In 2000, the American Board of Medical Specialties (ABMS)

MOC Sparks Anger, Frustration in Physician Community Anti-MOC advocates wonder why they cannot get a seat at the table to discuss changing the system. BY BRYAN BECHTEL In 2000, the American Board of Medical Specialties (ABMS) proposed changing the way specialty boards certified participating physicians. 1 Instead of a lifelong board certification, the new policy enacted a 10-year time limit, after which those physicians wishing to remain board certified would have to recertify. Since its passage, the ABMS has maintained that this program, known colloquially as Maintenance of Certification (MOC), ensures doctors continual commitment to learning and maintaining good and current standards for quality patient care. Yet, within the ranks of medicine, those who have become subject to the MOC process have labeled it unfair, onerous, expensive, misguided, and even potentially a restriction of fair trade. The anti-moc side has raised questions not only about the potentially legality of MOC, but also about the appropriateness of having a purportedly voluntary process such as board certification count as a condition for employment or reimbursement status. Those complaints about MOC, it turns out, are rather on the milder side. Some in the anti-moc contingency are more blunt in their critique of the board certification process, charging that MOC has more to do with profits than improving the state of medicine. In a 2013 article in Newsweek, The Ugly Civil War In American Medicine, Kurt Eichenwald suggested that the American Board of Internal Medicine (ABIM) may be failing physicians for the mere purpose of having them retest at considerable cost. 2 According to Mr. Eichenwald, starting in 2010, there was a precipitous decline in pass rates among test takers, declining from 88 percent to 80 percent in 2014, with sharp declines noted in certain subspecialties: Hematologists dropped from 91 percnet [sic] to 82 percent. Interventional cardiologists went from 94 percent to 88 percent. Kidney specialists, 95 percent to 84 percent. Lung experts, 90 percent to 79 percent. Those failure rates, he wrote, followed from increasingly irrelevant questions presented to test takers, but coincided with a swelling of ABIM organizational revenue, peaking at more than $55 million in 2013 thanks to MOCrelated income. Mr. Eichenwald further reported that the ABIM had used some of its cash influx to finance a high priced condominium and to shower its executives with disproportionate pay while it condoned the practice of letting its board members bring their spouses along on business trips to exotic locales. When condominiums and lavish salaries and free trips and making money off of physicians failing tests became a priority, the evidence suggests the organization lost its way, Mr. Eichenwald wrote. Amid the highly charged rhetoric surrounding MOC, however, are very real concerns that the process does little to ensure that physicians are up to date on the literature. In a series of interviews with prominent dermatologists, Practical Dermatology learned that many clinicians believe that MOC is not evidence-based, but a seemingly incongruous paradox in the modern age of medicine that demands that physician behavior be predicated on strong evidentiary standards. Moreover, they say, if the goal is to ensure practitioners are current in their medical knowledge, then why are physicians who got their certification before 1992 grandfathered into lifetime board certification? But the issue that seems to be rankling practicing physicians the most? That all of the changes to MOC have been dictated by the specialty boards with no chance for physicians to participate in a constructive conversation about the process. As it turns out, one of the biggest bones of contention by the anti-moc movement is that physicians were never involved in formulating the system. 50 PRACTICAL DERMATOLOGY SEPTEMBER 2016

The refrain is that they re trying to create good standards for practice and they re implying that this is the only way to do it, but without any proof whatsoever, noted one prominent dermatologist who Practical Dermatology spoke to for this article. APPROPRIATENESS AND LEGALITY OF MOC Those who reject MOC are quick to point out that they do not oppose the principles behind the process, but that the manner in which they are being asked to recertify as competent to practice within their subspecialty is wholly unjustified and unfair. I think that continuing my medical spectrum of education is critical to my success and critical to my patients success and to their overall health, said Jeanine Downie, MD, a dermatologist from Montclair, NJ. But MOC is not about value, it s not about competence and quite frankly, it s not about anything having anything to do with the betterment of the patients. The reality is that