Category Archives: News

Update on the Final ABMS Vision Commission Report Regarding Recommended Changes to MOC

Dear Colleagues,

The National Board of Physicians and Surgeons (NBPAS), as advocates for reasonable and appropriate certification of physicians, would like to update you on new developments relevant to Maintenance of Certification (MOC) process.  Last week the final Vision Commission Report on MOC was released.  To view:  https://visioninitiative.org/wp-content/uploads/2019/02/Commission_Final_Report_20190212.pdf

As you know, NBPAS created a shared public comment to the draft report that recommended strengthening the Commission’s recommendations to include, among other things, a moratorium on harmful MOC exams. Over 21,000 physicians signed the “petition-like” comment. To view the shared comment, click here: https://nbpas.org/respond-to-vision-commission-onerous-moc-components/

We believe our efforts had impact. 

Of note, the Commission’s report recommends all ABMS boards move to assessments that are “formative” (“assessment of a physician with the primary purpose of providing feedback for learning and improvement…without passing judgement”), not “summative” (“assessment of learning with the primary purpose of establishing whether performance at a single defined point in time meets established performance standards, permanently recorded in the form of a score”). 

As examples, the Commission report is supportive of the anesthesia board’s (ABA) MOCA Minute and the OB/GYN (ABOG) article-based assessments (both are formative) that have received encouraging feedback from diplomates, and is highly critical of the ABIM’s new Knowledge Check-in tests (which is summative).

While the final report does not recommend a moratorium on “summative” exams, the report’s recommendations are significantly strengthened to now include a timeline.

Page 9-10 : Short-Term and Intermediate Recommendations. Final paragraph: “Unlike initial certification, assessments for continuing certification should be formative…The Commission recommends that by the end of 2019 all ABMS Boards that have not moved to these types of assessments…submit a transition plan with milestones and timelines.”

We also bring to your attention a very strong Vision Commission recommendation about the use of board certification status that could significantly mitigate physician harm from MOC:

Page 16: “ABMS must encourage hospitals, health systems, payers and other health care organizations to not deny credentialing or privileging to a physician solely on the basis of certification.”

While not fully embracing our “petition,” we believe the Vision Commission report represents a significant step in the right direction. The over 21,000 physicians who signed the “petition” are to be congratulated. Those of you who signed positively influenced the final report. 

We still have a long way to go, but at a minimum, NBPAS strongly urges all ABMS boards to immediately adopt the Vision Commission’s recommendations, especially the recommendation against the use of board certification status, or the lack thereof, to deny credentialing and privileging.  One class action lawsuit has already been filed (against the ABIM) and there are indications of several more to come. NBPAS will be looking for significant announcements of change on the part of ABMS boards while carefully watching this litigation.

To learn more about obtaining Board Certification from the National Board of Physicians and Surgeons (NBPAS), visit our website NBPAS.org.  

Sincerely,
Paul Teirstein, MD on behalf of the NBPAS Board
NBPAS, President
Chief of Cardiology, Scripps Clinic

Urgent – Help NBPAS Respond to the Vision Commission by Requesting a Moratorium on Onerous MOC Components

Dear Colleagues,

Last year, in response to a continued groundswell of MOC criticism, the ABMS formed an independent “Vision Commission” on MOC. On December 11th, 2018, after listening to 21 hours of testimony, the Vision Commission released its Draft Report. Although the draft accurately describes many MOC deficiencies, it contains little, if any specific, immediately actionable, recommendations for change. The Commission report clearly describes physician harm due to MOC. As physicians, we learn “first, do no harm.” Therefore, we believe it is essential the Commission recommend an immediate moratorium on several harmful components of MOC. 

To review the commission’s draft report, CLICK HERE.

The Vision Commission requests public comment to the draft by January 15th, 2019. To provide your personal comments directly to the commission’s website, CLICK HERE.

To facilitate responses to the draft report, the National Board of Physicians and Surgeons (NBPAS) has created a prepared, online, petition-like comment you can quickly sign which we will submit to the commission. If you agree with the NBPAS comments, it will take you under 2 minutes to click and digitally sign the document.

To review and sign the prepared comment, CLICK BELOW. All you will be asked for is your name and state. While optional, we encourage you to note if you are a physician, and provide your email.

After submitting you will see the current tally

A COPY (PREVIEW) OF THE PREPARED “PETITION-LIKE” COMMENT IS BELOW:

To ABMS Vision Commission:
Although the report accurately describes many MOC deficiencies, it contains little, if any specific, immediately actionable, recommendations for change. As physicians, we learn “first, do no harm.” The Commission’s draft report clearly documents significant physician harm resulting from current MOC requirements1,2. Therefore, until generally acceptable and/or truly evidence-based practices are developed, the Commission must recommend an immediate moratorium on the most questionable components of MOC.

