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From MOC to CMP:
An Educational Service or More Indentured Servitude?
Westby G. Fisher, MDCardiac ElectrophysiologyNorthShore University HealthSystemClinical Associate Professor of MedicineUniversity of Chicago
Twitter: @doctorwesBlog: “Dr Wes” http://drwes.blogspot.comEmail: [email protected]
Disclosures
On Transparency
“They may carry on the most wicked and pernicious schemes under the dark veil of secrecy. The liberties of a people never were, nor never will be, secure, when the transactions of their rulers may be concealed from them.”
Patrick Henry, Constitutional Ratifying Convention, June 9, 1788.
Maintenance of Certification (MOC®)US Medicine’s Version of the “The Big Short”
Background
1936-1990 lifetime
1968
1974 voluntary “Continuous Professional Development” (CPD)
1990time-limited
uncertain circumstances2005
MOC®• EXCEPTION:
1 Glassock, R. J., Benson, J. A., Copeland, R. B., Godwin, H. A., Johanson, W. G., Point, W., Popp, R. L., Scherr, L., Stein, J. H., & Tounton, O. D. (1991). Time-limited certification and recertification: the program of the American Board of Internal Medicine. Annals of Internal Medicine, 114(1), 59–62.
U.S. Physician Board Certification Shell Game
Initial (Lifetime) Certification “Maintenance” of Certification (MOC)
“Continuous” Certification (CMP)
Adequacy “Something Else?”
• Practice Improvement Projects• Patient Voice• Patient Surveys
CME
1990
Evidence No Evidence
U.S. Physician Board Certification Shell Game
2019Science “Story-telling”
The Concern
MOC®: A Highly-Effective Financial Strategy
U.S. Physician Credentialing System
Accreditation Council for
Graduate Medical Education
(ACGME)
AMA AHA AAMC NBME CMSS AOA AACOM ABMS
ABIM
ABFM
ABP
21 more…
$662M $280M $452M
$1 Billion
$52M $0.4M $70M $21M
The American Board of Internal Medicine (ABIM) is the largest member board of the American Board of Medical Specialties and is responsible for credentialing one quarter of all US physicians.
What Happens to Doctors Who Fail MOC®?
* Would we ever prescribe a medication without first knowing its side effects?
PPA Survey on US Board Certification (n = 7007)MOC® Harms (n = 4697)
394 (8%) failed
21 (5%) Lost Their Job30 (8%) Disenrolled from Insurance Plan
220 (56%) Adverse Psych15 (4%) Relocated
67 (17%) to Retire
Have you ever failed a MOC® examination, lost your Board certification (even briefly) or experienced harm because of MOC® / OCC requirements?
n / N (%)
Yes 394 / 4697 (8)
No 4303 / 4697 (92)
Please check all effects of MOC for failing or losing your Board certification (check all that apply)
Paid for a re-score of my examination 41 / 390 (11)
Re-took the examination for free 28 / 390 (7)
Re-took the examination for an additional fee 218 / 390 (56)
Never attempted to retake the examination andlet my board certificate “expire”
56 / 390 (14)
Lost my hospital/admitting privileges 38 / 390 (10)
Lost my job 21 / 390 (5)
Was dis-enrolled from an insurance company’s payment plan
30 / 390 (8)
Eventually passed my repeat examination 204 / 390 (52)
Failed to tell my workplace of my examination results 67 / 390 (17)
Failed to tell my family/friends about my test results 107 / 390 (27)
Became depressed, anxious, embarrassed, or suicidal 220 / 390 (56)
Relocated as a result of this failure 15 / 390 (4)
Plan to retire to avoid MOC / OCC 67 / 390 (17)
I retired because of this failure 1 / 390 (0)
Of those …
38 (10%) Lost Adm/Hosp Privileges
ABMS Vision Commission Final Recommendations
ACC/HRS CMP: What Do Physicians Really Think?A Survey of Working Cardiologist/EP Perceptions
CMP Survey: Demographics (n = 101)
92
9
0102030405060708090
100
Male Female
Gender
5
55
35
6
0
10
20
30
40
50
60
21-35 36-50 51-65 > 65
Ages
1713
52
12
5
0
10
20
30
40
50
60
Private
Group/In
dep
HospSys
Group/D
epOth
er
Practice Setting
CMP Survey: Geography of Respondents
CMP Survey: Physician Specialty
43
57
10
10
20
30
40
50
60
Cardiology EP CT Surg
Specialty
0
5
10
15
20
25
30
35
40
0-10 11-20 21-30 >30
Years in Practice
CMP Survey – Board Certification Status
4
11
41 40
3
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4+
Active Board Certificates
77
7
14
10
10
20
30
40
50
60
70
80
90
0 1 2 3
Board Certificates Before 1990
Q1: Should the ACC, HRS, and HFSA leverage their self-assessment program product sales to maintaining your ABIM board certification?
