News

Maintenance of Certification (MOC) Update

Dear CCACC Members:

There is indeed a lot of turmoil and misinformation that surrounds the issue of MOC.   A fellow ACC Governor, Dr. Allen Seals, has put together a tremendously informative piece on the issue. Please take a few minutes of your time to read this comprehensive summary of what actions have been taken and where we currently stand on this very important issue to us all.

Best Regards

Ed Tuohy MD, FACC

Governor, Connecticut Chapter of the American College of Cardiology

Unless you just returned from a three year vacation to Mars, you have undoubtedly been reading about what has now been termed by many as the “MOC Crisis”.  In an effort to bring you up-to-date, let me first highlight some of the events over the last two years, and the extraordinary response that we have seen from professional organizations, especially the ACC.  In fact, the ACC response to this “crisis” should leave no doubt whatsoever in the minds of any Cardiologist of the value of ACC membership.

The American Board of Internal Medicine (ABIM) was founded 80 years ago in answer to a public and professional need to establish uniform standards for physicians.  ABIM is one of 24 medical specialties boards that make up the American Board of Medical Specialties (ABMS).  Through ABMS, the boards work together to establish common standards for physicians to achieve and maintain board certification.  ABMS is an independent, non-profit organization not affiliated with ACC.  The passing of the subspecialty exam (now known as Part III) was commonly referred to as the “Boards”, and was widely accepted as a single event that would establish a physician’s credentials for life.

This concept of lifetime certification was challenged, and in 2006, substantive changes were introduced to include the need to establish documentation of meaningful learning activities, and established a “point system” (now known as Part II) and the term, “maintenance of certification” (MOC) was introduced.  This was then later expanded to include the requirement that patient satisfaction and physician practice quality metrics were to be measured (Part IV).

Then, in multiple announcements in 2012-2013, the ABIM proposed even more widespread changes and a radical set of new requirements and standards that forms the basis for the current controversy.  The American Board of Internal Medicine (ABIM) instituted these significant changes to its MOC process on January 1, 2014.  The modifications apply to all physicians, including those who received lifetime certification prior to 1990 (“grandparents”), and mandate the completion of all ABIM requirements, summarized as Part I – state licensure in good standing; Part II – MOC approved education efforts (with requirement that physicians start accumulating “MOC points” starting within 2 years of eligibility and with a requirement of 100 points over 10 years); Part III passing of the secure exam once every ten years (each exam has a designated statistical pass level), and Part IV – patient satisfaction and practice quality improvement modules (also with the allocation of “points”).

Needless to say, the extreme revision of standards has sparked heated discussions across all ABIM covered physician specialties.  Specifically, in cardiology, multiple ACC sponsored polls have demonstrated that the vast majority of the ACC membership has called into serious question the validity, relevance, utility, and associated financial and opportunity costs of meeting these revised MOC requirements.  ACC members have clearly expressed their frustration and dissatisfaction with the process and have proposed several alternative approaches.

In direct response and on behalf of member cardiologists, ACC leadership has responded in a forceful manner in a series of high level meetings between ACC leadership and the Board of Directors of the ABIM.  With considerable investment of leadership time, energy and effort, ACC senior leadership has discussed with the ABIM possible modifications of the MOC requirements.  These dialogues have included the following: 1) a private meeting in March 2014 with ACC leadership and the chief executive officer (CEO) of ABIM, and an open forum with ABIM’s CEO and the ACC Board of Trustees and Board of Governors in Washington, DC, during the 2014 ACC Annual Scientific Session; 2) senior ACC staff participation in an internal medicine subspecialty society meeting convened on March 12, 2014, by the American College of Physicians in Philadelphia, Pennsylvania; 3) a private meeting on May 27, 2014, in Philadelphia with ABIM’s CEO and the ACC’s President, CEO, and Executive Vice President of Science, Education, and Quality to discuss problems associated with MOC; 4) ACC leadership and senior ACC staff participation in a subspecialty society meeting convened on July 15, 2014, by the ABIM in Philadelphia; 5) senior ACC staff participation in ABIM’s semiannual Liaison Committee for Certification and Recertification in Philadelphia on September 15, 2014, and 6) a conference call on November 3, 2014, with the ACC President, senior ACC staff, and ABIM’s CEO.

