early May (just after the deadline to enroll closed), the ABIM reported that 24% of grandparented rheumatologists had enrolled. At the same time, ABIM reported 82% of rheumatologists with time-limited certifications had enrolled.

In a press release issued May 8, David H. Johnson, MD, chair of the ABIM Board of Directors, stated, “Although participation in MOC is a voluntary activity, ‘board certification’ has sufficient credibility and public acceptance that many hospitals, health systems and patients use it to help decide with whom they want to work.”⁴

Certification and MOC are voluntary, as Dr. Johnson points out, but in many cases it may not feel that way because many of us have experienced certification as a requirement by payers and hospitals. It remains to be seen what “meeting” or “not meeting” the MOC requirements will mean and how it will affect those grandparented. Currently, program directors must be certified in the specialty or subspecialty they lead; however, there is no requirement to be enrolled in MOC. Thus, “Certified, Not Meeting MOC Requirements” is currently acceptable to ACGME. Will this change? The answer is unclear.

With all of this uncertainty looming, each grandparent must do what we think will be best for us personally. As a practicing physician planning to retire at some date in the future and knowing that I am keeping up in the field whether or not I am doing so through the official MOC program, I am still weighing whether or not to participate in MOC. On one hand, I am proud of my reputation, and I certainly do not want any observer to wonder if I am up to date or not, or whether I am actively engaging in practice improvement. On the other hand, I am not sure the expense of going through this process will be worthwhile for me. I am also a bit resentful that the rules have changed so late in my career.

I am proud of my certification, and I am happy to participate in continuing medical education in order to maintain my Ohio medical license. In fact, I have routinely exceeded the state medical board’s required number of hours in CME.

I have colleagues who are grandparented and taking a different route—paying each year to participate and completing MOC activities along the way. They will not need to take and pass a secure examination until 2023 to be “Meeting MOC Requirements,” so some will not be practicing at that time. Others will opt to take the exam before 2023, and others still will opt not to take the exam and will no longer be meeting requirements in 2023. The number of people still practicing with grandparented credentials will be rather small by then.

Where Does the ACR Fit into MOC?

No matter which route I ultimately pursue, I know the ACR will have my back. The ACR is not the creator or the driving force behind MOC, but because it’s a process required of our members, we have made a commitment to provide rheumatologists with the resources and tools we need to navigate the process and earn MOC points. To this end, the ACR has developed online self-paced, self-assessment modules for medical knowledge and practice improvement and, more recently, modules that coincide with live sessions, such as those at the Annual Meeting. The ACR’s goal is to help rheumatologists earn MOC points for activities we’re already doing and reduce the burden via time- and cost-efficient programs. Most importantly, we have programs that are rheumatology specific.

With that goal in mind, at our Annual Meeting in Boston this year, the ACR is piloting a series of three sessions designed to refresh your knowledge in key areas of the MOC blueprint and allow you to claim MOC, as well as CME credits. The CARE: MOC Sessions module will be free to all Annual Meeting attendees. More details on the program and how it will work will be provided closer to the meeting date.

Although not all of the ACR MOC modules are free, the ACR is sensitive to the cost of recertification and sets rates at the lowest possible margin to help offset the development costs. In addition to developing rheumatology-specific, MOC-approved products, the ACR actively advocates for members.⁵ In April, the ACR collaborated with other medical specialty societies on a letter submitted to the ABIM that voiced concerns from our members, leadership and staff regarding the MOC process. This effort was led by the American College of Physicians, which recently published its position in Annals of Internal Medicine. Although the ACR and the other societies believe in lifelong learning, practice improvement and the purpose of MOC, we do not agree with all of the ways the program is implemented. Some of the issues the concerned societies asked the ABIM to address are:

• Rising costs: MOC is expensive and overly burdensome—not only in terms of the fees to enroll, which increased almost twofold for specialty certifications this year—but also in terms of the cost to purchase modules, and enroll in review and study courses, and in the time it takes to complete all of these programs in an already time-taxed profession.
• Secure exam—Pass rates: First-attempt pass rates for rheumatology have been up and down over the past several years, and in 2013 the rate dropped to 85%. Internal medicine pass rates have been on a steady decline over the past five years, dropping from 90% in 2009 to 78% in 2013.⁶ This is an alarming statistic when we consider that many specialties are already experiencing workforce shortage issues.
• Secure exam—Format: Physicians are required to use high-security testing facilities for an exam that seems to lack relevance to everyday practice, including the inability to use open information resources relevant to specific clinical scenarios.
• Lack of products available to cover the wide variety of professional activities and roles of physicians: Many researchers, educators and administrators who are minimally clinically active find it difficult, if not impossible, to complete parts of the requirements, such as patient safety and patient feedback requirements.

As this column is being written, the ACR has not received a response from the ABIM.

The controversy may continue, but MOC is probably here to stay. Although this may not be the best way to assure the public that physicians are competent, it’s the current choice with the institution whose responsibility it is to do just that. Know that the ACR will continue to advocate and provide support for our members. That includes those officially “meeting requirements” and those “not meeting requirements.”

At the End of the Day

When the extraordinary business of this year as ACR president wanes, I will likely begin the MOC process myself. After all, I wouldn’t want anyone to think that I was not all that my reputation purports me to be. I may resent the time and money the process will entail, and I will continue to voice my concerns to the ABIM. No matter what my choice, I feel strongly that the ACR will stand with me in the endeavor as the ACR continues Advancing Rheumatology!

Dr. Joseph Flood is a rheumatologist at the Columbus Arthritis Center and adjunct professor of internal medicine in the Division of Rheumatology at The Ohio State University College of Medicine and Public Health, both in Columbus. Contact him at [email protected].

References

1. Maintenance of certification: Petition to recall ABIM’s MOC requirements hits 15,000 signatures; recertification rates drop below 80% for internal medicine. Policy and Medicine. May 20, 2014. http://www.policymed.com/2014/05/maintenance-of-certification-petition-to-recall-abims-moc-requirements-hits-10000-signatures-recertification-pass-rates.html?utm_source=feedblitz&utm_medium=FeedBlitzRss&utm_campaign=FeedBlitzRss&utm_content=Maintenance+of+Certification%3a+Petition+to+Recall+ABIM’s+MOC+Requirements+Hits+10%2c000+Signatures%3b+Recertification+Pass+Rates+Drop+Below+80%25+for+Internal+Medicine.
2. Statement from Richard J. Baron, MD, MACP, president & CEO of the American Board of Internal Medicine regarding anti-MOC petition. American Board of Internal Medicine. April 28, 2014. http://www.abim.org/news/statement-from-richard-baron-regarding-anti-moc-petition.aspx.
3. Wood S. Not today: Cardiologists, MOC deadline extended to April 30. Medscape. April 1, 2014. http://www.medscape.com/viewarticle/822847.
4. Physicians enroll in the ABIM MOC program in record numbers. American Board of Internal Medicine. May 8, 2014. http://www.abim.org/news/physicians-enroll-in-ABIM-MOC-program-in-record-numbers.aspx.
5. Centor RM, Fleming DA, Moyer DV. Maintenance of certification: Beauty is in the eyes of the beholder. May 13, 2014. http://annals.org/article.aspx?articleid=1871129&resultClick=3.
6. First-time taker pass rates—Maintenance of certification [November 1997–November 2013]. American Board of Internal Medicine. (n.d.) http://www.abim.org/pdf/pass-rates/moc.pdf.