MOC, MOL, OCC, C-MOCPQRS-MOC and the futureAlphabet soup of physician regulatory capture

MOC, MOL, OCC, C-MOCPQRS-MOC and the future

Alphabet soup of physician regulatory capture

Paul M Kempen, MD, PhDBoard certified 1989, 2005

And never again! Time to actively pursue legislation!

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Regulatory Capture:

• “Regulatory capture” occurs when special interests co-opt policymakers or political bodies — regulatory agencies, in particular — to further their own ends.

• ABMS and FSMB have declared themselves as Sole “official agents of verification of physician abilities-yet provide NO educational materials-this is left to the national specialty societies who are coerced for the $$$$$$$$$$

First certification with 2 year “cycles of profit”

Revisions @ 5-8 years/ renewal=2

NO license= useless document

Does a physician really need this?

The Certification industry“Millions for nothing” but a promise!

“ “CME PRA CME PRA RR””AMA “recognition Award”AMA “recognition Award”

Licensure and credentialing confer, in the eyes of the public a “Good Housekeeping Seal of Approval”(To Err is Human 1999 page 3)

License and certification:Limiting competition via Guilds

(Restricting competition)

• Milton Friedman, (1962)– “the pressure on the legislature to license an

occupation rarely comes from the members of the public . . . On the contrary, the pressure invariably comes from the occupation itself.”

• Harold Demsetz, (1968)– “… regulation has often been sought because of

the inconvenience of competition.”

The FSMB:MOL• National non-profit corporation claiming membership representation of

the 70 State medical and osteopathic boards-but no income from membership on IRS 990 forms.

• Founded in 1912, specializes in promoting legislation to state medical boards to regulate the practice of medicine on a national level.

• Provides no physician continuing medical educational (CME) programs or patient care;

• Educates only lawyers and state regulators • Specific corporate lobbying budget of $221,222 (2009- IRS

990).• Annual gross receipts FSMB exceed $38 million in 2011—• FSMB is a parent organization of the Accreditation Council for Continuing Medical

Education (ACCME) and the Educational Commission for Foreign Medical Graduates (ECFMG).

– FSMB memberships include the National Board of Medical Examiners (NBME), the Accreditation Counsel for Graduate Medical Education (ACGME), and the ABMS.

– FSMB was a founding member of what was to become ABMS and remains an associate member of that body.

Sells “tests,” not education, as a “corporate product”: ECFMG, FLEX, SPEX, USMLE part I, II, III,….IV?..........

FSMB planning for MOL

• FSMB is planed pilot projects with 11 states starting early 2012, including:

• Ohio. Calif.(D.O.), Colo., Del., Iowa, Mass., Mississippi, Okla. (D.O.), Ore., Va., Wis.

• All States WILL follow!• Politics are local and

changes must be addressed primarily ---at the state level!

------------------------------------------

------------

New ABIM MOC and Recertification Requirements, Summary

• Prior initial ABIM certification in Internal Medicine• Posses unrestricted, valid U.S. or Canadian medical licensure • Every 10 years

– Enroll in the MOC program by paying the yearly fee– Pass exam

• Every 5 years– Earn 100 MOC points

• At least 20 points in medical knowledge• At least 20 points in practice assessment • 60 points from either area

– Complete a patient survey– Complete a patient safety module

• Every 2 years– Complete an MOC activity

Robert I. Goodman, M.D., F.A.C.P.11 September 2013

• Certification and MOC have been and continue to be evolutionary processes. In order to help you keep pace with the changes in the science of medicine and assessment, ABMS and ABIM believe that a more continuous MOC program is vital to fulfilling our mission of assuring patients that Board Certified physicians are committed and qualified to provide high-quality care.

These Weren't The Rules When I Certified. Why Do I Have To Do This Now?

http://moc2014.abim.org/q-and-a.aspx

• ABIM will honor all certifications already issued, and diplomates who received certifications that are valid indefinitely will remain certified (assuming you hold a current and valid license).

• However, for all ABIM Board Certified physicians, regardless of when they were initially certified, ABIM and ABMS will begin reporting whether or not they are "Meeting MOC Requirements."

• In addition to the "Meeting MOC Requirements" requirement, diplomates with a certification that is valid indefinitely will need to pass the MOC exam in their certification area by 12/31/23 in order to be reported as "Meeting MOC Requirements." This is in addition to continuing to meet the point requirements of the MOC program.

• Grandfathers who do not meet the MOC program requirements will be reported as "Certified, Not Meeting MOC Requirements." They will NOT be reported as Not Certified for failing to meet MOC requirements.

I Hold Certification That Is Valid Indefinitely. Why Are You Reporting That I Am Not Meeting MOC Requirements

When I Don't Have Any Requirements To Meet?


(The PQRS-MOC TRAP from ABMS/CMS)

American board of-2011 990s (Millions)

gross reciepts

profits/revenue

Net assets

Exec salary($ thousands)

FAMILY MEDICINE 55 2.8 48.9 728INTERNAL MEDICINE 49.3 -1.7 -45.4 787EMERGENCY MEDICINE 39.1 4.3 22.9 532.2EMERGENCY MEDICINE 39.1 4.3 22.9 532PSYCHIATRY AND NEUROLOGY 33.2 6.3 50.4 827.3PEDIATRICS 27.1 3.7 46.1 933RADIOLOGY 19.2 -0.28 30 660

AMERICAN BOARD OF MEDICAL SPECIALTIES 14.8 1.55 11.9 562.5OBSTETRICS AND GYNECOLOGY 14 2 31.8 566ANESTHESIOLOGY 13.6 1.2 17.6 272SURGERY 12 -1.7 12.1 670ORTHOPAEDIC SURGERY 12 1.3 25.2 493PATHOLOGY 10 0.86 9.3 406OPHTHALMOLOGY 7.6 0.659 5.1 366 OTOLARYNGOLOGY 5.9 1.4 7.1 494