Specific recommendations should include:
1. An immediate end to requiring secure, high stakes examination components of MOC. As described in the Commission report, exam questions are difficult to tailor to the individualized content of established physician practices3, and do not reflect real world physician access to colleagues/internet4 (i.e. systems-based practice). Additionally, robust evidence does not exist that correlates physician grades on secure MOC exams, with patient outcomes.5-7
2. An immediate end to requiring Quality Initiative (QI)/Practice Improvement (PI) components of MOC. As described in the Commission report, many current QI/PI requirements are onerous (overly burdensome), and often duplicate other physician mandates.8-10Additionally, robust evidence does not exist that correlates current QI/PI requirements of MOC, with improved patient outcomes.5
3. Retention of the CME and Professionalism (licensure etc.) components of MOC only.
4. A reduction in fees charged for MOC, preferably, to under $100/year, irrespective of the number of certifications maintained. As described in the Commission report, fees charged for MOC should be the minimum necessary.11 ABMS member boards should adjust their expenses accordingly.12 While not within its mandate, the Commission should consider recommending member boards also vastly reduce fees charged for initial certification (currently $2,950 for several boards). Charging high fees to young physicians, just entering practice, contradicts our standards of professionalism. Further, as alluded to in the report, to maintain board credibility, independent financial oversight is required to ensure expenses, including employee compensation/travel, are reasonable.13

To view references, see below.

If not already, please consider obtaining continuing board certification by the National Board of Physicians and Surgeons at NBPAS.org

PLEASE PASS THIS EMAIL ON TO YOUR COLLEAGUES, MEDICAL STAFF AND NON-PHYSICIAN STAKEHOLDERS.

Thank you,
Paul Teirstein, MD
NBPAS, President
Chief of Cardiology, Scripps Clinic

References from the Vision Commission draft report:

1. Commission report, page 25, para 5: “The Commission heard compelling testimony from all stakeholders that loss of certification can lead to loss of employment or certain employment opportunities for diplomates or loss or reimbursement from insurance carriers.”
2. Commission report, page 25, para 5: “It is not the intent of the ABMS Boards for continuing certification to be used as the only criterion for credentialing and privileging decisions. ABMS does not support he credential being used as the sole criterion to deny a diplomate an employment opportunity or loss of insurance reimbursement.”
3. Commission report, page 14, para 9: “Diplomates cited that the content of the examination was not relevant, was not a reflection of the application of knowledge in the clinical environment and was not current with advances in medicine.”
4. Commission report, page 15, para 1: “Diplomates routinely access medical knowledge on their computers and smartphones while providing patient care. Assessments that rely exclusively on knowledge recall are not aligned with how diplomates practice.”
5. Commission report, page 28, para 3: “There are gaps in the research evidence that conclusively demonstrate that diplomate participation in continuing certification leads to better patient outcomes.”
6. Commission report, page 15, para 3: “It is recommended that the ABMS boards no longer use a single point-in-time examination (or single point-in time assessments) as the only measure to determine the continuing certification status of a diplomate. In addition, the Commission recommends ABMS Boards move to truly formative assessment approaches that are not high-stakes nor highly-secured formats.”
7. Commission report, page 15, para 3: “Diplomates did not consider more frequent, shorter assessments done in a highly-secured or remote proctoring environment (e.g. ABIM’s Knowledge Check-in) to be formative, but rather just more frequent high-stakes assessments in a different form.”
8. Commission report, page 17, para 3: It is acknowledged that measuring practice improvement can be challenging.”
9.Commission report, page 19, 3rd para: “The Commission appreciated the practical and significant difficulty placed on diplomates for meeting practice improvement requirements.”
10. Commission report, page 19, 3rd para: “…diplomates did not find value in check box activities or activates not relevant to practice. Diplomates complained that requiring multiple PDSA (Plan-Do-Study-Act) cycles in a quality improvement activity or requiring improvement in an activity in order for the activity to count in the certification program was onerous and artificial.”
11. Commission report, page 28, para 2:“Fees charged to diplomates should be the minimum necessary to finance Board operations and to have sufficient reserves to invest in programmatic initiatives that advance the quality and applicability of certification programs.”
12. Commission report, page 30, para 4: “Some diplomates who testified expressed how they did not trust their Boards to appropriately manage resources. Specific issues include how some Boards have used diplomate fees in the past as well as how these Boards have transferred funds to associated foundations. They also questioned the judgement of the Boards leadership compensation, locations of board meetings, and other expenses not viewed as justifiable for certification programs.”
13. Commission report, page 29, para 2: “Boards’ finances were perceived as very opaque. Transparency about the efficiency of operations, the appropriateness of fees, and the stewardship of funds was essential to increasing diplomates trust.