19
74
0
10
20
30
40
50
60
70
80
Yes No
Q2: There are TWO costs for the CMP program (1) the costs for ACCSAP, EP-SAP and Heart Failure SAP materials from ACC, HRS, and HFSA (Currently $1600 every 5 years for the ACCSAP) and (2) $160 annually to the American Board of Internal Medicine (ABIM).
Were you aware CMP will cost physicians at least $5200 every 10 years?
23
70
0
20
40
60
80
Yes No
Q3: I believe the costs for CMP are:(Too high, about right, better then I expected)
86
6 10
102030405060708090
100
Too High About Right Better Than Expected
Q4: Do you plan on participating in the new Collaborative Maintenance Pathway (CMP) from the ACC, HRS, or HFSA?
20
73
0
10
20
30
40
50
60
70
80
Yes No
Q5: Do you think the ACC has made maintaining your board certification easier or harder with its new Collaborative Maintenance Pathway? (Easier, About the Same, Harder)
15
34
44
05
101520253035404550
Easier Same Harder
Q6: Should any ACC, HRS, or HFSA educational product have the potential to limit your hospital privileges, insurance panel participation, or your right work as a physician?
2
90
0102030405060708090
100
Yes No
Q7: Before partnering with the ABIM, should the ACC, HRS, and HFSA await the outcome of the class action antitrust/RICO lawsuit against the ABIM before implementing the Collaborative Maintenance Pathway for "maintaining" board certification?
81
11
0102030405060708090
Yes No
Q8: If they could do it again, should the ACC, HRS, and HFSA have partnered with the National Board of Physicians and Surgeons rather than the American Board of Internal Medicine?
73
18
01020304050607080
Yes No
Q9: Have you donated to the GoFundMe page sponsored by Practicing Physicians of America to help defer legal expenses for the four plaintiffs who filed the class action anti-trust / RICO lawsuit against ABIM?
37
56
0
10
20
30
40
50
60
Yes No
CMP Survey Limitations
Reality: Medical Specialty Societies Need Operating CashSources of Revenue
Realty: Growth in MOC® Fees
$795$995
$2,200
$2,750$2,800
$4,600
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
$5,000
Gen Medicine Subspecialty
2000 2018 2020
352% increase (17.6% / year)
462% increase (23.1% / year)*
* Does not include annual HRS/ACC membership fee
ACC
/HRS
CM
P*
Reality: Base-Case Cost Analysis of MOC® in 2015
ABIM’s Growing Payroll/Benefits
$22,342,620
$24,537,790
$25,907,935
$25,643,562
$27,291,362
$29,989,202
$31,963,647
$32,205,299
$20,000,000 $22,000,000 $24,000,000 $26,000,000 $28,000,000 $30,000,000 $32,000,000 $34,000,000
2009
2010
2011
2012
2013
2014
2015
2016
ABIM Annual Payroll/Benefits*
* ABIM Form 990
Reality: ABIM’s Mounting Legal Fees*
$159,405 $152,671 $105,808 $131,068$209,722
$344,047$421,386
$1,028,770
$1,700,799
$2,319,356
$1,951,670
$1,052,722
$767,999$947,441
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
MOC® Introduced
* Source: ABIM Form 990
Some Thoughts on MOC® / CMP
right to work
Some Thoughts on MOC® / CMP
ABMS Member Board Litigation Currently Underway• June 2013
American Board of Medical Specialties Antitrust
• Sept 22, 2015
Breech of contract, Copyright infringement, Liable
• Dec 6, 2018 2:18-cv-05260-RK
American Board of Internal Medicine (ABIM)• Class Action, Antitrust, Fraud, RICO, Unjust Enrichment
• 23 Jan 2019 ABMS, Am Board of Emergency Medicine, and Am
Board of Anesthesiology• Class Action, Antitrust
• 26 Feb 2019 Am Board of Radiology
• Class Action, Antitrust, Unjust Enrichment• 6 Mar 2019 Civil Case 1:19-cv-01614 Emily Elizabeth Lazarou and Aafaque Akhter vs Am Board of
Psychiatry and Neurology• Class Action, Antitrust, Unjust Enrichment
Final Thoughts on MOC®
https://practicingphysician.orghttp://drwes.blogspot.com
* * *
https://www.gofundme.com/practicing-physicians-of-america