PHYSICAL MEDICINE & REHABILITATION 4.3 0.91 9.9 437PLASTIC SURGERY 3.2 -0.084 3.12 315NEUROLOGICAL SURGERY 2.8 0.097 2.6 173DERMATOLOGY 2.7 1.2 6.2 140UROLOGY 2.6 0.664 5.7 135THORACIC SURGERY 2 0.059 10.1 277.3ALLERGY AND IMMUNOLOGY 1.7 0.285 3.6 103PREVENTIVE MEDICINE 1.3 0.133 2.7 193NUCLEAR MEDICINE 1 0.055 2.2 110MEDICAL GENETICS 0.564 -0.127 1.6not reported

Totals ABMS and affiliates 374.064 29.9 343.6 10,712.3

The millions in 2011 (gross receipts)

PEDIATRICS 933Stockman MD CEO

PSYCHIATRY AND NEUROLOGY 827.3Faukner CEOINTERNAL MEDICINE 787Cassel CEOFAMILY MEDICINE 728Puffer CEOSURGERY 670Lewis MDRADIOLOGY 660G Becker MD Exec Dir

OBSTETRICS AND GYNECOLOGY 566L Gilstrap MD Ex DirAMERICAN BOARD OF MEDICAL SPECIALTIES 562.5K Weiss MD CEOEMERGENCY MEDICINE 532.2E ReisdorfEMERGENCY MEDICINE 532Reisdorf MD OTOLARYNGOLOGY 494Miller MDORTHOPAEDIC SURGERY 493Hurwitz

PHYSICAL MEDICINE & REHABILITATION 437A Tarvestad JDPATHOLOGY 406B Bennet MDOPHTHALMOLOGY 366Clarkson MDPLASTIC SURGERY 315Barett MDTHORACIC SURGERY 277.3Boumgartner MDCEOANESTHESIOLOGY 272exec dir non-MDPREVENTIVE MEDICINE 193Merchant MDNEUROLOGICAL SURGERY 173Sanderson Exec DirDERMATOLOGY 140Hood MD

The income in thousands in 2011 CEO executive salaries

29% of US Doctors never certified!

http://www.abms.org/MOC_Myths_And_Facts/download/ABMS.pdf

Only ½ all US Doctors performing MOC!

•

NursesColleagues

Patients & familiesPrivate interest groups

Also: Hospital boards, other physicians, nurses, Better business bureau, etcAlso: Hospital boards, other physicians, nurses, Better business bureau, etc

Do we need any more “quality control”Do we need any more “quality control” in medicine???in medicine???

http://www.medibid.com/blog/2013/04/medicrats-increase-healthcare-costs/

Physician vs Administrator growth in Healthcare

“Parallels The increasing need to document in healthcare”

ACA in PRINT

States with active anti MOC/MOL resolutions: Fighting as professionals

• Ohio• Michigan• New York• Texas• North Carolina• Iowa

Medical Society of the State of New York: resolutions 2013

• RESOLVED, That the Medical Society of the State of New York acknowledges that the certification requirements within the Maintenance of Certification process are costly, time intensive and result in significant disruptions to the availability of physicians for patient care; and be it further

• RESOLVED, That MSSNY acknowledges and affirms the professionalism of individual physicians to self-determine the best means and methods for maintenance of their knowledge and skills; and be it further

• RESOLVED, That MSSNY communicate to the American Medical Association (AMA) and American Board of Medical Specialties (ABMS) examples of disproportional fees, onerous time requirements and unnecessary fragmentation of commonly recognized specialties; and be it further

• RESOLVED, That MSSNY oppose mandating Maintenance of Certification until such time as evidence-based research demonstrates MOC is linked to improved patient outcomes; and be it further

• RESOLVED, That a copy of this resolution be transmitted to the AMA House of Delegates for its consideration.

The anti-MOC/MOL resolutions adopted by the AMA House of Delegates (2013 in Chicago) included:

•Opposition to mandatory specialty board recertification programs and discrimination by hospitals and other entities against physicians who don't recertify•Support of lifelong continuing medical education and lifelong specialty board certification•A call for increased transparency by the ABMS and its component specialty boards through published reports on revenue, expenses, and compensation of board members and senior staff•A request that the AMA work with ABMS and component boards to integrate existing data-reporting programs with certain recertification programs

How to organize

• States have rights to legislate licenses-the battle will be drawn here-PASS LEGISLATION & RESOLUTIONS!

• Organization of State opposition among physicians-DATABASES/EMAIL!

• Proactive measures to meet real needs• Define the truth-expose the lies with State’s own

data! MONITOR YOUR MEDICAL BOARD’s work!• Require only Certification and NOT recertification

for:– Hospital privileges– Group membership– Insurance payment and participation

Time to actively pursue legislation!

American Board of OB/GYNSent as Email: Thu, Sep 12, 2013 7:23 pm

• ABOG-Certified Diplomates are expected to practice consistent with this more expanded definition. Failure to do so may result in loss of certification.

• Physicians who do not limit a minimum of 75% of their practice to the areas of medicine listed in the above-named Bulletins shall not be eligible to become certified in or to maintain their certification by ABOG. Specifically, a physician who does not limit at least 75% of their practice to the areas of medicine included in the Bulletins listed above:

• shall not be eligible to sit for the Basic Oral Examination and not be eligible to become ABOG certified;

• if the physician is ABOG certified, that physician will not be eligible to participate in the ABOG MOC process; and

• if the physician is ABOG certified, such certification may be revoked

American Board of OB/GYNSent as Email: Thu, Sep 12, 2013 7:23 pm

• In addition, to remain certified by ABOG the care of male patients is prohibited except in the following circumstances:

• Active government service, • Evaluation of fertility, • Genetic counseling and testing of a couple, • Expedited partner treatment of sexually transmitted diseases, • Administration of immunizations, • Management of transgender conditions, • Emergency care when the Diplomate is required by their

hospital to participate in general emergency care, and • Family planning services, not to include vasectomy.