ABMS Response to DOJ Opinion Letter Supporting Competition in Physician Certification

Dear Colleague,

As the physician community knows well, the American Board of Medical Specialties (ABMS) program on Maintenance of Certification (MOC) is onerous. It imposes unjustifiable financial costs on physicians, distracts from treating patients, and is not tied to better patient outcomes (see https://nbpas.org/moc-journal-club/). On September 10th, the U.S. Department of Justice (DOJ) in an opinion letter regarding a Maryland bill to promote competition in certification (see link below), explained that MOC may also harm competition, “increasing the cost of healthcare services to customers” and in particular by “imposing overly burdensome conditions on physicians who wish to maintain their certification.” The government expressed concerns about dominant entities like ABMS that are comprised of “active market participants” because they may have incentives to stifle competition.

On September 18th, ABMS responded on their website (see link below). The ABMS response said nothing about the Justice Department’s concerns that MOC may harm competition. It made no reference to the government’s suggestion that ABMS implement internal procedures to ensure its decisions reflect the public interest. As the Justice Department recognized, competitors like the National Board of Physicians and Surgeons (NBPAS) can provide physicians with much-needed alternatives to MOC and encourage certification agencies to offer the best possible programs. ABMS’s statement that it “supports and encourages a competitive marketplace for specialty certification” is little more than lip service. In its next breath, ABMS rejects a meaningful role for other certifying entities, suggesting its competitors lack rigor and will confuse patients. ABMS asserts that, “when compared to any other specialty certification programs, ABMS Boards can clearly demonstrate the superiority of their certification programs in giving useful information to hospitals, payers, and patients” and yet ABMS is unwilling to take steps internally or support legislation that will facilitate that very comparison. ABMS can only point to illusory fears of harm to patients, while ignoring the very real harm to patients and physicians that an uncontested MOC has wrought and continues to wreak upon the medical community.

Contrary to ABMS suggestions, NBPAS offers a rigorous certifying credential. In some ways, its certification is more demanding than that of the ABMS. For example, NBPAS requires good standing with respect to hospital admission privileges, which is absent from most ABMS member board requirements. Indeed, initial ABMS board certification is a requisite of the NBPAS credential. The difference is NBPAS uses continuous certification criteria that reflect what doctors need to practice at the highest level. The truth is that ABMS does not want competition in MOC. ABMS has used the MOC program to generate windfall revenues, harming doctors and patients alike.

NBPAS will continue to promote competition and, in so doing, a more effective and diverse menu of physician continuing certification options. As more hospitals and payers recognize the value of the NBPAS continuous certification over the MOC credential, such competition will require all certifying bodies to offer the best and most effective programs that reflect the needs of the medical community. This is the virtue of competition. The Maryland legislation being considered is one small but significant step in promoting a better educated and less burdensome certification standard. NBPAS thanks the DOJ for recognizing the need for reform.

DOJ opinion letter: https://www.justice.gov/atr/page/file/1092791/download

ABMS response to DOJ opinion letter: https://www.abms.org/news-events/abms-statement-on-us-doj-response-to-proposed-maryland-legislation/?cat=position-statements