it s not about practicing medicine, it s about the money. According to Dr. Downie and others, the commitment to go to medical school and to subject to rigorous residency training ought to be sufficient in demonstrating a willingness to serve patients best interests. And as for continually staying up to date with the current thinking in evidence-based practice, she said, there were already adequate systems in place before the 10-year recertification requirement was enacted. CME is sufficient, Dr. Downie said. There was nothing wrong with the requirement of continual CME to ensure physicians stay up to date. The CME system was not broken. One simple answer to the MOC question is to simply opt out. After all, participation in board certification is intended to be a voluntary process. Yet, there is a movement within medicine to make board certification a necessary component of employment or the ability to practice or, more perilously, a necessary component to participate in Medicare. On its website, the ABMS notes the differences between board certification and medical licensure: Obtaining a medical license sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board Certification demonstrates a physician s exceptional expertise in a particular specialty and/or subspecialty of medical practice. 3 Yet, on that same webpage, ABMS introduces a proposition that some find extremely troubling, that Many hospitals have independently made the decision to require Board Certification for staff privileges. Various quality organizations and health care purchasers are committed to increasing value of the care provided. They look to the ABMS specialty certification system to help them identify excellence and commitment to professionalism, and continuous performance assessment and improvement. However, the notion that employment or practice privileges are contingent on board certification may be an overreach by the ABMS. The idea sounds really good, it plays well: We need to make sure that doctors are keeping up to date with the literature, said H.L. Greenberg, MD, of Las Vegas. But that is not the responsibility of the board to do that. It s the responsibility of the state, because the state determines licensure. In fact, it may be legally problematic to link employment, insurance panel status, and reimbursement to board certification. According to 482.12(a)(7) of the Code of Federal Regulations (CFR) the codification of general and permanent rules published in the Federal Register it is impermissible to base employment solely on board status. The regulation requires that hospital governing bodies Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society. 4 The Centers for Medicaid and Medicare Services has supported this stance in its Interpretive Guidelines 482.12(a)(7). 5 In making a judgment on medical staff membership, a hospital may not rely solely on the fact that a MD/DO is, or is not, board-certified. This does not mean that a hospital is prohibited from requiring board certification when considering a MD/DO for medical staff membership, but only that such certification must not be the only factor that the hospital considers. In addition to matters of board certification, a hospital must also consider other criteria such as training, character, competence and judgment. PUSH BACK There are already several organized challenges to the legitimacy of MOC. In 2013, the traditionally conservative and anti-government Association of American Physicians & Surgeons brought an anti-trust lawsuit against the ABMS, stating that the MOC process restricted patient access to physicians and established an unjustifiable requirement for practicing medicine or being on a hospital staff. 6 More recently, a group of osteopathic doctors initiated a class action lawsuit against the American Osteopathic Association for return of membership fees, which are paid for the stated purpose of obtaining and maintaining board certification, but which the class feels are egregiously in excess of the actual cost of MOC. 7 In April of this year, the state of Oklahoma passed a law banning forced participation in MOC. 8 Similar laws have been proposed in other states. Meanwhile, state medical societies from California, Florida, Georgia, Indiana, Iowa, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, SEPTEMBER 2016 PRACTICAL DERMATOLOGY 51

