MOC, MOL, OCC and now C-MOC Beyond mere Board Certification



Paul M Kempen, MD, PhD Board certified 1989, 2005 And never again!

First certification with 2 year “cycles of profit” NO license= useless document

Does an anesthesiologist really need this?

PEA, Ventricular tachycardia (VT) fibrillation (VF)

ACLS circular 2 min. cycle

Circulation 2010, 122:S729-S767

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

Physician vs Administrator growth in Healthcare

“Parallels The increasing need to document in healthcare”

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

“CME PRA R” 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)

Lifelong Education or testing?
• Pursuit of “Journal’s cutting edge” IN YOUR area of expertise!

• 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?

License and certification: Limiting competition/Guilds
• 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.”

ABIM, with the FSMB leads the Certification industrial complex


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

MOC and MOL vs CPD little 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

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!

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.


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-) certification in geriatrics occurred only in 1998 and 2005, without the recommended primary recertification in internal medicine.

Dr. Christine Karen Cassel
Certification Area Certification Status Certification History Comments 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.

Internal Medicine


Certified 09/12/1979, Certificate valid indefinitely
Certified 01/01/1998, Certificate valid through 12/31/2004 Certified 02/17/2005, Certificate valid through 12/31/2015

Geriatric Medicine


Requires basic IM certification for validity

Humayun J. Chaudhry, DO, MS, MACP, FACOI Secretary FSMB President/CEO
Dr. Humayun Javaid Chaudhry Certification Area Certification Status Certification History Comments

Internal Medicine

Not Certified

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

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

Specialty or Subspecialty Neurology Certificate No. 29063

Certification History Certified on

certificate valid indefinitely

Status as of 1/13/2013 Certification Status: Certified MOC Status: Not Meeting MOC Requirements and Is Not Required To Do So Clinical Status: Unknown

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

• 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

First comprehensive review 2000
• 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!

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’

Awareness of Whether or Not Primary Doctor is Board-Certified • DK=”Don’t know” RF=Relative frequency??

2003 THE GALLUP ORGANIZATION for The 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 checking vs “knowledge” (72%) of certification on last slide!
From: 2003 THE GALLUP ORGANIZATION for The American Board of Internal Medicine

Testing Frequency
From: 2003 THE GALLUP ORGANIZATION for The American Board of Internal Medicine


Also: Hospital boards, other physicians, nurses, Better businessNurses bureau, etc
Colleagues Patients & families Private interest groups

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 materialsthis is left to the national specialty societies who are coerced for the $$$$$$$$$$

FSMB planning for MOL
• FSMB is planning pilot projects with 11 states starting early 2012, including: ------ Calif.(D.O.), Colo., Del., Iowa, ------ Mass., • Ohio. --------------Mississippi, Okla. (D.O.), Ore., Va., Wis. • All Politics are local and changes must be addressed primarily --at the state level!

States with 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.

How to organize
• States have rights to legislate licenses-the battle will be drawn here • Organization of State opposition among physiciansDATABASES/EMAIL! • Proactive measures to meet real needs • Define the truth-expose the lies with State’s own data! • Require only Certification and NOT recertification for:
– Hospital privileges – Group membership – Insurance payment and participation

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

American Society of Anesthesiologists

American Society of Anesthesiologists

American Society of Anesthesiologists



_____________ ________________________________________


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

Medicare Physician Quality Reporting System PQRS-MOC Incentives and Penalties


0.5% if no MOC, 1% if MOC (performance year for 2015 penalty)
0.5% -1.5% -2%

2014 2015 2016

The 9 ABMS (all subspecialties) “qualified” for the 2012 Physician Quality Reporting System Maintenance of Certification Program Incentive.
Allergy and Immunology Dermatology Emergency Medicine Internal Medicine Neurological Surgery Nuclear Medicine Obstetrics and Gynecology Ophthalmology Radiology American Osteopathic AssociationThe following boards are qualified: Internal Medicine Obstetrics and Gynecology Pediatrics Radiology

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

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

• 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 highquality care.

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

• 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

How Much Does It Cost?
• 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.

Will Any Of These Changes Benefit Me?
• 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.

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?

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.

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.

Is ABIM The Only ABMS Board With A Continuous Program?
• 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.

Five Things Physicians and Patients Should Question Participating Internists
Other specialties sure to follow! ”just say no”? To what? Patient satisfaction? Lawsuits?

• • • • • • • • •

• • • • • • • • •

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

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

'I'll make him an offer he can't refuse'
• Certification improves nothing:
– Physicians are and remain competent for many reasons-NOT because of MOC – By creating legally mandated MOL, MOC becomes an “offer you cannot refuse”

• Protection racketeering:
– You don’t really need the protection – Until after the need is created by the offering entity!

Solicitation from 5/16/2013
The American Board of


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

Phone: (866) 999-7501 | Fax: (866) 999-7503 | Email: | Website:

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 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,, and click the link labeled “Register for a MOCA Cognitive Exam.” NOTICE: This message contains information from the American Board of Exam Dates (Select One): July 13-27, 2013 Registration Deadline: May 21, 2013

Fee: $2,100

Re-Examination Fee: $800

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.

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 groups: 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%

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