The results of these meetings were frequently discussed in an open way by Pat O’Gara, MD, FACC, Immediate Past President of ACC, in multiple web-based articles and were the subject of national “all members invited” teleconferences.  In one quote, Dr. O’Gara stated, “The ABIM-imposed changes in the MOC process have called into question the optimal methodology for achieving the intertwined goals of lifelong learning and high-value care.”  As the newly elected Governor for Florida, I attended every briefing and it was clear to me that national ACC leadership took this issue very seriously.

In July 2014, the ABIM responded by modifying the MOC policy and committed to the following:

 *   Provide a 1-year grace period for those who have attempted but failed to pass the secure examination.

 *   Update its governance and financial information on its website.

 *   Ensure a broader range of CME options for medical knowledge and skills self-assessment (Part II).

 *   Provide more feedback regarding test scores.

 *   Evolve the “patient survey” requirement to a “patient voice” requirement and increase the number of ways this requirement can be met.

 *   Reduce the data collection requirement for the practice assessment requirement; utilizing performance improvement activities already in place and minimizing the time and complexity of data input.

 *   Investigate changes in the secure examination to increase relevance with specific attention to exploring applications for practice focus areas (“modular examinations”) and open-book examinations.

In August 2014, the ACC released the following statement:

The ACC recognizes that the ABIM’s mission as a standards-setting organization differs from its own mission as an educational organization. The ACC strongly supports the ideals of lifelong learning and continuous professional development.  The College and its members are acutely aware of the need to continuously maintain the public trust by transparently demonstrating ongoing competence as guided by the principles of high-value patient care.  Our membership holds itself to the highest professional standards.  The ACC is an educational organization in which the ongoing learning of our members is accorded strategic priority. Educational activities must be designed and delivered in ways that enhance provider performance and improve patient outcomes.

In direct support of membership, the ACC pledged to immediately do the following:

 *   Continue to have ongoing discussions with ABIM leadership, in partnership with other cardiovascular professional organizations whose members are similarly affected, to review these issues and to explore changes in MOC requirements that will result in       more meaningful outcomes and less onerous burdens for ACC members;

 *   Request ACC representation at the ABIM to participate in discussions involving MOC, including its educational and financial aspects;

 *   Review the evidence base underlying current recommendations;

 *   Investigate the impact of MOC changes on non-ABIM-certified members.

In the interim, the College will support its membership by:

 *   Free provision of web-based MOC modules and navigation tools;

 *   Expansion of Part IV MOC modules through ACC programs, such as the NCDR’s inpatient registries and the PINNACLE registry;

 *   Creation of mechanisms for ACC members by which patient safety and patient survey requirements can be efficiently fulfilled;

 *   Bidirectional communication with and engagement of membership through chapters, sections, and councils.

The ACC sought the most efficient method possible to provide information on the ABIM and the myriad of changes to the MOC process and introduced a highly functional major addition to their website, entitled, “MOC INFORMATION HUB”.  This major information resource was launched by the College as a significant member benefit to allow FACC physicians to better understand and keep current with the “complex situation that continues to be top-of-mind for ACC leadership, staff, and most importantly ACC members affected by the changes.”

In late 2014, the ACC took additional action:

 *   Released a special video that catalogs the suite of ACC resources available to help members meet the MOC Part IV requirements.

 *   Determined that free-standing MOC modules (MOC education Part II) will be offered to ACC members at no charge.

 *   Posted online (CardioSource.org/MOC) a comprehensive list of ACC MOC Part II offerings. New modules will be added as they become available.

 *   Under the direction of Dipti Itchhaporia, MD, FACC, established a monthly ACC Journal Club to allow members to earn MOC points in a web-based virtual Journal Club.