To join NBPAS, go to NBPAS.org

Sincerely,
NBPAS Board Members

Paul Teirstein, M.D., President NBPAS, Chief of Cardiology, Scripps Clinic
John Anderson, M.D., Past President, Medicine and Science, American Diabetes Association, Frist Clinic, Nashville, TN
David F. Dies, M.D., MBA, Medical Director of Liver Transplantation, John C. McDonald Regional Transplant Center
David John Driscoll, M.D., Professor of Pediatrics, Mayo Clinic College of Medicine
Daniel Einhorn, M.D., Immediate-Past President, American College of Endocrinology; Past President, American Association of Clinical Endocrinologists
Bernard Gersh, M.D., Professor of Medicine, Mayo Clinic College of Medicine
C. Michael Gibson, M.D., Professor of Medicine, Harvard Medical School
Michael R. Jaff, D.O., Massachusetts General Hospital, Professor of Medicine, Harvard Medical School
Paul G. Mathew, M.D., FAAN, FAHS, Assistant Professor of Neurology, Harvard Medical School
Jordan Metcalf, M.D., Professor and Research Director, Pulmonary. & Crit. Care, Oklahoma University Health Sciences Center
Jeffrey W Moses M.D., Professor of Medicine at Columbia University Medical Center, NY, NY
Jeffrey Popma, M.D., Professor of Medicine, Harvard Medical School
Harry E. Sarles Jr., M.D., FACG, Immediate Past President for the American College of Gastroenterology
Hal Scherz, M.D., Chief of Urology- Scottish Rite Children’s Hospital, Assoc Clinical Professor of Urology Emory University
Karen S. Sibert, M.D., Associate Clinical Professor: UCLA Health; President-Elect: California Society of Anesthesiologists
Gregg W. Stone, M.D., Professor of Medicine, Columbia University College of Physicians and Surgeons
Eric Topol, M.D., Chief Academic Officer, Scripps Health; Director & Founder, Scripps Translational Science Institute, Executive VP, Scripps Research
Bonnie Weiner, M.D., Professor of Medicine, University of Massachusetts Medical School
Mathew Williams, M.D., Chief, Division of Adult Cardiac Surgery, New York University Medical Center

Landmark Opinion from the Justice Department about MOC

Dear Colleagues,

This week, the U.S. Department of Justice Antitrust Division issued a landmark opinion about MOC, vindicating NBPAS’s long-held position that alternative organizations are needed to promote competition in physician certification. In an opinion letter, the DOJ validated the NPBAS four year struggle to make continuous physician certification more meaningful and less burdensome. This public position by the DOJ should be emphasized by physicians and other stakeholders as they ask hospital boards and insurance companies to accept alternative certification organizations when setting criteria for hospital privileges and payer contracts.

The DOJ opinion letter came in response to a pending Maryland bill promoting competition in physician certification that was introduced by NBPAS board member and Maryland legislator Dr. Dan Morhaim. The DOJ explained that the ABMS Program on MOC may have the effect of “harming competition and increasing the cost of healthcare services to customers.” ABMS may do so “by imposing overly burdensome conditions on physicians who wish to maintain their certification.” The DOJ added, with respect to ABMS, “[the] vast majority of [its] board members are medical doctors”—i.e., “active market participants”—who may have incentives to limit competition through “industry self-regulation.” As a result, the DOJ warned, “there would be competition concerns, if dominant certifying bodies [like ABMS] set de facto participation requirements that did not sufficiently correspond to health, safety, or other procompetitive justifications.”

As physicians familiar with MOC know, current ABMS MOC programs have not been shown to correlate with quality of practice or patient outcomes, and yet the burden they impose on doctors is severe. NBPAS provides a more meaningful form of continuous certification. The DOJ urges such competition. It encourages legislatures to promote competition by recognizing “additional, legitimate certifying bodies” such as NBPAS, whose recognition the DOJ believes “could allow for a competitive alternative to ABMS in certifying medical specialists.” Such competition may provide a host of benefits, including physicians’ passing on “extra time and lower costs in the form of savings or extra care for consumers”, physicians’ “seek[ing] additional subspecialty certification or [staying] in practice longer”, and “further encourage[ing] the incumbent certifying body to continue refining their processes to be competitive.”

The DOJ was strongly supportive of competition in MOC stating “If other new bodies, unaffiliated with ABMS or NBPAS, can offer a more (or similarly) efficient and accurate way to certify medical specialists, the interests of competition may be better served if they have an opportunity to compete on the merits of their approach with physicians, hospitals, payers, and consumers, without needing new, ad hoc legislation to support their entry.”

NBPAS applauds the DOJ for addressing the important issues surrounding MOC. The DOJ’s legislative comment is a watershed moment. It lends powerful support for the positions NBPAS continues to press with all stakeholders in the industry.

For the full text of the letter, see the link below from the DOJ

From: Haar, Daniel
Sent: Monday, September 10, 2018 4:57:27 PM
To: Morhaim, Dan Delegate
Subject: RE: Response regarding MD 857

Delegate Morhaim,

To follow up, I wanted to let you know that our letter responding to your inquiry is also now available publicly at the following link:

https://www.justice.gov/atr/page/file/1092791/download

All the best,
Daniel

WASHINGTON STATE MEDICAL ASSOCIATION OFFICIAL ACTIONS OF THE 2015 HOUSE OF DELEGATES: Recognize Alternatives to the ABMS MOC and Recertification Process (ADOPTED AS AMENDED)