Certificate of achievement or license?

Gone from 1989: “attainment of consultant status”

Gone to 2005: “awarded MOC”

Change or degradation of certification?

• Specialties offered by physicians and group practices• Board certification• If the physician is using electronic health records• Physician affiliation with hospitals and other healthcare professionals

CMS Redesigns Physician Compare WebsiteListings include:

20130.5% if no MOC, 1% if MOC (performance year for 2015 penalty)

2014 0.5%

2015 -1.5%

2016 -2%

Medicare Physician Quality Reporting System PQRS-MOC Incentives and Penalties

https://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system.page

STATEMENTSTATEMENT

________________________________________________________________________________________________________________________________________________________________

2010

__________________________________________________________________________________________________________

________________________________________________________

STATEMENT 2010

'I'll make him an offer he can't refuse''I'll make him an offer he can't refuse'

• Certification improves nothing:Certification improves nothing:– Physicians are and remain competent for many Physicians are and remain competent for many

reasons-NOT because of MOCreasons-NOT because of MOC– By creating legally mandated MOL, MOC becomes By creating legally mandated MOL, MOC becomes

an “offer you cannot refuse”an “offer you cannot refuse”• Protection racketeering: Protection racketeering:

– You don’t really need the protectionYou don’t really need the protection– Until after the need is createdUntil after the need is created

by the offering entity!by the offering entity!

Historical overview• 100 years ago

– No licenses or “certifications”– Lifelong learning and apprenticeships

• 1960’s– Medicare/-caid government as new “payer”-need to document– AMA “strong horse” and CME-PRA as documentation (75%)

• 2000– Board certification switch to “10 year cycles” prevalent– First steps to regulatory capture of physician CME as MOC– 2010 MOL and significant resistance, MOC @ 50% participation– 2014-MOC to become C-MOC, AMA declined to 15% membership

“MOC” points vs CME

Lifelong Education or testing?

• Pursuit of “Journal’s cutting edge” IN YOUR area of expertise!

Or • Review regurgitation of textbook “factoids” • Does “one size fit all” and with 168 different

board certifications-how is that equal/fair?• Multiple certifications to become extinct?

• We identified officers in various internal medicine organizations using official websites

Editorial board certification statusJuly 2013- 35 physician members

• Two individuals recertified as of Jan 1, 2014– “in advance of date”

• Only ONE primary (1st) certification after 2000 making for older lifelong certified “leaders”

• Zero life-long “Grandpa” recertified in 2000, – 2 never recertified to date

• Eleven NEVER certified:– Two US based and 9 from abroad– NO foreign “leaders” are ABA certified

• Only Eight actively enrolled in MOC

Dr. Christine Karen CasselCertification Area Certification

Status Certification History Comments

Internal Medicine CertifiedCertified 09/12/1979, Certificate valid indefinitely

Certificates awarded in Internal Medicine prior to 1990 do not require renewal. However, ABIM encourages all diplomates voluntarily to renew certificates relevant to their practice.

Geriatric Medicine Certified

Certified 01/01/1998, Certificate valid through 12/31/2004Certified 02/17/2005, Certificate valid through 12/31/2015

Ex-President of the ABIM was a member of the same 2000 ABIM Task Force on Recertification and originally certified in medicine in 1979, (re-) certificationin geriatrics occurred only in 1998 and 2005, without the recommended primary recertification in internal medicine.

Requires basic IM certification for validity

Dr. Humayun Javaid Chaudhry

Certification Area Certification Status Certification History Comments

Internal MedicineNot Certified

Certified 08/21/1996, Certificate valid through 12/31/2006

Humayun J. Chaudhry, DO, MS, MACP, FACOI SecretaryFSMB President/CEO

D.O . Osteopathic Continuing Certification (OCC) only created in 2013

From: Lance Allen Talmage, MD

To: Ohio Medical Open Forum

Posted: August 23, 2013 11:23 AM

Subject: Recert of Dr. Chaudhry

Dr. Chaudhry is in fact recertified by the American Board of Osteopathic Internal Medicine from 2006 to 2016. The FSMB has developed a policy for nonclinically active Physicians to allow them to document appropriate Continuing Professional Development as an alternative. -------------------------------------------Lance TalmageProMedica Physicians Group

Specialty or Subspecialty Certification History Status as of 1/13/2013NeurologyCertificate No. 29063

Certified on

01/30/1987certificate valid indefinitely

Certification Status: CertifiedMOC Status: Not Meeting MOC Requirements and Is Not Required To Do SoClinical Status: Unknown

Lois Margaret Nora, MD, JD, MBA President and Chief Executive Officer

Finally recertified in April 2013

ASA 1990-1999 Closed Claims Project analysis

• Analyzed claims from the 1990-1999, before 10 year cycles were imposed

• Board certification status was unknown in 51% of claims. • There were board certified 1330 claims (39%) vs 361 (11%) no

board certification identified• Currently 76% BC vs 24% NBC rates compare to 78% and 22%

of claims analyzed in the 50% where known.• There was no statistically significant difference between There was no statistically significant difference between

groups: In both groupsgroups: In both groups – death occurred in 27% of claims;– permanent injury (6-8) in 22%, – and temporary or non-disabling injury 51% of claims in each group.

