Maintenance of Certification

• Maintenance of Certification
• ABIM
• MOC
• Certification
• Maintenance
• Specialty Boards

The strong public discussion about The American Board of Internal Medicine (ABIM) maintenance of certification (MOC) program has been remarkable. This discussion stems from a quiet struggle that many physicians have faced. To be a physician, one is subjected to a succession of tests demonstrating medical knowledge, starting with the Medical College Admission Tests and progressing to specialty board certification. Maintenance of board certification continues thereafter and acts as a form of quality assurance, ensuring that physicians maintain their knowledge of established standards of care.

Nephrologists work with patients in hospitals, dialysis units, and the office. Many of these venues require current ABIM board certification to maintain medical staff membership. As such, nephrologists will be participating in the ABIM MOC program for the foreseeable future. The question is how well does the MOC program meet the needs of nephrologists and patients?

The notion underlying MOC seems reasonable—physicians demonstrate ongoing learning through periodic examinations reflecting their knowledge. In practice, however, this idea has flaws. The 2014 changes to the MOC program, the increased frequency of testing, complicated activities, and higher prices sparked these public discussions. Paying thousands of dollars in fees to demonstrate ongoing learning and take the examination was difficult to reconcile. Moreover, the examinations were all or nothing testing opportunities, offered only a few times per year. Failure resulted in the revocation of board certification. The testing was only offered through a single vendor with often inconvenient locations. It is unsurprising that the value of the “Board Certified” moniker for nephrologists is being questioned. In a world of increasing clinical and administrative demands (and decreasing reimbursement), the perceived return on investment for the studying, materials, travel, and lost work is greatly diminished.

The content of the MOC program has also been criticized. Asking detailed questions about immediate post-transplant management, subtle variations in GN, or other highly specific topics makes sense if the goal is to create a wide distribution of scoring among nephrologists who deliver all aspects of renal care. However, many test takers felt that this content was unrelated to their daily practice. Moreover, the care rendered by many front-line practicing nephrologists was not included in the typical questions. Managing CKD in older patients with multiple chronic diseases, the ethical and practical considerations of renal replacement in complex medical and social situations, and the management of polypharmacy are all more reflective of the typical nephrologist’s experience. In addition, MOC testing was dependent on the memorization of numerous facts and formulas. In the real world, diagnoses are often established when reviewing patient data and with access to the full complement of online medical information. Treatment plans are often compromises between the recommended ideal and the limits dictated by a physician’s ability to communicate with clarity and compassion combined with the patient’s willingness and resources. Being able to recall numerous medical facts during a closed book, time-limited test does not guarantee that one is a successful nephrologist.

More broadly, there is concern with the idea that board certification is synonymous with high-quality care. There have been a number of studies reviewing the correlation between board certification and various measurable outcomes. A summary of these data, recently published in a JAMA editorial, enumerated the lack of compelling evidence that board certification decreased hospitalizations, decreased costs, or improved metrics of primary care performance (1).

The ABIM and others have responded to these criticisms. Alternative efforts at maintaining board certification have been developed by organizations, such as the National Board of Physicians and Surgeons, which offers a low-cost recertification process for actively licensed physicians who have been ABIM certified, earn 50 hours of continuing medical education credits every 24 months, and maintain specialty privileges in applicable care facilities. Although this approach to certification is enticing, it is not a solution for many nephrologists. Only a small percentage of United States hospitals recognize National Board of Physicians and Surgeons certification, and the Centers for Medicare and Medicaid Services (CMS) still requires ABIM certification for dialysis unit medical directors under the conditions for coverage (2,3).

The discussion over MOC has also spilled into the political realm as well. In the last few years, 17 states have had proposed legislation attempting to decouple board certification status from some combination of hospital privileges, insurance contracting, medical licensing, and/or physician employment (4). Although few states have enacted any legislation, state medical societies, the ABIM, and others are dedicating resources toward lobbying and related efforts. Either way, these legislative efforts do not seem to address the problem of how to best measure physician knowledge and care delivery.

In response, the ABIM has recently introduced an expanded set of options for participating in MOC activities. The most recent changes include flexible testing (shorter, every 2-year open book tests or one longer 10-year test) and more options for earning MOC points (such as coupling MOC to continuing medical education activities or for participating in dialysis unit quality improvement activities). When combined with lower pricing, it seems that some of the most abrasive ABIM policies have been softened.

However, these efforts still feel incomplete. Health care quality carries a wide range of definitions as shown by the variety of metrics to which physicians are subjected. The CMS’s Quality Payment Program (QPP), insurance carrier physician ranking efforts, and even the consumer-oriented rating websites measure cost and quality in different ways. Also, the existence of these programs indicates that the medical profession does not have an accessible system of measuring and reporting quality from our patients’ and payers’ perspectives.

Undoubtedly, most nephrologists are honorable and dedicated professionals. For those on the front lines, it would be ideal to have metrics that capture one’s skill at delivering health care. These should capture knowledge along with customer service, communication, and documentation skills. However, this is easier said than done. The reality is that, even in hospitals and other settings with governance bodies and bylaws, it is challenging to hold clinicians accountable for anything but clinical knowledge and “the standard of care.” In small organizations, such as private practice, measuring and improving performance across any of these domains are an enormous undertaking. How much leeway do we give to a busy, clinically competent physician who does not work as a “team player?” What are the right questions to determine if a physician will complete his or her notes and bills on time? How do you quantify whether a physician is calling back his/her referring physicians or communicating appropriate information? Earning and maintaining board certification do not capture these elements. The fact that there are countless webinars and nonpeer-reviewed articles on these topics speaks to the lack of tools for measuring and improving these problems. However, there is a compelling and urgent need. Documentation audits, external surveyors, and patient experience metrics, with all of their imperfections, are becoming the norm at all venues of care delivery. However, few of these tools are developed or controlled by the physicians being measured.

Evolving technology and payment policy may offer guidance. For instance, with more robust data movement between our electronic records, specialty-specific Quality Clinical Data Registries, health learning systems, patient portals, and population health programs, it is possible to see a path to linking provider-specific care, the illnesses treated, patient-specific outcomes, and patient experience. To be sure, this “data nirvana” is years away and has many hurdles before realization. However, recent changes in the specifications for Certified Electronic Health Record Technology and QPP are beginning to align the right incentives. When combined with the CMS and other payer efforts at publically reporting physician performance, one can see how both financial incentives and peer pressure could work toward a more comprehensive process of showing both processes and outcomes of care. To be clear, quality measures alone cannot be a surrogate for testing of medical knowledge. However, a future in which interval testing is combined with data from the measured outcomes offers a more realistic reflection of knowledge and application of that knowledge.

For the time being, it would seem that we need some system of MOC to capture the adequacy of physician learning. There is no one set of tools that is both unobtrusive and comprehensive. Our current MOC program is not ideal, but neither are the alternative programs and solutions being offered. MOC is the measurement system over which physicians have the most control. Physicians write the questions and can, therefore, shape the content. To that point, we must be actively involved—pushing the ABIM, our medical societies, our electronic health record vendors, and ourselves to determine and use new ways to measure our medical knowledge combined with our skills at customer service, communication, and documentation. These areas are important to health care consumers, to payers, and for the legitimacy of a self-policing health care profession. Undoubtedly, we will be held increasingly accountable for the cost and quality of care. If we do not solve these problems, our government and payers will continue to solve them for us.

• Copyright © 2018 by the American Society of Nephrology