Texas, Virginia, Washington, West Virginia, and Wisconsin have each proposed resolutions in opposition to MOC. 9-22 Pushback against MOC has also taken shape at the medical society level. At the 2016 annual meeting of the American Medical Association, representatives from state medical societies representing Florida, California, Georgia, Pennsylvania, Washington, New York, and Virginia successfully steered Resolution 309 through the groups house of delegates, creating as policy That our American Medical Association call for the immediate end of any mandatory, secured recertifying examination by the American Board of Medical Specialties (ABMS) or other certifying organizations as part of the recertification process for all those specialties that still require a secure, high-stakes recertification examination. Even professional boards have spoken out against MOC. The American Board of Radiology announced plans to potentially replace the requirement for 10-year recertification, perhaps bringing the process online to make it more convenient for diplomates. 23 These developments signify progress to the anti-moc movement, but they are also isolated and do not apply to all practitioners. In fact, dermatologists, if they wish to overturn MOC requirements, appear to have a long road ahead. In 2015, Dr. Greenberg presented a resolution to the MOC Advisory Board Committee of the American Academy of Dermatology (AAD) to consider ending time-limited certification. The proposal, he said, was met with an abrupt denial with no explanation. Dr. Greenberg, however, decided to try again, this time working with the AAD on drafting a more formal bylaw proposal to change the MOC process. Dr. Greenberg was told that all he had to do to get a vote on his proposal was to gather enough signatures which was not hard to do after tapping into the growing groundswell of anti-moc resentment. With his more than 400 signatures in hand, he presented his recommendation to the AAD s Bylaws Committee for submission to the Board of Directors to change the bylaws and amend the AAD s stance on MOC. However, the AAD Board of Directors rejected the proposal on the grounds that it was tantamount to a policy statement, and thus, it conflicted with all other sections of the bylaws. The Bylaws Committee said that this has nothing to do with the bylaws so they did not allow a vote on it, Dr. Greenberg explained. They agreed if I got the requisite number of signatures, that we could have a vote on ending maintenance certification and recertification. But the academy is opposed to ending MOC, and they have entrenched itself in that stance. CONCERNS WITH THE PROCESS The AAD and the American Board of Dermatology have held joint meetings intended to improve the MOC process. Earlier this year, the two organizations released a joint statement introducing changes to the process, namely the availability of more CME that qualifies for Part 2: Lifelong Learning and Self-Assessment. 24 The statement announced no changes to Part 1: Professionalism and Professional Standing, but did state that the ABD had suspended Part 4: Improvement in Medical Practice for two years starting January 1, 2016. Regarding Part 3: Assessment of Knowledge, Judgment, and Skills, the joint statement stated that it would consist of a formal evaluation: a 100-question General Dermatology module plus a 50-question subspecialty module of the diplomate s choosing. According Heidi Waldorf, MD, Director of Laser and Cosmetic Dermatology at The Mount Sinai Hospital and Associate Clinical Professor at The Icahn School of Medicine, that general knowledge requirement underscores a fundamental problem with the entire MOC process: that a diagnostic challenge quiz does little to nothing to prove that a dermatologist is likely to provide quality care. At a very basic level, she said, the ability to identify a disease entity in a picture suggests nothing about knowing the latest treatment trends or how to critically assess a patient s exposure history. They can t say that if you know these 150 diagnoses that means you re a better dermatologist, Dr. Waldorf said. My training taught me to think like a dermatologist. We learned to think that way and that test does not test that. It is counterintuitive, she added, to test clinicians, who are trained to follow principles of science, with a process that has never been proven to improve practice. In fact, a study in 2014 suggested an opposite effect, noting that ambulatory care sensitive hospitalizations (ACSHs) per 1,000 beneficiaries rose after implementation of MOC as did per beneficiary costs. The authors concluded that Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries. 25 Other studies, with admittedly small sample sizes, have suggested no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. 26 However, studies link new MOC requirements with a significant increase in cost. One study estimated the average cost to an internal medicine practitioner would be $23,607 over 10 years, with a estimated cumulative price tag of $5.7 billion in 2015 an increase of $1.2 billion over 2013 numbers. 27 Included in the estimate is approximately $5.1 billion in time costs and $561 million in testing costs. The time potentially lost to MOC activities is of significant concern to already busy dermatologists. Dr. Greenberg predicted he would inevitably lose time to interact with patients while 52 PRACTICAL DERMATOLOGY SEPTEMBER 2016