1990s Close Claims:board certified (BC) vs. not certified (NBC)

• Information regarding whether a claim was paid or not includes payments by any defendant, not just the anesthesiologist

• Payment reported reflects only payments made on behalf of the anesthesiologist

• Anesthesiologist median payment:– BC: $187,000 (range $3,000 - $2.7 Million) – NBC: $150,000 (range $1,000 - $6 Million)

• Claims resulted: – BC: 47%– NBC: 58%

Dermatol Surg 2012;38:171–177

CONCLUSIONS:• Continued analysis reveals that medically necessary office surgery does not represent an emergent hazard to patients. •The data obtained from 10 and 6 years of adverse event reporting in Florida and Alabama, respectively, are comparable and consistent. •Medically necessary surgical procedures performed in the office setting by dermatologists have an exceedingly low complication rate, and complications that arose were largely unexpected, isolated, and possibly unpreventable.•Requiring physician board certification and physician hospital privileges does not seem to increase safety of patients undergoing surgical procedures in the office setting.

in-office adverse event data

All incidents in:•Florida from March 2000 to January 2010 and in •Alabama from December 2003 to December 2009 •Filed with the Florida AHCA and Alabama Board of Medical Examiners, respectively, were collected and analyzed.


________________________

• “There was no pattern of more adverse events in those who were not board certified or had no hospital privileges although the sample sizes of non-board certified physicians and physicians without hospital privileges were too small to analyze.

• No conclusions can be drawn regarding effect of physician hospital privileges or board certification on overall safety of patients undergoing surgical procedures in the office setting.

• The overwhelming majority of physicians (93% ofFlorida and 100% of Alabama) reporting adverseevents were board certified.“


ABIM, with the FSMB leads the Certification industrial

complex

_______________________

Voluntary recertification failed

• progressively fewer diplomates opted to participate in each recertification cycle: – 3355 in 1974 – 2240 in 1977 – 1947 in 1980– 1403 in 1986

• Only 8945 diplomates, less than 10% of those eligible, elected to undertake voluntary recertification.

•

Voluntary recertification failed

• “This decrease occurred despite strenuous efforts to make the process more relevant and attractive by:– linking it with the American College of Physician’s

Medical Knowledge Self-Assessment Program, – offering modular formats and choice of content, – charging low fees.”

SO the answer is to just FORCE everyone into high cost compliance!

• Meta-analytic statistics were not feasible due to variability in outcome measures across studies.

Board Certification and Clinical Outcomes:The Missing Link

• Purpose: no systematic review has examined the link between certification and clinical outcomes.

• Method. Data sources consisted of studies cited between 1966 and July 1999– identified 1,204 papers;– selected 237 based on subject relevance;– reduced to 56 based on study quality– identified only 13 that met inclusion criteria

ABMS statement on certification

ABMS 2012: ‘FACT: ABMS recognizes that regardless of the profession - whether it is health care, law enforcement, education or accounting - there is no certification that guarantees performance or positive outcomes’

http://www.abms.org/Maintenance_of_Certification/pdfs/ABMS_MOCMythsFacts12_26_2012_final_revised01092013.pdf

Standard Contract American Board of Pathology

All rights to board-none to you!

AM Board Pathology Standard Contract Excerpt

__________________________________________________________

______________________________________

Testimonial to cost• National specialty societies/academics are becoming the

MOC Franchise supporters of the ABMS Testing industry:• "On Sunday I spent 5 hours on the computer completing

a course to be accepted as my Part IV module for maintaining my board certification in Family Medicine. The course was free. Today I found out that in order for the course to be credited to my MOC I have to pay the American Board of Family Medicine $625 !! How do they justify this?"

Dr. M

Questions?

Paul Martin Kempen, MD, PhD

[email protected]

Thank you!Thank you!

WWW.CHANGEBOARDRECERT.COM

• Thank you –Questions?

First comprehensive review2000

• Overwhelmingly retrospective data base review as method

• Little real data to be presented• Conclusions typically favorable in spite of

limited science

• Overwhelming influence from ABMS in sponsorship and authors noted!

Awareness of Whether or Not Primary Doctor is Board-Certified

• DK=”Don’t know” RF=Relative frequency??

From:

2003 THE GALLUP ORGANIZATIONforThe American Board of Internal Medicine

Incidence of Having Researched A Physician’s Credentials

• Q.13 Have you ever asked or checked with anyone, such as a receptionist, nurse, doctor, friend, or coworker, if a doctor was board-certified?

• Q.14 Have you ever visited a web site or other source of information to verify a doctor’s credentials?

• Very low rate (33%) of Very low rate (33%) of checking vs checking vs ““knowledge” (72%)knowledge” (72%)

of certification on last slide!

From:2003 THE GALLUP ORGANIZATIONfor The American Board of Internal Medicine

Testing Frequency

From:2003 THE GALLUP ORGANIZATIONfor The American Board of Internal Medicine

_____________________________________________

American Society of Anesthesiologists



The 9 ABMS (all subspecialties) “qualified” for the 2012 Physician Quality Reporting System Maintenance of Certification Program Incentive.

Allergy and ImmunologyDermatology

Emergency MedicineInternal Medicine

Neurological SurgeryNuclear Medicine

Obstetrics and GynecologyOphthalmology

Radiology

American Osteopathic Association-The following boards are qualified:

Internal MedicineObstetrics and Gynecology

PediatricsRadiology

https://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system.page

Coming January 2014: A more continuous ABIM MOC program

( Certification will become only an entry point for subscriptions to MOC ) :

"Certified, Not Meeting MOC Requirements."

