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Maintenance of Certification or Maintenance of Cash: A call to check the checkers

Maintenance of Certification, known as MOC, has riled up the entire physician community. More than 15,000 physicians have already signed a petition against it.

Many fear that MOC, with all of its demands and requirements, will put them on a perpetual treadmill that will consume exorbitant amounts of time and money. Many who have gone through MOC realized little value from it and do not plan to do it again.

Missing evidence

In a time of “evidence-based medicine,” where is the evidence to support putting physicians through such an onerous process? Where is the evidence that recertification even matters?

Ironically, the strongest advocate of evidence-based medicine, the American Board of Medical Specialties (ABMS), has none for this MOC scheme that it has forced on physicians. But it does have a disclaimer stating that board certification does not guarantee “performance or positive outcomes.” Conversely, there is no evidence indicating that physicians who are not board certified provide worse care than those who are certified.

Richard O. Dolinar, MD

Richard O. Dolinar

So whom does MOC help? The physician? The patient? Or someone else?

And doesn’t continuing medical education accomplish the goal of keeping physicians current in their medical knowledge? The annual meetings of the American Association of Clinical Endocrinologists have physicians attending not only from all over the United States but also from all over the world. Each year, attendance records are broken. Physicians are so eager to participate in the learning that even the 6 a.m. sessions are packed. Is the competency of physicians so poor that they need to be saddled with another layer of regulatory requirements involving MOC?

Data from Ohio argue otherwise. Lack of competency is an extremely rare problem in licensing actions there. In 2011, it was the cause of action for only one of the 42,000 practicing physicians in the state.

Opposing viewpoints

Meanwhile, what is being done about MOC? Some have decided not to do it and just vote with their feet. Others have become active on websites opposing MOC. The most active website is that of the Association of American Physicians and Surgeons (AAPS), www.AAPSonline.org. Also, www.ChangeBoardRecertification.com and www.Rebel.md have been very active.

The American Medical Association House of Delegates wants an impact study of MOC on patient outcomes and voted to oppose MOC as a condition of licensure. Medical societies have initiated dialogues with ABMS and the American Board of Internal Medicine (ABIM). Surveys show that most physicians oppose MOC. But with millions of dollars involved, the leaders of some of these societies may be tempted to find enough common ground with the Boards to get in bed with them and share in some of the revenue generated, despite the objections of their members. Of course, the Boards may not be willing to share.

On the legislative side, the American Legislative Exchange Council has proposed model state legislation that, if passed by the individual states, would prohibit MOC as a condition of medical licensure. It would also prohibit state medical boards and any facilities accepting state funding (such as hospitals) from discriminating against physicians who do not participate in MOC. CME would suffice to demonstrate professional competency.

Legal action underway

It is in the courts where the real action is. On April 23, 2013, AAPS filed a lawsuit claiming ABMS is in violation of Section 1 of the Sherman Antitrust Act and is misrepresenting its proprietary recertification program and thereby reducing patient access to physicians.

AAPS alleges that MOC is “a money making … scheme that reduces the supply of hospital physicians and decreases the time physicians have available for patients.” The lawsuit goes on to accuse ABMS of enriching itself, its executives and coconspirators by “promoting falsehoods that its proprietary product is somehow indicative of the professional skills of a physician, when it is not.”

AAPS alleges that ABMS “acted in concert with The Joint Commission … to require formal recertification as a condition of having medical staff privileges” in hospitals. The physician involved in the lawsuit was board-certified in family medicine and had been on the hospital staff in good standing for 29 years. His practice consisted mostly of indigent patients. He lost his hospital privileges because he chose to serve his many charity patients, who needed him, instead of spending time going through the laborious process of MOC.

Furthermore, the lawsuit alleges that ABMS acted with other groups to induce insurance companies to utilize MOC and attempted to influence states to have MOC as a requirement for Maintenance of Licensure (MOL). ABMS planned to encourage patients to look up their doctor on its website. Physicians who declined its MOC product would be listed as “Not Meeting MOC Requirements.” AAPS said this would create the false impression that the physician was therefore less competent. In the marketplace, the most important thing a physician has is his reputation.

