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    MOC controversy fueled by new studies

    Two recent studies in the Journal of the American Medical Association are sparking fresh controversy over the effectiveness of, and need for, the maintenance of certification (MOC) requirements mandated by the American Board of Internal Medcine (ABIM.)

    The studies in JAMA’s December 10 issue both look at MOC’s impact on the costs and quality of patient care, although in different ways. The first study, led by ABIM’s Bradley Gray, Ph.D., compared costs and outcomes for two groups of Medicare beneficiaries during the years 1999-2005: one group treated by internists who received board certification in 1991, and were thus required to recertify in 2001, and a second group treated by internists who certified in 1989, and were thus grandfathered out of ABIM’s recertification requirements.

    The study used a quality measure the annual incidence of ambulatory care-sensitive hospitalizations (ACSH) per 1000 beneficiaries. (The authors define ACSH as “hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care.”)

    The study found no statistically significant association in ACSH growth between the MOC-required and MOC-grandfathered physicians, but did find a 2% slower growth in the cost of care provided by the physicians who had to recertify compared with the grandfathered cohort.

    The second study, led by John Hayes, MD, of the Zablocki VA Medical Center in Milwaukee, Wisconsin, compared performance data of 71 MOC-required and 34 MOC-grandfathered physicians at four VA medical centers, including Zablocki, for 12 months starting in October, 2012. The ten performance measurements ranged from colorectal screening to blood pressure control to post-myocardial infarction use of aspirin. It found “there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification om 10 primary care performance measures.”

    While the study results might appear to provide ammunition to MOC opponents, an accompanying editorial by Thomas Lee, MD, MSc, chief medical officer for Press Ganey and a practicing internist, notes that “another assessment might be that the effect of MOC is unknown at best and that changes to its structure must be undertaken with caution and sensitivity to their effect on physicians’ professional lives.”

    Lee points out that ACSH, the outcome measure used in the Gray-led study, “was designed to assess access to primary care in populations, not the quality of care delivered by individual physicians” and applied only to about 80 patients in each participating physician’s panel. Moreover, “the 2% reduction in spending is as large or larger than the savings recorded by Medicare accountable care organizations in their first two years, so further study to determine if this finding is real and reproducible is critical.”

    (Gray and his co-authors note in their study that even small per-patient savings, when extrapolated over Medicare’s nearly 50 million beneficiaries, would far exceed the costs of administering the MOC program.)

    The most significant finding of the Hayes study, Lee says, is that all the performance measurements were significantly better than those of the general population, regardless of whether the patient received care from a MOC-required or MOC-grandfathered physicians, and thus “provide a reminder that healthcare today has become team-based.”

    In mid-December JAMA convened a webcast to discuss the studies’ findings and answer questions. Judging by tweets accompanying the events, MOC’s critics remain unconvinced of the value of ongoing recertification.