Questions and Answers


• Certification and MOC have been and continue to be evolutionary processes. In order to help you keep pace with the changes in the science of medicine and assessment, ABMS and ABIM believe that a more continuous MOC program is vital to fulfilling our mission of assuring patients that Board Certified physicians are committed and qualified to provide high-quality care.

These Weren't The Rules When I Certified. Why Do I Have To Do This Now?


• ABIM will honor all certifications already issued, and diplomates who received certifications that are valid indefinitely will remain certified (assuming you hold a current and valid license).

• However, for all ABIM Board Certified physicians, regardless of when they were initially certified, ABIM and ABMS will begin reporting whether or not they are "Meeting MOC Requirements."

• In addition to the "Meeting MOC Requirements" requirement, diplomates with a certification that is valid indefinitely will need to pass the MOC exam in their certification area by 12/31/23 in order to be reported as "Meeting MOC Requirements." This is in addition to continuing to meet the point requirements of the MOC program.

• Grandfathers who do not meet the MOC program requirements will be reported as "Certified, Not Meeting MOC Requirements." They will NOT be reported as Not Certified for failing to meet MOC requirements.

I Hold Certification That Is Valid Indefinitely. Why Are You Reporting That I Am Not Meeting MOC Requirements

When I Don't Have Any Requirements To Meet?


• No, ABMS is requiring that all of its 24 member Boards implement a more continuous MOC program. The American Boards of Colon and Rectal Surgery, Dermatology, Family Medicine, Ophthalmology, Pediatrics, and Physical Medicine and Rehabilitation are just a few of the Boards which currently provide or are working to provide continuous programs.

Is ABIM The Only ABMS Board With A Continuous Program?

What Is The Evidence That Supports The Need To Meet MOC Requirements On A More Continuous Basis? How Do You Know The Public Wants This?

The Institute of Medicine (IOM) has argued that in a profession with a "continually expanding knowledge base" a mechanism is needed to ensure that practitioners remain up-to-date with current best practices.

The growing knowledge base requires that training and ongoing licensure and certification (????) reflect the need for lifelong learning and evaluation of competencies.

Research has shown that the public expects that physicians undergo a rigorous, periodic examination of knowledge.


• For all ABIM Board Certified physicians, ABIM and ABMS will begin reporting whether or not you are "Meeting MOC Requirements" (i.e., completing an MOC activity every two years, earning 100 points every five years, etc.).

• In order to be reported as "Meeting MOC Requirements", you will be required to complete an MOC activity to earn ABIM MOC points every two years and earn 100 ABIM MOC points in the correct distribution every five years. The points earned every two years will count toward your five-year requirement.

• The exam requirement has not changed. You need to pass the exam in each certification area you want to maintain every 10 years

What Are The Changes To ABIM's MOC Program In 2014?


• To maintain more than one certification, the cost will be the fee of the most expensive certification plus half for each of the others.

• For no additional cost, you may be eligible for CME credit for the completion of ABIM MOC products. MOC, in one of the internal medicine specialties, ranges from $206- $257 per year.

• Keep in mind that, for most ABIM Certifications, you do not need to maintain internal medicine certification to remain certified in the subspecialty.

How Much Does It Cost?


• The secure exam, taken once every 10 years, can earn 20 MOC points.

(VS CME???)• You will now have the option of paying

for the program on an annual basis or for the full 10 years in advance at a discount.

• Your MOC fee includes unlimited access to all of ABIM's self-evaluation products, many of which earn CME credit.

Will Any Of These Changes Benefit Me?


Needless testing and “Choosing Wisely”

• Stop wasting money on testing in patients

Yet

• Test physicians yearly to “screen out the very few marginal ones”

• Would the ABMS or MOC have mattered in Kermit Gosnell’s case???

Standard Contract American Board of Pathology

All rights to board-none to you!

P4: YOUR obligations!• I understand and agree that, if I meet all of the

qualifications for certification, my certificate will be valid for 10 years contingent upon my timely satisfaction of all requirements of the American Board of Pathology Maintenance of Certification program.

• I agree to be legally bound by the foregoing.

• Signature

Solicitation from 5/16/2013The American Board of

Anesthesiology

4208 Six Forks Road, Suite 1500Raleigh, NC 27609-5765

Phone: (866) 999-7501 | Fax: (866) 999-7503 | Email: [email protected] | Website: www.theABA.org

RE: Register for MOCA Cognitive Examination We greatly appreciate your voluntary participation in the ABA’s Maintenance of Certification in Anesthesiology Program

(MOCA)! As a reminder, you are eligible to register for the July 2013 MOCA Cognitive Examination.

If you wish to register for the July 2013 MOCA Exam, the deadline is May 21, 2013.

Please log into your ABA portal account at www.theABA.org to register.

The 4-hour, computer-delivered examination will be administered to candidates at test centers in more than 300 cities

located throughout the United States, Canada and the U.S. Territories. Registration Deadline and Fees:

To register for the MOCA Cognitive Examination, please log in to your portal account via the ABA website, www.theABA.org, and click the link labeled “Register for a MOCA Cognitive Exam.”

Exam Dates (Select One): July 13-27, 2013Registration Deadline: May 21, 2013Fee: $2,100

Re-Examination Fee: $800

NOTICE: This message contains information from the American Board of Anesthesiology that may be confidential and legally privileged. If you are not an intended recipient, please notify the sender immediately, then destroy this email and refrain from any disclosure, copying, distribution or use of this information. Thank you.

• State Medical Boards have been doing this for decades as well!