The lawsuit alleges that ABMS acted “to maximize its revenues by compelling physicians, more than 90% of whom oppose MOC, to purchase and spend time on MOC.” Thus, a physician could now not only lose his patients and hospital privileges, but also be excluded from insurance plans, and even lose his license because he was not participating in MOC. Quite an outcome for a program characterized as “voluntary.”

Cost of participation

AAPS estimates that participation in MOC requires more than 100 hours and can cost thousands of dollars in fees and travel expenses. It then goes on to explain that such “burdens lack value, as illustrated by how ABMS itself appointed as its new President/CEO in 2012 someone who was ‘Not Meeting MOC Requirements’, but received an exemption not available to many others.”

How many other professions have to retake their board or bar exams? Lawyers don’t. Nor do accountants, architects, nurses or pharmacists.

Could it be that the primary purpose of MOC is really Maintenance of Cash? According to AAPS, the point of MOC is to enrich the executives at ABMS. AAPS reports that the publicly available IRS Form 990 shows ABMS executive compensation is often well more than $700,000 a year. This is a paltry sum when compared with salaries of professional athletes, but it’s a princely sum when compared with those of the physicians by the bedside actually caring for the patients.

As Lord Acton said, “Power tends to corrupt, and absolute power corrupts absolutely.”

So, who is checking the checkers? AAPS is.

AAPS v ABMS, No. 3:13-cv-2609-PGS-LHG (D. New Jersey, 2013).
Christman KD. Journal of American Physicians and Surgeons. 2012;17:76-79.
Richard O. Dolinar, MD, is a senior fellow with The Heartland Institute and a clinical endocrinologist specializing in diabetes in Phoenix. He can be reached at rdolinar@heartland.org. Dolinar reports no relevant financial disclosures.
Editor’s Note: The views expressed here are the views of the columnist and not endorsed by Endocrine Today.

Maintenance of Certification, known as MOC, has riled up the entire physician community. More than 15,000 physicians have already signed a petition against it.

Many fear that MOC, with all of its demands and requirements, will put them on a perpetual treadmill that will consume exorbitant amounts of time and money. Many who have gone through MOC realized little value from it and do not plan to do it again.

Missing evidence

In a time of “evidence-based medicine,” where is the evidence to support putting physicians through such an onerous process? Where is the evidence that recertification even matters?

Ironically, the strongest advocate of evidence-based medicine, the American Board of Medical Specialties (ABMS), has none for this MOC scheme that it has forced on physicians. But it does have a disclaimer stating that board certification does not guarantee “performance or positive outcomes.” Conversely, there is no evidence indicating that physicians who are not board certified provide worse care than those who are certified.

Richard O. Dolinar, MD

Richard O. Dolinar

So whom does MOC help? The physician? The patient? Or someone else?

And doesn’t continuing medical education accomplish the goal of keeping physicians current in their medical knowledge? The annual meetings of the American Association of Clinical Endocrinologists have physicians attending not only from all over the United States but also from all over the world. Each year, attendance records are broken. Physicians are so eager to participate in the learning that even the 6 a.m. sessions are packed. Is the competency of physicians so poor that they need to be saddled with another layer of regulatory requirements involving MOC?

Data from Ohio argue otherwise. Lack of competency is an extremely rare problem in licensing actions there. In 2011, it was the cause of action for only one of the 42,000 practicing physicians in the state.

Opposing viewpoints

Meanwhile, what is being done about MOC? Some have decided not to do it and just vote with their feet. Others have become active on websites opposing MOC. The most active website is that of the Association of American Physicians and Surgeons (AAPS), www.AAPSonline.org. Also, www.ChangeBoardRecertification.com and www.Rebel.md have been very active.

