ing in educational and self-assessment activities deter- mined by each board;
• Specialty-specific skills and knowledge, shown by pass- ing a written exam; and
• Improvement in medical practice, shown by engaging in quality improvement activities.
In addition to multiple-choice tests, for instance, MOC
activities might include simulation work or other clinical skills assessments asking physicians to discern a diagnosis and recommended treatment. Newer, much-maligned re- quirements for physicians to demonstrate quality improve- ments under the ABMS Portfolio Program drew criticism for requiring projects inaccessible to smaller practices or unrelated to real-world medicine or for duplicating physi- cians’ existing work with other institutions. “It’s a good idea to make sure doctors are keeping up
with the literature and CME in their specialty. But there are other requirements that have built up that are too much to bear,” Dr. Monday said. She estimates spending $10,000 to maintain her three board certifications, not accounting for the cost in time it takes to complete all the pieces involved. Physicians also point to stud-
ies showing the recertification process has become more ex- pensive with little to no patient care benefit. Most recent studies focus on the American Board of Internal Medicine (ABIM) — the largest ABMS member board — whose policies have drawn ex- ceptional criticism. A pair of 2014 Journal of
A LEGISLATIVE SOLUTION Yet, failing to maintain board certification carries serious, negative consequences affecting physicians’ livelihoods, a hazard TMA is seeking to eliminate with the help of the state legislature, says TMA Council on Legislation Chair Ray Callas, MD. The Beaumont anesthesiologist estimates his test fees to
be around $3,000, plus another $1,500 to take a simulation course and the time away from his practice to study, travel, and take the exams. “Why do I need a simulator when I see patients every single day?” he asks. ABMS says board certification is a voluntary process,
above and beyond medical licensure. No states, including Texas, require MOC as a condi- tion of licensure. However, MOC, in effect, has
“Doctors have had enough of mandates that don’t result in quality patient care. Period.”
the American Medical Associa- tion studies compare internists grandfathered in with lifelong certification with those subject to MOC. One report (tma.tips/JAMAMOCReport1), which looked at internists providing primary care at four Veterans Affairs medical centers, found no significant dif- ferences between those with time-limited ABIM certifica- tion and those with time-unlimited ABIM certification on 10 primary care performance measures. In a second study (tma.tips/JAMAMOCReport2), re-
searchers who looked at certain preventable hospitaliza- tion measures found no difference in quality between the two groups, but a small reduction in cost growth among the MOC-required internists. A 2015 Annals of Internal Medicine study (tma.tips/In
ternistsMOCCosts) found a 2014 increase in ABIM fees and requirements for MOC — some of which ABIM has since suspended in 2015 — would “generate considerable costs, predominantly due to demands on physician time.” (See “MOC Costs for Internists,” page 29.)
30 TEXAS MEDICINE September 2016
become a mandatory process in some cases for physicians to keep seeing patients, Dr. Callas says, now that hospitals, public and private payers, and even some employers require con- tinuous certification in order to practice within those entities. Medical liability coverage also could hinge on board certifica- tion, he adds. “MOC is held over physicians’
heads and made punitive, when it’s financially draining and not improving the quality of care,” Dr. Callas said. Nor is there much need for board-mandated MOC when physi- cians already must meet continuous CME requirements in their specialties to maintain their licenses. “It’s a better way of allowing us to learn based on what we practice.” TMA is one of a growing number of state medical as- sociations with policies on the books opposing compulsory MOC. New American Medical Association policy adopted in June at AMA’s 2016 House of Delegates meeting in Chi- cago pressures boards to put an end to high-stakes exams, while reaffirming principles advocating MOC programs should be evidence-based, clinically relevant, affordable, and physician-developed. (See “AMA House Takes Action on MOC,” opposite page.) Physician pushback has sparked legislative action in a
number of states that has garnered medical societies’ sup- port. Most notably, Oklahoma’s elimination of MOC as a
“Doctors are data-driven, and there’s no data to support all the extra work,” Dr. Monday said. ABMS officials say the recertification standards are
meant to keep up with increasingly rapid changes in medi- cine. They point to their own body of research showing MOC participation improves care (tma.tips/MOCImpro vesCare).
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