MOC and MOL vs CPDlittle difference

• Goal is to provide documentation to unwitting external agents and make money in the process

• Like its predecessor, the CPD program has three major (non-validated) components: – 1) self-evaluation of the components of clinical

competence, (CME)– 2) evaluation of essential knowledge and clinical

judgment, (TESTS for $$$)– 3) verification of credentials and attestation of

institutional and community good standing

Subspecialty or added qualification

• Recertification in a subspecialty, such as cardiology or gastroenterology, will not require the maintenance of an active internal medicine certificate;

• Certificates of added qualifications, such as geriatric medicine or clinical cardiac electrophysiology, will continue to require an active certificate in the underlying discipline.

Year 2000

• Active participation in CPD was made mandatory for continuing ABIM directors regardless of whether their certificates are “permanent” or time-limited.

• Directors will receive no special treatment, financial or otherwise.

»Really????

“boilerplate disclamer” covers ABP

• I hereby release, discharge, covenant not to sue, and hold harmless the ABP, its trustees, officers, members, examiners, representatives, agents, and any person who supplies information regarding my credentials from any actions, suits, claims, demands, or damages arising out of, or in connection with any action taken by any of them regarding this application, the gathering, collecting, and use of information about my practice or education, ………………………..

……..disclaimer Continued

• ……..the grade or grades given with respect to any examination, the failure of the ABP to certify me, or the revocation of any certificate. It is understood that all decisions as to my credentials and qualification for admission to the examination and for certification rest solely and exclusively in the ABP, that its decision is final, and my exclusive appeal from any adverse decision is pursuant to the ABP's rules and procedures.

P2: I understand that:

• (1) the giving or receiving of aid in an examination as evidenced either by observation or by statistical analysis of incorrect answers of one or more participants in the examination; or (2) the unauthorized possession, reproduction, or disclosure of any materials, including, but not limited to, examination questions or answers, before, during, or after the examination; or ………

P2 recourse• …….(3) the offering of any benefit to any agent

of the ABP in return for any right, privilege, or benefit which is not usually granted by the ABP to other similarly situated candidates or persons may be sufficient cause to terminate my participation in such examination, to invalidate the results of my examination, to withhold or revoke my scores or certificate, to bar me from future examination, or to take other appropriate action.

Paragraph 3

• I understand that the ABP may require me to retake one or more portions of an examination if presented with sufficient evidence that the security of the examination has been compromised, notwithstanding the absence of any evidence of my personal involvement in such compromise.

P 3: Legal protections ABP

• I understand that the examination and all test questions are the exclusive property of the ABP and are protected by copyright law. Because of the confidential and proprietary nature of these copyright materials, I agree not to retain, copy, disclose, or reveal any part of these examination materials.

• Under threat of lawsuit-ABIM

10 shortcomings of medical certification

• This complicated system for the recognition of specialists has become a subject of controversy within the medical profession.

• Critics have noted 10 shortcomings of medical certification-from:

Douglas A. Wallace, Occupational Licensing and Certification: Remedies for Denial, 14 Wm. & Mary L.Rev. 46 (1972), http://scholarship.law.wm.edu/wmlr/vol14/iss1/3


• First, the existence of numerous sharply defined specialties and subspecialties has resulted in overlapping jurisdiction among the boards, necessitating arbitration of the inevitable jurisdictional disputes.

• Second, the membership of the boards is unrepresentative. (all grandfathers!)

• Third, the members are not accountable for their decisions.


• Fourth, some requirements for certification are arbitrary Particularly objectionable is the requirement that an applicant for certification obtain references from certified men in his local community; this may enable a specialist who has already attained "diplomate" status to "blackball" a local competitor."

• Fifth, the examination system is unnecessary and redundant to the residency programs, especially since some boards tend to pass almost every candidate while others fail 40 to 50 percent of their applicants."'


• Sixth, some boards deny or revoke the certificate without an explanation or hearing."'

• Seventh, the large number of autonomous boards has caused a lack of unity in educational policy and programs among specialty boards in contiguous fields and has contributed to the absence of an authoritative policymaking body responsible for supervising the development of graduate medical education in terms of the actual demands of medical care.


• The eighth criticism concerns the utility of certification. – It could be an invaluable source of information

concerning the qualifications of a medical specialist. – Patient and doctor alike are frequently ill-prepared to

determine the merits of self-proclaimed specialists; board certification might function as a guarantee that a specialist has advanced training in his chosen field.

– However, empirical studies of the quality of patient care have shown that the quality of care usually given by certified specialists is not superior to the care given by non-certified physicians.


• Ninth, with the rapid advance of medical technology, the boards typically have failed to require that member specialists keep abreast of developments.

• Tenth, the specialty certification system tends to increase the incomes of board-certified doctors by restricting hospital staff privileges to board-certified men, to the exclusion of general practitioners and non-certified specialists.

Studies and science

all 3 are ABIM executives and employees

Contact ABIMAmerican Board of Internal Medicine510 Walnut StreetSuite 1700Philadelphia, PA 19106-3699

John J. Norcini, Ph.D.FAIMER’s first President and Chief Executive Officer Foundation for Advancement of

International Medical Education

• Dr. Norcini spent 25 years with the American Board of Internal Medicine serving in various capacities, including Director of Psychometrics, Executive Vice President for Evaluation and Research, and finally, Executive Vice President of the Institute for Clinical Evaluation.

• The Foundation for Advancement of International Medical Education and Research (FAIMER) was incorporated as a nonprofit foundation of ECFMG in September 2000

http://www.faimer.org/about-staff.html

Rebecca S. Lipner, PhD, Senior VP of Evaluation, Research and Development, ABIM

• Dr. Lipner oversees a team of research design and analysis experts who employ both qualitative and quantitative methods to ensure and enhance the high quality of assessment programs across the ABIM enterprise while disseminating evidence-based research findings to the public

• In her previous role as Director of Psychometrics for ABIM, she was involved in the implementation of new programs in maintenance of certification and computer-based testing.

http://www.abim.org/about/executives.aspx#lipner

• Specifically, our retrospective chart review study compared certified and self-designated family practitioners, internists, and cardiologists (no assurance of equal training-especially in 1993)

• in-hospital mortality rates (adjusted for severity of illness)

• the characteristics of the hospitals the physicians worked in;

• physicians’ own characteristics:– time since graduation from medical school – number of AMIs they each treated in 1993.