The American Medical Association House of Delegates wants an impact study of MOC on patient outcomes and voted to oppose MOC as a condition of licensure. Medical societies have initiated dialogues with ABMS and the American Board of Internal Medicine (ABIM). Surveys show that most physicians oppose MOC. But with millions of dollars involved, the leaders of some of these societies may be tempted to find enough common ground with the Boards to get in bed with them and share in some of the revenue generated, despite the objections of their members. Of course, the Boards may not be willing to share.

On the legislative side, the American Legislative Exchange Council has proposed model state legislation that, if passed by the individual states, would prohibit MOC as a condition of medical licensure. It would also prohibit state medical boards and any facilities accepting state funding (such as hospitals) from discriminating against physicians who do not participate in MOC. CME would suffice to demonstrate professional competency.

Legal action underway

It is in the courts where the real action is. On April 23, 2013, AAPS filed a lawsuit claiming ABMS is in violation of Section 1 of the Sherman Antitrust Act and is misrepresenting its proprietary recertification program and thereby reducing patient access to physicians.

AAPS alleges that MOC is “a money making … scheme that reduces the supply of hospital physicians and decreases the time physicians have available for patients.” The lawsuit goes on to accuse ABMS of enriching itself, its executives and coconspirators by “promoting falsehoods that its proprietary product is somehow indicative of the professional skills of a physician, when it is not.”

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AAPS alleges that ABMS “acted in concert with The Joint Commission … to require formal recertification as a condition of having medical staff privileges” in hospitals. The physician involved in the lawsuit was board-certified in family medicine and had been on the hospital staff in good standing for 29 years. His practice consisted mostly of indigent patients. He lost his hospital privileges because he chose to serve his many charity patients, who needed him, instead of spending time going through the laborious process of MOC.

Furthermore, the lawsuit alleges that ABMS acted with other groups to induce insurance companies to utilize MOC and attempted to influence states to have MOC as a requirement for Maintenance of Licensure (MOL). ABMS planned to encourage patients to look up their doctor on its website. Physicians who declined its MOC product would be listed as “Not Meeting MOC Requirements.” AAPS said this would create the false impression that the physician was therefore less competent. In the marketplace, the most important thing a physician has is his reputation.

The lawsuit alleges that ABMS acted “to maximize its revenues by compelling physicians, more than 90% of whom oppose MOC, to purchase and spend time on MOC.” Thus, a physician could now not only lose his patients and hospital privileges, but also be excluded from insurance plans, and even lose his license because he was not participating in MOC. Quite an outcome for a program characterized as “voluntary.”

Cost of participation

AAPS estimates that participation in MOC requires more than 100 hours and can cost thousands of dollars in fees and travel expenses. It then goes on to explain that such “burdens lack value, as illustrated by how ABMS itself appointed as its new President/CEO in 2012 someone who was ‘Not Meeting MOC Requirements’, but received an exemption not available to many others.”

How many other professions have to retake their board or bar exams? Lawyers don’t. Nor do accountants, architects, nurses or pharmacists.

Could it be that the primary purpose of MOC is really Maintenance of Cash? According to AAPS, the point of MOC is to enrich the executives at ABMS. AAPS reports that the publicly available IRS Form 990 shows ABMS executive compensation is often well more than $700,000 a year. This is a paltry sum when compared with salaries of professional athletes, but it’s a princely sum when compared with those of the physicians by the bedside actually caring for the patients.

As Lord Acton said, “Power tends to corrupt, and absolute power corrupts absolutely.”

So, who is checking the checkers? AAPS is.

AAPS v ABMS, No. 3:13-cv-2609-PGS-LHG (D. New Jersey, 2013).
Christman KD. Journal of American Physicians and Surgeons. 2012;17:76-79.
Richard O. Dolinar, MD, is a senior fellow with The Heartland Institute and a clinical endocrinologist specializing in diabetes in Phoenix. He can be reached at rdolinar@heartland.org. Dolinar reports no relevant financial disclosures.
Editor’s Note: The views expressed here are the views of the columnist and not endorsed by Endocrine Today.