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American Journal of Kidney Diseases

Maintenance of Certification, Self-regulation, and the Decline of Physician Autonomy

Published:August 27, 2018DOI:https://doi.org/10.1053/j.ajkd.2018.06.015
      FEATURE EDITOR:
      Daniel E. Weiner
      ADVISORY BOARD:
      L. Ebony Boulware
      Kevin Erickson
      Eduardo Lacson Jr
      Bruce M. Robinson
      Wolfgang Winkelmayer
      Policy Forum highlights aspects of nephrology relating to payment and social policy, legislation, regulation, demographics, politics, and ethics, contextualizing these issues as they relate to the lives and practices of members of the kidney community, including providers, payers, and patients.
      Physicians who have earned initial certification by one of the 24 American Board of Medical Specialties (ABMS) specialty boards are required to recertify by completing Maintenance of Certification (MOC) requirements, which vary across specialties. According to ABMS, the “privilege of self-regulation” that physicians have is confirmed through MOC, a process intended to assess “each physician’s continued expertise, judgement, and skills.”
      • Irons M.B.
      • Nora L.M.
      Maintenance of certification 2.0—strong start, continued evolution.
      Because this process aims to “uphold the trust-based relationship between medical professionals and patients,” physicians have the autonomy to establish their “own educational standards and the right of self-regulation through external assessment holding [self-regulation] to high standards” (Box 1).
      • Irons M.B.
      • Nora L.M.
      Maintenance of certification 2.0—strong start, continued evolution.
      Maintenance of Certification: A Four-Part Process
      Part I: Professionalism and Professional Standing
      • Possess a valid unrestricted medical license
      Part II: Lifelong Learning and Self-Assessment
      • Engage in high-quality unbiased educational and self-assessment activities
      Part III: Assessment of Knowledge, Judgment, and Skills
      • Pass a written examination and other evaluations
      Part IV: Improvement in Medical Practice
      • Participate in ongoing assessment and improvement activities to improve patient outcomes
      Based on information at the American Board of Medical Specialties website.

      American Board of Medical Specialties. Board certification: a trusted credential assessed through a four-part framework. http://www.abms.org/board-certification/a-trusted-credential/assessed-through-a-four-part-framework/. Accessed June 8, 2018.

      ABMS describes this summative assessment as a “continuous process of ensuring physician competence.” However, for this process to work, physicians, medical societies, government, and the public must trust MOC as the appropriate form of self-regulation. Without this trust, the process becomes an obstacle, rather than a foundation, to providing the best patient care. Increasingly, physicians have lost faith in the concept of recertification in general and in the MOC process in particular as an accurate measure of professional competence. This crisis of confidence has the potential to damage initial certification as well. One in 5 US physicians is uncertified by one of ABMS’s 24 specialty boards, and among certified physicians, a subset of more senior physicians will never recertify because they were exempted when ABMS’s boards started to move to time-limited certification.
      • Young A.
      • Chaudhry H.J.
      • Pei X.
      • Halbesleben K.
      • Polk D.H.
      • Dugan M.
      A census of actively licensed physicians in the United States, 2014.
      Many in the medical profession have asked why some physicians should be forced to complete MOC every 6 to 10 years, while those who are exempted can avoid a process perceived as expensive, burdensome, irrelevant, not evidence based, and misaligned with adult learning theory. For example, ∼17% of the nation’s 10,816 nephrologists completed training before 1989, which means they are not required to recertify.
      American Medical Association
      AMA Physician Masterfile.
      Additionally, with medical care increasingly delivered by interprofessional teams, assessing competency becomes more challenging. Regulatory bodies responsible for overseeing each team member—physicians, doctors of pharmacy, pharmacists, advanced practice providers, nurses, dieticians, and social workers—each view recertification differently, some not requiring the process and others offering a choice between continuing education and an examination.
      Even among younger physicians, MOC varies. By 2025, a total of 20% of US physicians are projected to be doctors of osteopathy, who certify and recertify through the American Osteopathic Association (AOA).

      White-Faines A. Status of the single accreditation system. Paper presented at: Council of Medical Specialty Societies Spring Meeting; May 12, 2017; Rosemont, IL.