Retrospective chart reviews and Science

• Designed to examine raw data and assess if formal study via Randomized Controlled Study method is warranted to confirm assumptions

• Is Highly susceptible to systematic design flaws which introduce bias/prejudice

• Validity of adjustments?• Corporate sponsorship suspicious of influence:

– Negative finding suppression– Intrinsic design to confirm desired outcome

Statistics and significance • Grouped all three into one group for analysis:

– Cardiologist and FP better than IM care!

• Predicted mortality always less in Non Certified group, while maximal risk severity always greatest there

Very different care settings

• BC have more advanced care, different settings and payor mix and more recently/younger trained Docs

Volume factor & significance

DISCUSSION Quotes• Purpose of this study:

– determine differences certified vs non-certified or self-designated

• We found lower patient mortality from AMI was associated with treatment:– by an attending physician who was a cardiologist,– cared for larger numbers of patients, – Was closer to his or her year of graduation from

medical school, and – was certified.

DISCUSSION Quotes• “However, there are a variety of issues having

to do with data collection that could potentially influence the findings of this study.”

• “Because to become certified physicians must satisfactorily complete accredited training and pass rigorous examinations.”– In 1993 self-proclaimed specialists may not have

had complete or significant training, unlike today, when certification “expires”

DISCUSSION Quotes

• “More primary care physicians than cardiologists are uncertified, so contrasting the two groups will overstate the magnitude of their differences.”

• (so we lumped them together)

• “Certification is associated with the quality of the medical schools physicians attend, as well as a variety of graduate experiences, including faculty–resident ratio and length of training.”

• Not true today with “certification expiration”

DISCUSSION Quotes

• “Lower mortality rates among patients with• AMI might be obtained by limiting their treatment

to those physicians who are certified, are relatively recent graduates from medical school, and have considerable experience with this condition.

• Not surprisingly, certified cardiologists best fit this description”

• (So see the one with most experience and experience with most advanced equipment ???)

DISCUSSION Quotes

• it is possible that more than one doctor may have contributed to clinical outcomes in some instances.

• However, where this occurs, its effect is to obscure differences among physicians, thereby working against the ability to make distinctions based on specialization and certification status.

DISCUSSION Quotes

• There are limitations in the risk-adjustment procedures the PHC4 used, including the inability to fully distinguish between complications and coexisting conditions, variations in coding, and categorization of the Admissions Severity Group score.

DISCUSSION Quotes

• In any retrospective study such as this, not all of the factors that lead to a particular patient’s outcome can be captured.

• Although the major causes of mortality were captured, it is not possible to rule out other uncontrolled factors.

DISCUSSION Quotes

• “certification should not be used as a sole marker of competence,”

• Repeated study from same data Using Certification data after completion of residency in all cases

• We compared certified (passed the examination) and self-designated (failed the examination but self-identified their specialty) internists and cardiologists with respect to their characteristics, the illnesses of their patients and the nature of the hospitals in which they worked.

Five Things Physicians and Patients Should QuestionParticipating Internists

• • American Academy of Allergy, Asthma & Immunology• • American Academy of Family Physicians• • American College of Cardiology• • American College of Physicians• • American College of Radiology• • American Gastroenterological Association• • American Society of Clinical Oncology• • American Society of Nephrology• • American Society of Nuclear Cardiology

Other specialties sure to follow! ”just say no”? To what? Patient satisfaction? Lawsuits?

NON-ABMS AMERICAN PHYSICIAN BOARDS

gross reciepts profits/revenue Net assets

(Millions) (Millions) (Millions)

Board of Osteopathic Medical Examiners 31.6 0.5 12

PODIATRIC SURGERY 5.5 0.861 9.75

ORAL AND MAXILLOFACIAL SURGERY 5.5 0.573 2.97

AMERICAN ASSOCIATION OF PHYSICIAN SPECIALISTS 2.9 -0.224 2

COLON AND RECTAL 0.702 0.094 0.589

FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY 0.639 0.037 0.676

LOWER EXTREMITY SURGERY 0.236 -0.003 -0.026

COSMETICS SURGERY 0.223 -0.085 -0.092

HAIR RESTORATION SURGERY 0.184 0.022 0.06

Oral Pathology 0.096 15 0.472

LASER SURGERY 0.063 0.01 0.054

SPINE SURGERY 0.047 -0.009 0.064

PEDIATRIC NEUROLOGICAL SURGERY 0.03 0.002 0.094

ABDOMINAL SURGERY 0.025 0.019 0.138

EYE SURGERY 0.017 0.015 -0.046

Also NON-ABMS AMERICAN paramedical BOARDS

Medical Society actions

• Is it possible to contact AAPS membership in ALL states and find out which states HAVE formed anti-MOC/MOL resolutions and activities and perhaps investigate why others have not?

• Ohio, New York, Texas, Michigan (New Jersy)

• Will AAPS initiate NOW an attempt to get ABMS high ranking officers to commit to an OPEN DEBATE at the AAPS next meeting or at some adequately distant "venue to be decided" so they cannot claim "conflicts of schedule"?

• Should an attempt be made to place such a venue a/through a "more neutral" state medical meeting, say in Georgia or Michigan?