he studies for an exam that may or may not have anything to do with his particular area of interest. Moreover, he said, it is more than likely that will have a trickle effect, because when he closes his office, his employees and staff also do not work. Dr. Waldorf pointed out that the financial impact may be much deeper than what appears on the surface. When she took the MOC, she signed up for a prep course held before the AAD annual meeting, immediately adding additional cost to the process. Travel to and from the meeting, plus additional time spent away from practice, only compounded the stress. In actuality, Dr. Waldorf s experience with the prep course raised additional questions about the merits of the MOC process. She was not able to attend the course because she was busy lecturing at the time; she did, however, manage to procure a copy of the Q&A used during the prep course and then worked diligently to memorize everything she could from that material. This was not a learning experience. I memorized the things that they said you had to know for the test. And, the time I was taking worrying about this test, and trying to do this test, and the money I spent on this test, really was not time well-spent. All the test showed was that I was willing to jump through a hoop. It did not show that I m a good dermatologist, because, frankly, I m a cosmetic dermatologist. None of my practice focus areas were even on there, she said. Worse yet, the pictures that were shown as part of the test were of such poor quality that Dr. Waldorf said she could barely make out the disease entity being shown. Alas, Dr. Waldorf did pass her exam, but therein lies another problem with the MOC process. According to the AAD-AMD joint statement about MOC, The goal of this formal evaluation of cognitive expertise is to document that participants are keeping up to date; the goal is not to fail anyone. For that reason, the pass rate has been more than 98 percent the first attempt and 100 percent by the third attempt. If nobody fails, then why give the test, at all? Then that s a useless test, Dr. Waldorf said. Added Dr. Greenberg, That just goes to prove my point that it has nothing to do with quality. The test isn t real. You want a real test? Then you fail people. If the goal is not to fail people, then just make us take a certain number of continuing education credits and move on. Dr. Waldorf wonders why physicians cannot simply accumulate enough CME credits during a three-year period and have that be sufficient for continual MOC. They could even dictate that practitioners have to get CME credits in certain types of programs. And define those. And then people could count going to meetings, like at the AAD, the therapeutic updates. Sessions like, When bad things happen to good surgeons. Things that are going to help you take better care of your patients. And in that way, you would be building on something doctors already have to do. Because most states, it s part of the licensing require that every three years you have a certain number of CME points, Dr. Waldorf said. Having a broad knowledge base for your specialty may not be relevant when you only focus on a certain area. I think it s fair that we have continuing medical education. In order to stay licensed in the state of Nevada, I have to have a certain number of hours of continuing medical education. That s just the law, Dr. Greenberg said. Being dictated to as to what I need to focus on, and what other dermatologists need to focus on, just doesn t seem right. When you become a specialist, you focus on your specialty and your area within the specialty. THE LONG VIEW The ABMS decision to change MOC requirements has engendered very palpable anger in the physician community, but the process does not appear to be changing, if for no other reason than doctors cannot seem to find a seat at the table to discuss the issue. To some, the entire process is humiliating and an insult to the hard work they have put into training. Dr. Waldorf described having to roll her sleeves up as she entered her proctored exam to prove that she was not cheating. She adds that the entire emphasis on MOC is misguided and misplaced when resources ought to be spent on educating the public about what it actually means to be board certified. Dermatology is facing encroachment from uncertified practitioners nurse practitioners and clinicians from other specialties offering cosmetic services while some falsely claim to be certified in practice areas that do not exist. There are people who say that they are board certified by the American Academy of Cosmetic Surgery, which we know is not an ABMS board, Dr. Waldorf said. People will say, I am, I am board certified in laser. There is no board certification in laser. I think the biggest threat to medicine isn t dermatologists trying to prove that they re better dermatologists than other dermatologists. It s people who aren t even physicians claiming to be dermatologists. That s a bigger threat to society, Dr. Greenberg said. To some, the anti-moc movement has become personal, endemic of a systematic overreach into the lives of individual practitioners. Dermatology appears likely to bear the brunt of the negative consequences of MOC, as it is a specialty that remains one of the last bastions of solo or small practice but if the costs of MOC become too burdensome, then dermatology will likely see continued consolidation to assure ample financial resources to keep clinic doors open. 54 PRACTICAL DERMATOLOGY SEPTEMBER 2016