      When AOA and the Accreditation Council for Graduate Medical Education (ACGME) launch a single accreditation system for residency and fellowship programs in 2020, both osteopathic and allopathic physicians may be able to pursue certification, recertification, or both through AOA instead of ABMS and its boards.
      Public and private payers have started to assess physicians and other providers on a continuous basis. By linking reimbursement to quality, the federal government intends to save money, control costs, and improve care. Medicare is implementing the Quality Payment Program, a new reimbursement system that elevates pay for performance. Under the Quality Payment Program, most physicians will participate in the Merit-based Incentive Payment System or in an Advanced Alternative Payment Model. Concurrently, private payers and medical societies continue to expand clinical quality guidelines, measures, and registries. These instruments are driving care delivery, informing payment, and becoming more relevant to physician practice.
      The health care system is rapidly changing. Advanced Alternative Payment Models and other care models are evolving care more quickly than certifying boards can assess, hospital medicine is changing educational and professional pathways, and accepted boards exist separate from ABMS (such as the American Board of Sleep Medicine). The amount of care delivered outside hospitals and hospital-based clinics is increasing, which will lead to more population-based measures of care. Health professionals and institutions are also incorporating shared decision making, including patients and families in assessing options for managing care.
      The United States faces an estimated shortage of 120,000 physicians by 2030.

      Association of American Medical Colleges. 2018 Update: the complexities of physician supply and demand: projections from 2016 to 2030. April 11, 2018. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/85/d7/85d7b689-f417-4ef0-97fb-ecc129836829/aamc_2018_workforce_projections_update_april_11_2018.pdf. Accessed May 28, 2018.

      Besides exacerbating the current geographic maldistribution of physicians, this shortfall will intensify physician burnout; elevate the responsibilities and autonomy of other health professionals; cause policymakers and patients to question the need for certification, let alone recertification; and force states and health care organizations struggling to attract physicians to question obstacles presented by certification requirements.
      Striving to access medical care, many Americans may increasingly rely on criteria unrelated to MOC. For example, social media, crowdsourcing, and data analytics have accelerated the development of a cottage industry that is already assessing physician quality. HealthGrades, the Leapfrog Group, Angie’s List, Consumers’ Checkbook, and Yelp are among the sources that patients now trust and access. In addition, telemedicine, cloud-based informatics, point-of-care diagnostics, advances in regenerative medicine, and precision medicine (now guided by a patient-centered perspective) are changing medicine daily and in unpredictable ways.
      Due to the dispute over MOC, state legislatures are questioning the value of recertification and therefore self-regulation and professional autonomy.
      • Seaborg E.
      Revolt against maintenance of certification makes legislative gains.
      In an ironic twist, physicians who are concerned about too much regulation are turning to the government for help. State legislatures and governors are responding by approving legislation that attacks the fundamental pillars of ABMS and the specialty boards: “the trust-based relationship between medical professionals and patients,” the ability of physicians to establish their “own educational standards,” and the “privilege of self-regulation.”
      • Irons M.B.
      • Nora L.M.
      Maintenance of certification 2.0—strong start, continued evolution.
      Some physician groups also are turning to the federal government for help in their battle against MOC. In 2017, advisors to the Federal Trade Commission (the agency tasked with protecting consumers and promoting competition) predicted, “Board certification marks the next phase of competition in health care markets….Competition amongst boards within a specialty could promote price competition, innovation in physician assessment, and the potential for increased signaling information for consumers.”
      • Gilman D.J.
      • Miller B.J.
      • Goldstein B.
      Board certification: a dose of competition.
      On a related note, Congress has even considered a proposal to block the effort by AOA and ACGME to establish a single accreditation system for residency and fellowship programs. If this proposal succeeds, it would further undermine physician self-regulation and autonomy, as well as complicate the accreditation of residency and fellowship programs, breaking the link between federal funding for graduate medical education (through the Medicare program) and accredited training programs, as well as challenging ABMS and the specialty boards’ current monopoly over initial certification of physicians in the United States.
      The American Board of Internal Medicine (ABIM), by far the largest of ABMS’s 24 boards, is responding to the rebellion over MOC differently than the rest of ABMS. First, although ABMS replaced the term “MOC” with both “continuous board certification” and “continuous certification” (the same term AOA uses), with most of its 24 boards following suit, ABIM still uses MOC. Second, ABIM’s alternative MOC pathway still requires a high-stakes examination, whereas ABMS and most other boards are piloting more formative assessments. For example, the American Board of Obstetrics and Gynecology (ABOG) allows its diplomates “to earn an exemption from the current MOC Examination if they reach a threshold performance during the first five years of the self-assessment program.”