• What is the deal in California with the State Medical Board separating investigations out to the Office of the attorney general? What is the position of AAPS on this? On the one hand this would result in constitutional rights NOT afforded by the Medical boards and legal minds adjucating the matters vs secrret decisions by victorian ethics appointed by the governor doing injustice?? Not sure if this is a good or bad move? In Ohio this could be a good move?See: http://www.latimes.com/news/local/la-me-rx-medical-board-20130426,0,5663708.story

http://www.medibid.com/blog/2013/04/medicrats-increase-healthcare-costs/

Physician vs Administrator growth in Healthcare

http://en.wikipedia.org/wiki/Health_care_in_the_United_States

http://www.rand.org/content/dam/rand/pubs/corporate_pubs/2005/RAND_CP484.1.pdf

Jun 30, 2012 – The US has the highest health spending in the world - equivalent to 17.9% of its gross domestic product (GDP), or $8,362 per person.





Medicare Is the Dominant Payer for the Elderly, Private Insurance for Those Under 65


To meet the requirements of IRC 501(c)(6) and Reg. 1.501(c)(6)-1, an organization must possess the following characteristics:

• It must be an association of persons having some common business interest and its purpose must be to promote this common business interest;

• It must be a membership organization and have a meaningful extent of membership support;

• It must not be organized for profit; • No part of its net earnings may inure to the benefit of any private

shareholder or individual; • Its activities must be directed to the improvement of business

conditions of one or more lines of business as distinguished from the performance of particular services for individual persons;

• Its primary activity does not consist of performing particular services for individual persons; and

• Its purpose must not be to engage in a regular business of a kind ordinarily carried on for profit, even if the business is operated on a cooperative basis or produces only sufficient income to be self-sustaining.

Dr. Janelle Arolyn Rhyne

Certification Area Certification Status Certification History

Internal Medicine Certified Certified 09/10/1986, Certificate valid indefinitely

Infectious Disease Certified


Met all recertification requirements 11/03/1999



http://www.fsmb.org/foundation_leadership.htmlFSMB Foundation Board of Directors:

Janelle A. Rhyne, MD, MA, MACPDirector

History of the ATLS® ProgramThe Beginning: In February 1976, a tragedy occurred that changed the first hour of trauma care for injured patients in the United States and in much of the rest of the world. Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a cornfield in rural Nebraska.•Recognizing how inadequate their treatment was, stated, "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed.“•Originally no time limits-but that has changedComplementary Courses

Trauma Evaluation and Management (TEAM) for Medical StudentsAdvanced Trauma Care for Nurses (ATCN) for Registered NursesPre-Hospital Trauma Life Support (PHTLS) for Pre-hospital care providers

Based on ATLS philosophies, these courses allow PHTLS-trained pre-hospital care providers to follow the same principles of care that are core to ATLS.

2013 Anesthesia ACLSNo time limits,

“NOT” AHA-ACLS

Certificate of achievement or license

requirement?

Authorization to practice medicine or specialty?

ABMS=501 (c) (6) corporation• ABMS Organization and Leadership American Board of

Medical Specialties is incorporated in the State of Illinois as a not-for-profit corporation by the Internal Revenue Service under Section 501(c)(6) of the Internal Revenue Code of 1986.

• The individual organizations comprising the membership of ABMS are classified as either Regular Members, often referred to as Member Boards, or Associate Members. The Regular Members include 23 Primary Boards and one Conjoint Board. The Associate Members consist of nine national organizations concerned with graduate medical education and specialty practice, but they are not specialty boards. Each Member Board and Associate Member Board pays annual dues and has voting rights.

501 (c) (6) corporation

• Its purpose must not be to engage in a regular business of a kind ordinarily carried on for profit, even if the business is operated on a cooperative basis or produces only sufficient income to be self-sustaining.

• Nevertheless, it is important to analyze IRC 501(c)(6) cases step-by-step because an organization must possess all the above characteristics to qualify under IRC 501(c)(6).

IRC 501(c)(6) Organizations – page K-4 http://www.irs.gov/pub/irs-tege/eotopick03.pdf

RECENTLYDid you know you can submit your completed ABIM PIM Practice Improvement Module® to a participating health plan to earn reward and/or recognition credit?Health plans recognize the value of ABIM's Maintenance of Certification (MOC) program as a relevant measure of performance and accept completed PIMs for credit in reward and recognition programs.Benefits of submitting your PIM to a health plan:

•By completing a PIM, you can receive recognition from multiple organizations (ABIM and health plans).•Reward and/or recognition programs champion physicians who are actively engaged in quality improvement activities.•Health plans recognize your PIM completion either by distinguishing you from other physicians in their quality networks or with monetary rewards.*

Log on to ABIM's website to submit your completed PIM today. It only takes a few minutes. In addition, you can also earn a financial bonus from CMS for participating in PQRS MOC in 2013.* The health plan program requirements vary by plan.

EARN RECOGNITION OR REWARDS FOR YOUR RECENTLY COMPLETED PIM

Protecting public or profits quality control vs forming Guilds

• 1985 ABA recognized: UK, Israel, S.Africa• No entry for acclaimed foreign national• Introduction of special pathway for Renown

researchers: – 8 year pathway via restricted research license

• Does a physician shortage exist? Why authorizing medical practice by:– Nurse Practitioners, Physician Assistants,

Pharmacists, CRNAs, Midwifes, etc

STATEMENT STATEMENT 2010

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With CMS: any "carrot" will quickly become a "stick" of penalty

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ACLS circular 2 min. cycle

Circulation 2010, 122:S729-S767

PEA, Ventricular tachycardia (VT) fibrillation (VF)


Documents

MOC, MOL, OCC, C-MOCPQRS-MOC and the futureAlphabet soup of physician regulatory capture