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    • Anonymous
      After relocating out of state, the Practice Improvement Module surveys could not even be distributed to my new patients since they had been under my care for less than 1year at the time I needed to be completing the PIM. Add to these stressors, surgery for an elderly parent, charting in the middle of the night to try and catch up, an employer who would not allow me to take any reduction to my schedule, and a for profit hospital system who cared little about quality care= disaster! I got the extra time I needed to study with a Pink Slip! Even with an additional surgery for my parent 3 months later I passed! .....but at what cost? Caregiver stress, loss of employment, non-compete clauses, and less expensive mid- levels have cost me my career and my livelihood. The additional time needed and accompanying stress pushed me over the edge into physician burnout. I now volunteer at a free clinic but have no income. A lifetime of studying and passing exams did not improve my patient's care. They lost their doctor with no explanation from the hospital.
    • Dr. Paul W. Johnson, DO
      If the ABIM remains inflexible to the outcry against the MOC, there is an alternative choice in the new National Board of Physicians and Surgeons (NBPAS), which will use CME requirements as a main criteria for recertification. Check it out at nbpas.org
      MOC is/should now be dead as an issue. There is absolutely no need for it, is detrimental to MD morale and time available for productive CME, and must be dropped as a requirement and as an issue. This issue is DEAD!! No benefit. Plenty of harm. Get rid of the bureaucratic requirement that benefits, as usual, only the regulators and is of no benefit to physicians or the real people who matter, the patients.
    • Anonymous
      Opposition to MOC continues to gain momentum, second only to Ebola as one of the top medical news stories of 2014. www.changeboardrecert.com has been updated with articles and physician commentary, videos and financial info about our "nonprofit" Boards, all showing MOC’s evolution into a discriminatory, costly burden to physicians and patient care, a profiteering scam without proof of efficacy or patient protection, with compliance rapidly being tied to practicing medicine. Please review the site, forward this to your colleagues and together can we make a difference. Note the recent additions: http://changeboardrecert.com/anti-moc.html
      So... i have no problem with trying to develop minimal criteria for evaluating and 'certifying' MDs. My problem is 'one size doesn't fit all', ie: a written test' need not be a REQUIRED part of that certification. eg: what do you do with a MD , previously grandfathered, 32 years in university, 4 years pvt. practice, 100 patients / week, published 16 articles in past 4 years, 2 book chapters, multiple national, local and international CME talks given each year, active NIH grant , Caste-Connelly 'Best Doc' for ?18 years, Heathtap score 95 ? I do not plan on spending time taking a test- time away from my other activities (especially as i actually help CREATE SELF-ASSESSMENT tests, know their vagueries) to satisfy MOC criteria. Shouldn't their be a process that encompasses multiple ways of evaluating quality- testing could be 1 way, but not a REQUIREMENT.
    • Dr. Brad Douglas, MD
      A couple of things - first as an ob/gyn - there are many aspects of ob/gyn that I no longer do, and hence doing MOC that covers everything is a bit ridiculous - and so let me put this to you from another career I had when I was a F-14 pilot years ago. The guys who use to fix my airplanes such as those who fixed the electronics, the airframes, etc really KNEW the F-14 well - but if they wanted to advance they had to take an ADVANCEMENT EXAM - well that Advancement exam included subjects from the OTHER aircraft the Navy flew such as A-6's, P-3's, Helicopters etc and my guys would COMPLAIN about this ALL the time as they thought it was NOT fair - well in TIME - the Navy saw the light of day and decided that it would be ONLY fair to test people in areas they knew and worked in. Well we as Doctors get tested EVERYDAY in our practice, and it is the PRACTICE of Medicine - we ALL look up stuff everyday - and hence doing MOC, at least the EXAM portion is a bit intimidating - for me it was - I had NEVER taken a Computerized Exam before - so when I took my MOC exam for the Ob/Gyn boards - it was not a comfortable feeling - but yes I passed. Personally as for MOC I like the Annual Article Requirement - I can read the 40 to 50 articles in a year and answer the questions - that much I do like. But studying for a test every 6 years - honestly I really do not think it proves anything. JUST MY TWO CENTS
      These two articles CLEARLY provide further evidence in the total lack of value of proprietary MOC programs! This is further true because the ABMS has repeatedly tried for DECADES to demonstrate "value" in their programs and have NEVER been able to provide anything more than VERY BIASED ASSOCIATIONS "supported" by their internally funded and written "(pseudo)studies". Certification is at best a slight, or possibly false, promise, recently openly admitted by the ABMS: ‘FACT: ABMS recognizes that regardless of the profession – whether it is health care, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes’. See:http://www.jchimp.net/index.php/jchimp/article/view/20326 It is time to dismantle the ABMS corporate machine and remove all influence of this extortion from american medicine. It is a TAX on healthcare equal to extortion and must be stopped. The ABIM has been the leader in this wasteful corporate enterprise and has very recently been exposed by Dr Wes Fisher at:http://www.kevinmd.com/blog/2015/01/physician-investigates-american-board-internal-medicine.html and EVERYONE should read this expose' entitled: A physician investigates the American Board of Internal Medicine Paul Kempen, MD, PhD
    • Anonymous
      No evidence demonstrating that MOC is effective. It all confirms my suspicion that this is a shake-down by the Boards. The cost in time and money is staggering. Also, we, the grandfathered ones, will all be retired or dead soon enough. Why sully our credentials and reputations as we wind down our careers?
    • Dr. David L. Keller
      The grandfathered internists had 20% more experience in practice than the MOC'ed internists! The "grandfathered" internists in the first study were certified in 1989, while the "MOC'ed" internists (those forced to undergo Maintenance of Certification) were certified in 1991. The study was conducted in 2001, so the grandfathered internists had 12 years in practice, while the MOC'ed internists had only 10 years in practice. The difference of 20 percent more practice experience could account for much of the difference between the two groups; for example, the fact that the more experienced internists spent more money on patient care might reflect their increased experience in billing Medicare and insurance companies, which is knowledge not taught during the MOC process; rather, skill at billing is acquired through years in practice. posted by David L. Keller, MD
      December 19, 2014 Medical Economics.com Re “MOC controversy fueled by new studies” by Jeffrey Bendix in December 19 issue: Is anyone really surprised that no significant difference was found between the MOC and Non-MOC physicians? Doctors spend years in lectures and poring over notes and textbooks and studying patients in hospitals. They are dedicated to life-long learning because they have to be whether they want to or not, as bad as that may sound. One simply cannot practice medicine without a certain minimal amount of scientific knowledge and go undetected for very long. For patients and colleagues are quick to identify bad doctors. Moreover, state licensing boards already have regulations in place requiring physicians to complete a certain number of continuing education hours every year. It seems that the MOC controversy is a replay of what happened in the early 1900s following the Flexner Report. Abraham Flexner who was not a doctor but an educator studied how doctors were trained and found numerous deficiencies. His findings ushered in a whole new era of academic medical education. Medical schools were annexed to universities and full-time professor were enlisted and the schools adopted a research-based approach. The improvements greatly improved the quality of physicians. But, there were some physician-educators who thought that too much emphasis was devoted to the sciences and that not enough attention was being paid to training “practical” doctors. And there are some indications that some politics and personal ambitions were behind Flexner’s success. The Rockefeller Foundation and the Carnegie Institute lent tremendous financial and political support to Flexner. One can only guess if there are any ulterior motives behind those who lead the MOC process. Only time will tell and it is good that physicians are giving this issue the attention it deserves. Edward Volpintesta MD

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