      American Board of Obstetrics and Gynecology. 2017 Bulletin for maintenance of certification for basic certification of diplomates. https://www.abog.org/Bulletins/2017%20MOC%20Basic%20Bulletin%20Final.pdf#page=18. Accessed December 11, 2017.

      ABOG’s certificates are time-limited for 6 years, as opposed to most boards, including ABIM, for which certificates are time-limited for 10 years. Third, ABMS and most other boards continue to require practice assessment, which ABIM suspended as a requirement in 2014. ABIM still allows diplomates to generate MOC points through practice assessment activities, such as the Quality Assessment and Performance Improvement in Dialysis Facility activity.
      ABMS has launched Continuing Board Certification: Vision for the Future, a commission intended to “bring together multiple partners to vision a system of continuing board certification that is meaningful, relevant, and of value, while remaining responsive to patients, hospitals, and others who expect that physician specialists are maintaining their knowledge and skills to provide quality specialty care.”

      American Board of Medical Specialties. ABMS launches continuing board certification: vision for the future. http://www.abms.org/news-events/abms-launches-continuing-board-certification-vision-for-the-future/. Accessed December 11, 2017.

      ABMS estimates that the commission will issue a final report by March 2019. Between now and then, more states may pass anti-MOC legislation, further diminishing physicians’ professional autonomy; differences over the high-stakes examination and practice assessment could worsen ABIM’s relationship with ABMS and the remaining 23 boards, forcing the internal medicine community to take sides; and alternative boards, such as the National Board of Physicians and Surgeons, may continue to gain credibility, posing an ever greater threat to the ABMS enterprise.
      Multiple other potential threats exist to ABIM: internal medicine specialties may become impatient with ABIM, spawning new relationships between internal medicine societies and other non-ABIM specialty boards; medical societies may examine AOA’s model of serving as both a membership organization and a certifying body, eliminating a separation that started in allopathic medicine in 1917; and the Centers for Medicare & Medicaid Services may allow dialysis facility medical directors to recertify through alternative boards to ABIM, reversing the long-standing policy reconfirmed in 2017.
      The uprising over MOC raises an existential question about the value of recertification. In 1989, when ABIM first required recertification, few predicted how society would evolve, how the practice of medicine would change, or how the demands on physician time would shift. Today’s physicians spend 49.2% “of their total time” on administrative tasks, including electronic health records, which was inconceivable only 20 years ago.
      • Sinsky C.
      • Colligan L.
      • Li L.
      • et al.
      Allocation of physician time in ambulatory practice: a time and motion study in four specialties.
      ABMS and its specialty boards, medical societies, and physicians agree on the key principles of self-determination, self-regulation, autonomy, and professionalism within the medical profession. Most of these stakeholders also agree on initial certification for every physician, ongoing assessment of competence for certified physicians, the need to align ongoing assessment of competence with clinical practice, and the value of relying on multiple methods to credential physicians.
      With so much agreement on key principles, the medical profession should replace MOC forever by focusing on continuing medical education, self-assessment programs, formative evaluation, and existing quality improvement initiatives. In ensuring that MOC’s replacement is less burdensome and less expensive to physicians, the medical profession must also avoid the temptation to turn recertification into a profit center. All physicians, regardless of specialty or practice setting, must join with medical societies and other stakeholders to overcome obstacles to meaningful change. Such change will support physicians, reward the desire of physicians to learn and improve, and promote the medical profession’s commitment to providing the best care to patients.

      Acknowledgements

      The author thanks Phillip Kokemueller, Adrienne Lea, Rachel N. Meyer, Kurtis Pivert, and Mark E. Rosenberg for insights.
      Disclaimer: The views expressed in this editorial reflect the author’s opinion, not the beliefs of ASN, CMSS, or ASM.
      Peer Review: Received June 19, 2018. Evaluated by 2 external peer reviewers, with direct editorial input from the Feature Editor, who served as Acting Editor-in-Chief. Accepted in revised form July 6, 2018. The involvement of an Acting Editor-in-Chief was to comply with AJKD’s procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies.

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