C-2 – Recognize Alternatives to the ABMS MOC and Recertification Process (ADOPTED
AS AMENDED)
RESOLVED, that the WSMA will support alternative pathways for board recertification
(i.e. NBPAS) and maintenance of certification; and BE IT FURTHER
RESOLVED, that the WSMA will propose this resolution to the AMA for consideration
at its next meeting. (Directive to Take Action)

To view link with all official actions from the 2015 annual meeting, click here:

https://wsma.org/doc_library/AboutWSMA/TheOrganization/HouseOfDelegates/HOD_2015_official_actions_final.pdf

NBPAS Update

The National Board of Physicians and Surgeons (NBPAS.org) continues to grow with well over 3,100 applicants. At this phase of the project it is essential for hospitals to start accepting NBPAS certification as a valid alternative to ABMS certification. This process usually starts with the hospital’s Medical Executive Committee (MEC) and/or Credentials Committee. Ultimately it requires a change to the hospital bylaws. These committees generally meet once per month so it takes at least several months before the bylaws are changed. We need your help. Please contact your Chief of Staff and request your hospital’s bylaws be changed to accept NBPAS. A sample letter you can personalize and email your Chief of Staff can be found here. It might be helpful to have dozens of your colleagues sign the letter, ie turn it into a petition.

If you are aware of hospitals accepting NBPAS certification not on the list below, please let us know at info@NBPAS.org
Helpful tips to hospital committee approval of NBPAS as an alternative:
1) Many hospital MECs approve of the concept but do not want to be the first. Please let your MEC know they will not be the first, and the list below is growing.
2) Make sure the various hospital committees understand that a requirement of NBPAS certification is previous certification by an ABMS member board. Accepting NBPAS only changes your hospital’s requirements for continuous certification, not initial certification.
3) Success requires several strong physician advocates. Start a petition in your hospital. Get your colleagues involved.

As of 12-31-2015 there are: 3,100 NBPAS diplomates

Hospitals accepting NBPAS as alternative certification for hospital privileges*

1)            Capital Region Medical Center – Jefferson City, MO (affiliated w/ Univ. of Missouri)
2)            Brandon Regional Hospital – Tampa, FL
3)            Shawnee Mission Medical Center – Kansas City, MO
4)            Mendocino Coast District Hospital – Fort Bragg, CA
5)            Florida Hospital Heartland Division – Sebring, FL
6)            Baylor St. Luke’s Medical Center/Texas Heart Institute – Houston, TX
7)            Sibley Memorial Hospital, Sibley Memorial, Johns Hopkins Medical System, Washington, DC.
8)            Southeast Missouri Hospital, Cape Girardeau, MO
9)            Columbia Basin Hospital, Ephrata, WA
10)         St. Mary Medical Center, Langhorne, PA
11)         St Luke’s Hospital, Cedar Rapids, IA
12)         Mercy Medical Center, Cedar Rapids, IA
13)         Hoag Hospital, Newport CA in process – MEC approval
14)         Texas Health Presbyterian Rockwall, TX
15)         Arkansas Heart Hospital, Little Rock, AR
16)         Lawrence & Memorial Hospital, New London, CT
17)         Providence Little Company of Mary, Torrance, CA
18)         Holmes Regional Medical Center, Melbourne, FL
19)         Palm Bay Hospital, Palm Bay Florida
20)         Wuesthoff Hospital, Melbourne. Florida
21)         Virginia Gay Hospital, Vinton, IA
22)         Frederick Memorial Hospital, Frederick, MA
23)         Oklahoma Heart Hospital, Oklahoma City, OK
24)         University of Pittsburgh Medical Center (UPMC) Hamot, Erie, PA
 

*Note: Some of the above hospitals have changed their bylaws to allow alternatives to ABMS certification that include NBPAS without specifically naming NBPAS

 

Last week the ABIM made another change in the MOC requirements and I have been asked by many to comment. Diplomats certified in nine subspecialties of internal medicine will no longer need to maintain underlying certifications to stay certified in those areas. This is a welcome change for many diplomats who believe the old requirement, requiring multiple board certifications. was onerous. Many of our societies lobbied for this change. I believe this change is helpful because it provides physicians with alternatives. However, I should point out that there may be unexpected consequences. Diplomats choosing this route will have to give up their board certification in the underlying specialty. This may be a problematic for many who in addition to their subspecialty, also continue to practice their underlying specialty. For example, many interventional cardiologists also provide care in general cardiology. If these subspecialists choose to limit MOC to interventional cardiology, they will lose their certification in general cardiology which may be problematic.

Sincerely,

Paul Teirstein