Who controls certification?
Author: Robert E. Johnstone, MD
Four decades ago, board certification was a mark of excellence, a goal for achievers and not a practice requirement. Certification designated an anesthesiologist with consultant-level knowledge and extraordinary capabilities. But times have changed. Many institutions and groups now require certification for clinician credentialing. No certification increasingly means practicing at small hospitals in temporary positions.
In 2000, the American Board of Anesthesiology (ABA) changed its process, making new certificates temporary, good for 10 years only, and developed requirements and fees to renew them. Other organizations, primarily the American Society of Anesthesiologists, developed products and programs that anesthesiologists could buy to meet these requirements. The laudable goals included lifelong professional development for clinicians, and enhanced status and outcomes for the specialty. Now some anesthesiologists are complaining that this maintenance of board certification (MOC) lacks relevance, is ineffective and costs too much. They are pushing back.
Anesthesiologist opposition to MOC has grown at a grassroots level, in sync with opposition by other specialists to their own MOC programs. Many clinicians seem unaware of this push-back, including society leaders, but that is likely to change. MOC Anesthesiology (MOCA) opponents are organizing through common-cause websites, informational articles and meetings. They are petitioning leaders, filing lawsuits and driving debate on the merits and costs of MOCA.
In a recent survey of published studies, Buscemi et al found little support for the assumption that certified or recertified internists have better patient outcomes.1 Paul Kempen, MD, PhD, an anesthesiologist, editorialized, “The MOC premise that physicians become outdated with extended time … is a fallacy. Experience is the significant factor at multiple levels of medical decision.” He asked, “Why comply with MOC?” and essentially answered, “Only because you currently must.”
Most anesthesiologists have ignored such protestations as uninformed rants from disgruntled clinicians. But MOC opposition is gaining followers. In a New England Journal of Medicine poll, 63% of 2,512 physicians recommended that those already board-certified not enroll in MOC.3 In the battleground state of Ohio where the Board of Medicine proposed a maintenance of licensure program to reinforce MOC, the Ohio State Society of Anesthesiologists, along with 10 other societies, signed a letter opposing any effort “to implement different maintenance of licensure requirements than those currently in place,” primarily 100 hours of continuing medical education every two years.
The Wall Street Journal reported in July that “many doctors are deriding the MOC requirements as costly, irrelevant and time-consuming, and largely a moneymaking venture for the specialty boards.” In September, Anesthesiology News published an article on derisive opposition to MOC. In the October ASA Newsletter, Jeff Andrews, MD, ABA secretary, wrote, “We understand that the cost of MOCA participation goes beyond the ABA MOCA fee and are exploring ways to increase the value of these costs. … The ABA is actively engaging in a variety of MOCA redesign activities.”
You can find the arguments of MOCA opponents on the websites of the Association of American Physicians and Surgeons (AAPS), the Change Board Recertification organization, and Docs 4 Patient Care. The AAPS has filed suit in federal court against the American Board of Medical Specialties (ABMS) “to end antitrust violations and misrepresentations by ABMS concerning its proprietary recertification program, which reduces access by patients to physicians.” The suit alleges that “ABMS enriches itself, its executives, and its co-conspirators by promoting falsehoods that its proprietary product is somehow indicative of the professional skills of a physician, when it is not.”
I have recertified three times during my career and supported MOCA for younger anesthesiologists, but am sympathetic to their complaints. It is expensive. The current fee for the recertification cognitive exam is $2,100. The simulation center nearest me charges $1,800 for its one-day MOCA-required course. The American Society of Anesthesiologists (ASA) online educational programs, which advertise that they help “meet MOCA Part 2 requirements,” cost $360 per year for members and $830 for non-members. Multiplied by thousands of purchasers, MOCA generates considerable revenues for both the ABA and ASA. With more than 750,000 U.S. physicians holding one or more certificates from ABMS member boards, the broader market involves billions of dollars.
So why do we have MOCA, and why do so many support it? The answers lie in public demand for physician competence and high-quality care, as well as recognition by anesthesiologists that best practices are changing, and MOCA is a good way to demonstrate keeping up. For the ABA and ASA, the answers also may lie in funds they need to keep their current programs going.
The ABMS describes MOC as a professional response to the need for public accountability and transparency. MOC allows physicians to demonstrate their quality of care compared with peers and national benchmarks. According to a 2010 ABMS survey, 95% of the public rates participation by their physicians in MOC as important. Consumer’s Checkbook, a nonprofit physician rating service, recommends that patients only select physicians who are board-certified, and advises that “participation in an ongoing MOC program is evidence that a physician is taking extra steps beyond getting initial certification to continue to keep up-to-date and improve.”
MOC is the culmination of years of professional self-regulation, meaning some physicians view it as theirs to continue changing. Patients and the public, however, are replacing physicians as the primary drivers of physician certification, and they want safety, efficiency and quality, not “buyer beware” health care. Through their control of Medicare and Medicaid, they have already implemented value-based purchasing, the physician quality reporting system, the Physician Payments Sunshine Act, and other quality and transparency initiatives, often over physician protestations. If MOC devolves into a compiler of self-selected educational credits, public takeover of board certification and MOC could follow.
Still, many physicians are pushing back against MOC. Delegates at the November meeting of the American Medical Association adopted principles emphasizing the need for an evidence basis to MOC and regular evaluations to ensure its relevance to clinical practice. Other principles adopted include prohibiting MOC for licensure, credentialing, payment or network participation, as well as ensuring it not be cost-prohibitive or present barriers to patient care.
So how will the contest between physician autonomy and public control end, specifically between anesthesiologist opposition and ABA support for MOCA?
· My first bet is on the public, that MOCA will increasingly become a way to assure anesthesiologist competence, because the need is great, demand powerful and changing times obvious.
· My second bet is that ABA and ASA leaders will accommodate MOCA enrollees and potential enrollees, finding ways to increase program relevance and reduce its costs. An understood military principle states that leaders too far in front of their troops when fighting breaks out get shot in the back.
· My third bet is that this will not be easy.