ASH Contends MOC Revision Process Falls Short

David A. Williams, MD

The American Society of Hematology (ASH) said it is deeply unsatisfied with the findings of a task force that convened to review Maintenance of Certification (MOC) standards for the American Board of Internal Medicine (ABIM).

In a letter to the president of ABIM this month, ASH President David A. Williams, MD, said that there is not enough stakeholder involvement in the process to develop a set of certification qualifications that are relevant in today’s healthcare marketplace. He argued that ABIM seems bent on trying to disqualify physicians rather than provide them with achievable, affordable means of keeping up their skills and knowledge in the workplace. Williams further contended that ABIM lacks sufficient transparency in its handling of affairs related to physician certification, particularly with respect to its reliance on certification fees to fund its operations.

“The current problems in MOC emerged from certifying boards that have no accountability to specialty societies or other outside organizations. The insular nature of ABIM governance needs to change, and the board needs to embrace transparency and accountability,” Williams wrote.

ABIM President Richard Baron, MD, said in response that ABIM fumbled in recent years when it upped the requirements for MOC, but that it has since sought to do things right by opening up the process to broad stakeholder input and by backtracking on some of the changes it instituted 2 years ago. He said ASH members have been a part of the proceedings lately and that ABIM leaders also went to ASH’s doorstep in August to hear what they had to say.

“We held an internal medicine summit a week ago, and ASH was there—the president and executive director of ASH. They were actively participating with us and 27 other internal medicine societies in trying to figure out the next steps.”

ASH’s criticisms follow the release in September of the Assessment 2020 Task Force’s report on how best to revamp the MOC. The extra time and money involved in maintaining certification has been a bone of contention for physicians in recent years. Before 1990, physicians passed their qualifying test and were certified for life. After 1990, ABIM made passage of a certifying test good for just 10 years, following which a fresh examination would have to be taken. In 2014, ABIM made it tougher by requiring physicians to rack up module training points at a faster pace. The ensuing protest led ABIM to put certain requirements on hold.

“Doctors felt the quotient of busy work to high value work wasn’t very high, and we agreed with them,” Baron said.

However, Baron contended the process of revising MOC requirements is not finished and has not been closed to outside contribution.

Richard Baron, MD

He said that ABIM is very interested in what stakeholders like the hematology community have to say about how to improve certification standards. Those groups know best what type of knowledge and skill are required for success in their professions, Baron said. “We need to talk to people practicing the discipline to get those answers. I think it’s reasonable for a group of hematologists to say that if you’re going to call yourself [a hematologist] there’s a minimum of core knowledge you need to have.”

The task force report calls for renovating the 10-year MOC exam so that it includes more meaningful assessments. It called for a focus on cognitive and technical skills, as well as an exploration of the need for certification in specialized areas, without the added requirement for underlying certifications.

In its point-by-point letter to Baron this month, ASH, whose membership includes most of the 8400 internists who hold hematology certificates issued by the ABIM, said it was not satisfied with the work of the task force and requested that ABIM reopen the process so that more stakeholder feedback could be incorporated. It called the suggested changes a move toward aggressive assessment of procedural skills, and also “unwarranted, unduly burdensome, and extremely costly.”

“ABIM continues to envision the MOC program as a way to police the quality of internists…However, the hematology community does not accept that the current MOC system has the ability to detect poor performance,” Williams said in his letter.

The letter contained the following requests and criticisms:

• That ABIM “recognize the special contributions to clinical care that physician-scientists provide and develop a more realistic approach for this group of practitioners.”
• The closed-book examination for MOC is not in step with the diversification of career paths in hematologic subspecialties. It creates needless stress, and much time is wasted in “memorizing facts to be forgotten after passing the exam.”
• The cost of MOC for diplomates is a burden and there is a perception that the test is used to “generate net revenues” for ABIM.
• The task force’s recommended changes would constitute an even more “complex and burdensome” process for assessing physicians’ skills and knowledge.

ASH did express some approval for the task force recommendations; namely, that the move “away from a focus on examination to a focus on assessment represents a step in the right direction,” though ASH qualified that statement with the remark that such a move would “blur the line between education and testing.”

The ABIM task force consisted of 19 members from a range of backgrounds, including the university medical establishment, patient advocacy, testing consultancy, and medical practice.

“Several of the people on the task force were expert psychometricians and expert assessors,” said Baron. “The group did very broad interviews with many stakeholders in healthcare—patient care groups, policy people, IT folks, assessment folks. Predicting the future is hard, so the group had a very diverse makeup designed to achieve its goal, which was to come up with recommendations about assessment.” Baron said he feels that many of ASH’s concerns have already been raised in discussions and addressed in the task force findings. “There’s remarkable congruence,” he said.

On the issue of affordability, he said the cost of MOC amounts to about $300 a year over a 10-year program. A study published in the Annals of Internal Medicine in August estimated the relative cost of MOC for hematologists-oncologists at $40,495 for a 10-year recertification program, but that figure is based on the average hourly rate plus benefits physicians would earn were they seeing patients instead of completing MOC training modules and assessments. Baron said that figure is also based on just 1.25 hours of MOC work a month.

Patients would expect their doctors to invest a lot more than 1.25 hours each month in keeping current with their profession, he said. “In any discipline, there’s time you spend staying current that is not reliably time you get compensated for.”

On the issue of transparency, Baron said ABIM’s website offers ample detail about its members' potential conflicts of interest, revenues, sources of revenue, and expenditures. “I think transparency is something we’re fully committed to. I would match our transparency with that of any other healthcare organization.”

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;163(6):401-408.