MOC - A Complicated Mess

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When physicians finish residency after medical school, they have the opportunity to become board certified in their particular specialty. This usually entails a written test and an oral exam. After passing these two tests, they are then considered board certified. Up until 1990, this certificate was not time limited, and there was no recertification process. Concerns arose as to whether physicians remained competent after years in practice. This was voiced by insurance companies and the public in general, and it seemed there should be continual measurements of competency throughout a physician’s career. From this intent for measuring physician competency arose MOC, maintenance of competency. As with so many good ideas, MOC became bigger and bigger, more related to insurance company demands than helping the physician stay competent, with subsequent measures of knowledge and skill.

The ABIM (American Board of Internal Medicine) was instrumental in setting up MOC in the early 1990’s. Prior to this time there were many different boards set up specifically to attest to the qualifications of a specialist physician. The beginnings of these were established in the 1920-30’s. The boards were a different, independent entity attached to a specialty society. The respective Boards of a society did the credentialing. Example: American Society of Anesthesiologists/American Board of Anesthesiology. The boards set the standards and were not beholding to the society or any government agency. Patients and insurance companies wanted assurances that physicians remained competent after being out of a residency for years and would not accept a lifetime certificate as evidence. Thus, the ABIM came up with MOC. Other specialty boards adapted this concept.

Physician complaints about MOC have continued to multiply exponentially in the last ten years. A 2016 Physicians Practice article listed 11 reasons why MOC was not the answer any more to assuring physician competency. Some of these concerns included: 1) it is too expensive 2) questionable monetary practices by the organizing structure of MOC 3) MOC had strayed from the original goals 4) it doesn’t seem to measure competency 5) it wastes a significant amount of time 6) a grandfather clause which let current practitioners continue their life-time certificates was a source of debate. In 2016, I was able to count over 75 journal articles criticizing MOC.

When MOC was established, the intentions were good, and there was a solid base of support. The basic premise was to re-test board certified physicians. The intent was to focus on clinical questions about their practice, hoping to assure continuing competency. This did not turn out to be so simple. The type of patients that an average board certified physician interacts with is quite varied, making an appropriate exam very difficult. The exams then strayed from clinical relevance to being largely irrelevant. At the same time, there seemed to be way too much pressure from insurance companies to continue these re-evaluations. They elevated the exam’s importance, potentially affecting reimbursement and re-credentialing. The MOC of the Boards also changed from a supportive element to paying their leaders exorbitant salaries and charging members exorbitant fees to re-certify. If these negatives were not enough, MOC, in many of the Boards, decided to expand the credential renewal requirements to include specialty specific CME’s and simulator testing. Up until this point, there was a lot of grumbling about MOC, but not an all-out rebellion. MOC was in trouble.

It was just a matter of time before the only place to re-certify had some competition. In January 2015, the National Board of Physicians and Surgeons (NBPAS) was open for business. This alternative to MOC, which had been set up by the Boards, was ready to take applications with a simplified process. NBPAS stood for simplicity, relevance, and cost effectiveness. It was set up by a Dr. Paul Teirstein and has a panel of very distinguished physicians. Many members of the NBPAS board are department chairmen of leading medical institutions.

The criteria for re-certification in the NBPAS is straight-forward and simple: 1) prior certification by a specialty Board 2) license to practice in at least 1 state 3) 50 CME’s in last 2 years 4) procedural specialties must have active privileges to practice that specialty in a US hospital. 5) clinical privileges in your specialty have not been permanently revoked. In addition to the criteria listed, the fees are significantly less and currently physician management and board members are unpaid.

NBPAS provides a well thought out alternative to a system that has broken down, is irrelevant and has become non-supportive to its physicians. The NBPAS only has to do with re-certification, not with initial certification after training. With the fees being less and more of a back-to-the-basics approach by the NBPAS, thousands of physicians have taken this path to re-certification. MOC is making some adjustments, but there are several pending lawsuits against it, mostly stating it is an out of touch monopoly. This is accompanied by thousands of disgruntled physicians. From my point of view, the changes in MOC may be like emergently stopping a train -- too little, too late.