In January 2015, Paul Terstein, MD, published in the New England Journal of Medicine, “Boarded to Death – Why Maintenance of Certification is bad for Doctors and Patients.”  Dr. Terstein opined:

Regardless of how the MOC issue is resolved, the recent focus on the ABIM has shed a bright light on how medicine is regulated in the United States.  The ABIM is a private, self-appointed certifying organization. Although it has made important contributions to patient care, it has also grown into a $55-million-per-year business, unfettered by competition, selling proprietary, copyrighted products.  I believe we would all benefit if other organizations stepped up to compete with the ABIM, offering alternative certification options.

In February 2015, ABIM published the now famous “ABIM mea culpa” letter to the physician community that began with the simple statement, “Dear Internal Medicine Community, ABIM clearly got it wrong.  We launched programs that weren’t ready and we didn’t deliver an MOC program that physicians found meaningful.  We want to change that…We got it wrong and sincerely apologize.  We are sorry.”  As of the date of that communication, the ABIM made the following changes:

 *   Suspended Part IV for at least two years

 *   Changed the language to describe a physician’s MOC status from “meeting MOC requirements to participating in MOC”

 *   MOC fees were frozen at the 2014 level (for at least 2 years)

 *   By the end of 2015, ABIM will recognize most forms of ACCME-approved Continuing Medical Education

In April 2015, Newsweek published a critical opinion column on the ABIM, followed by a response to the critique on the ABIM website.  Meanwhile, the ABIM CEO, Richard Baron, MD, has come under increasing scrutiny, and has been interviewed by The New York Times, Politico, Medscape, Medical Economics, Marketplace and other news outlets.  He stated his wish to cooperate with the media in “good faith”.  Some of these articles are critical of ABIM and the content of each is available on the respective publications’ websites.

In April 2015, ACC leadership published a letter signed by all current and most recent past ACC leadership, entitled, “Urgent Message from ACC Leadership Regarding MOC”.  These eight senior leaders of the ACC stated:

All of us continue to be troubled by the complex situation presented by the changes in re-certification by the American Board of Internal Medicine (ABIM) over the past year.  We have heard clearly that our members are unhappy, and many are dissatisfied with ACC actions to date.  Our approach to the issue has been careful and deliberate, perhaps leading to the assumption that the ACC is not adequately addressing the problem.  The current ACC approach is as follows: We respect the intelligence of our members in analyzing the best path for continuing education/certification individually and realize that it may not be the same for each of us; we are not wedded to one solution for all.

Accordingly, in May 2015, the ACC established two active task forces to begin the work to a solution to the current “MOC Crisis”.  First, an ACC Task Force led by ACC Immediate Past President Patrick T. O’Gara, MD, MACC, is focused on continuing to provide input to ABIM to see if proposed temporary changes become permanent and to see if their processes can further improve to the extent that they are helpful and acceptable to members.  A second ACC Task Force led by ACC President-Elect (and Florida Chapter member), Richard Chazal, MD, FACC is aggressively exploring whether an alternative board should/could be developed by ACC for our members.  Potential possibilities could include: new board(s); working with already established alternate boards and/or other organizations; working within or without ABMS framework; and other solutions. While working as rapidly as possible, we want to be cautious, realizing the great complexity of the situation.  In the interim, all of us as members have alternatives.  These include joining a new board, waiting to see a final ABIM proposal, and waiting to see if an alternate ACC Board is feasible and/or needed. Recent ABIM suspension of MOC Part IV/patient modules and expansion of much CME to MOC II gives some potential breathing room (we are watching to see what actions will be permanent, what will be done with 10-year exams, and how to approach multiple certifications…among other problems).  See more at:http://blog.acc.org/post/urgent-message-from-acc-leadership-regarding-moc/#sthash.3GtbiR6H.dpuf

In summary, the “MOC crisis” is a complex situation that continues to be top-of-mind for ACC leadership, staff and most importantly for the ACC members affected by the changes.  The ACC’s approach to addressing the changes over the past year has been careful and deliberate — looking for the best ways to help members and their patients in proceeding forward.  In these matters headway has been made, and continues to be made, both in terms of working with ABIM to re-evaluate and change their requirements, and also in exploring alternative options to ABIM.

A. Allen Seals, MD, FACC

President / Governor Florida Chapter

American College of Cardiology