I didn t go to medical school for four years so that I could become a slave to the American Academy of Dermatology, Dr. Greenberg said. I m frustrated as a dermatologist that we actually have to keep recertifying when lawyers don t have to recertify, accountants don t have to recertify. No other profession has to recertify, said Dr. Downie. But then we have put ourselves, unwittingly, in the situation where we re allowing people to dictate to us that we have to keep taking tests and keep taking tests. And the bottom line is that it s completely unfair. In an interview for this article, Dr. Downie added a salient reminder that fighting MOC is not simply about unburdening individuals from a process that is flawed, imperfect, unnecessary, and perhaps even inappropriate. Not only could MOC force some people out of the practice of medicine, it has the potential to undermine the very future of medical excellence. My daughter wants to be a dermatologist. I m involved in this for her. This is not why I became a doctor so I could be re-studying for stuff that, quite frankly, is not helping me or my patients out in any way, shape, or form. It s not why I became a doctor, and it s not why other people want to become doctors, Dr. Downie said. n 1. Kempen PM. Maintenance of Certification - important and to whom? J Community Hosp Intern Med Perspect. 2013; 3(1): 10.3402/jchimp.v3i1.20326. 2. Eichenwald K. The ugly civil war in medicine. Newsweek. Available at http://www.newsweek.com/2015/03/27/uglycivil-war-american-medicine-312662.html. 3. ABMS. A Trusted Credential. Available at: http://www.abms.org/board-certification/a-trusted-credential/. Accessed August 29, 2016. 4. Available at: https://www.gpo.gov/fdsys/pkg/cfr-2011-title42-vol5/pdf/cfr-2011-title42-vol5-sec482-12.pdf. 5. Available at: https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r37soma.pdf. 6. Available at: http://aapsonline.org/aapsvabmsresponse-6-3-2014.pdf. 7. Available at: http://www.duanemorris.com/site/static/aoa_class_action_complaint.pdf. 8. Available at: http://openstates.org/ok/bills/2015-2016/sb1148/. 9. http://changeboardrecert.com/documents/actions-of-the-2013-hod.splitted-and-merged.pdf 10. http://changeboardrecert.com/documents/flresolultions.pdf 11. http://www.mag.org/sites/default/files/downloads/hod2014-rca-107.pdf 12. http://www.communitysynergy.com/cc/files/client_266/indiana_am.pdf 13. https://www.iowamedical.org/iowa/iowa_public/resources/policy_compendium/policies/pf- 275_020_Licensure_and_Discipline_Oppose_Maintenance_of_Certification_and_Support_Lifelong_Learn. aspx?websitekey=f4c25891-c13b-4ac1-8b57-3f829e9a16ef 14. http://changeboardrecert.com/documents/a10_020_murray-leisure_moc_adp.pdf 15. http://www.communitysynergy.com/cc/files/client_266/2015michiganresolutionsexerpt.pdf 16. http://changeboardrecert.com/documents/resolution-oppositiontomaintenanceofcertification.pdf 17. http://www.aapsonline.org/index.php/site/article/medical_society_state_of_ny_house_of_delegates_adopted_resolutions_in_oppos/ 18. http://www.ncmedsoc.org/non_members/annual_meeting/2012/2012-ref-comm-resolutions.pdf 19. http://www.changeboardrecert.com/documents/pamedsocmocstatementofprinciples.pdf 20. http://changeboardrecert.com/documents/resolutione-3mancuso2014amended.pdf 21. http://changeboardrecert.com/documents/hod_2014_wsma-page7.pdf 22. http://www.communitysynergy.com/cc/files/client_266/2014_final_house_of_delegates_action_wisconsin.pdf 23. http://www.theabr.org/sites/all/themes/abr-media/pdf/abr_moc_part_3_changes_press_release.pdf. 24. AAD - ABD Joint Statement Regarding MOC. Available at https://www.aad.org/education/moc/aad-abd-jointstatement-regarding-moc. 25. Gray BM, Vandergrift JL, Johnston MM, Reschovsky JD, Lynn LA, Holmboe ES, McCullough JS, Lipner RS. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. 26. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA. Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. 2014 Dec 10;312(22):2358-63. 27. Sandhu AT, Dudley RA, Kazi DS. A Cost Analysis of the American Board of Internal Medicine s Maintenance-of- Certification Program. Ann Intern Med. 2015 Sep 15;163(6):401-8. 56 PRACTICAL DERMATOLOGY SEPTEMBER 2016