Maintenance of Certification (MOC) Update: A Health Reform Lesson

The 1967 Corvair. A non-PHB version

Long ago, when the Population Health Blog was courting the future PHB spouse, our unspoken understanding was that if the PHB liked its unsafe-at-any-speed 1967 Corvair, it could keep its unsafe-at-any-speed Corvair.

The sweet perfume of our relationship more than made up for the odor of car exhaust, unsightly blemishes, noisy rattles and rusted floorboards.

Cracking the windows, touches of spray paint, the AM radio volume knob and care where you placed your feet also helped.

It wasn't until courtship turned to relationship that the spouse's true thinking began to manifest itself.

That's why, years later, the PHB was unsurprised by President Obama's disavowal of his you-can-keep-your-health-plan assurances. Substitute Federal minimal essential benefit requirements, narrow networks and unaffordable premiums for spousal safety demands, mocking eye-rolling and intrusive hints about the merits of a new car, and readers should understand the PHB's acquiescence.

So the PHB shrugged off the notification that its life-long American Board of Internal Medicine (ABIM) specialty credential wasn't really a life-long credential.  

Enter maintenance of certification or "MOC."

More background can be found here, but, briefly, the sweet perfume of accomplishment was overcome by the MOC stink of intrusive, unproven as well as expensive documentation, education and testing renewal requirements.

Thousands of the PHB's physician colleagues were less submissive about the matter in print and on-line. There were also competitive threats, lawsuits, online petitions, and websites. The American Medical Association weighed in. And then state medical societies, which have a vital interest in serving their membership, began to sound the alarm.

And it paid off. 

While the PHB would have predicted that the academics populating the ABIM leadership were about as likely as Mr. Obama or the PHB spouse to change their minds, they've issued a "we got it wrong and sincerely apologize" announcement. 

As a result, many of their documentation requirements are on hold, the test is being revamped, fees are being reduced and the education options are being broadened.

Good for the ABIM and good for the practice of internal medicine.

This kind of mea culpa is a good first step in engaging the opposition and is likely to turn many critics into allies. More importantly, this is a great example of the impact of grass roots activism and the advocacy of organized medicine.

If this can happen in this corner health care, perhaps there are other areas of health reform where a well placed apology might be a good first step.

The magnanimous PHB is also happy to admit that, in retrospect, the spouse was right about the Corvair. At one point, highway snow was blowing up into the passenger compartment.  At 60 miles an hour.  Seriously.

Since then, it has gotten to like and keep lots of other stuff.  It makes having to pay so much for its own heath insurance a little more tolerable.

Image from Wikipedia

Maintenance of Certification in Internal Medicine: What the Population Health Community Needs to Know

Since population health provider organizations work closely with physicians, they're aware that "board certification" is an important credential.  Being "boarded" in family practice, pediatrics or internal medicine is widely regarded as evidence of extensive training.

They may not be aware of the controversy brewing over board certification in the internal medicine physician community.

The American Board of Internal Medicine (ABIM) is the certifying Board for the nation's internists.  After meeting training requirements involving years of training after medical school graduation, candidates have to pass an examination.  Once physicians do that, they have the credential that documents their expertise. 

It used to be that once you did the training and passed the test, you were credentialed as a "board certified" internist.... forever.  With increasing recognition that skills can grow stale with time, in 1990 the ABIM decided to require recredentialing on a periodic basis. 

That process has evolved under the umbrella term "maintenance of certification" ("MOC").  You can read more about that here and here, but it basically involves earning "points" through activities such as documentation of learning, participation in quality improvement, chart audits and taking a repeat test.

Unfortunately, MOC and the ABIM have become a focus of physician ire.  While the academics and organized medical societies' leaders believe in the process, many rank and file practicing physicians disagree. 

Among their concerns that are nicely documented here and here:

1. It takes a considerable amount of time, documentation, and paperwork to complete the 10 years' worth of continued training/chart audits and to prepare for the repeat examination.  (That's especially true thanks to the difficulty at extracting electronic records data; it also puts smaller practices at a disadvantage, since they may not have the support personnel to help with all those tasks).

2. It's also expensive.

3. If a physician doesn't pass the test, it needs to be taken again at additional cost.  Over the past five years, the failure rate has increased from 10% to 22%.  Since it's unlikely that the pool of docs entering the MOC process are dumber, that suggests the test is getting unnecessarily harder. Some physicians wonder if ABIM has a financial incentive to increase the failure rate. 

4. Unlike the initial process of board certification, there is little hard evidence that MOC-credentialed physicians  attain better patient outcomes compared to non-MOC physicians.

5. Physicians are unhappy that the MOC process does not recognize the practical wisdom that comes with decades of patient care.  It is "one size fits all" and can't be tailored to account for different practice settings.

6. There is a possibility that MOC could evolve from a voluntary exercise in professionalism to a mandatory condition of licensure, hospital/insurer participation or employment.

7. ABIM not only has a monopoly, it has no oversight. Whatever the merits, the ABIM's MOC actions are seen by some as capricious, arbitrary, disconnected to the real world and only adding to physicians' low morale.  One survey suggests a majority of practicing physicians are skeptical about the MOC.

 The Population Health Blog suspects this is a controversy that is not going away anytime soon.  Population health service providers will always be interested in helping their "orphan" patients without a PCP become engaged with a physician, and may use "board" status as one criterion for referral.  It remains to be seen if "MOC" participation should be part of that calculus.

Stay tuned!