MOC Squabble Reignites Over Cost Analysis

Research finds that 90% of the cost to meet the American Board of Internal Medicine's Maintenance of Certification requirements is attributable to revenue lost because of the time it takes physicians to fulfill those requirements. 

I didn't know when I started to look into the American Board of Internal Medicine's Maintenance of Certification requirements that I would feel like the girl who kicked the hornet's nest.

Sure internists, hospitalists and internal medicine subspecialists became enraged last year when ABIM raised expectations in continuous professional development by increasing the number of MOC points required. Physicians complained vigorously that the learning activities associated with earning MOC points are frequently irrelevant to the practice of medicine.

Infuriated by MOC Rules, Physicians Unleash on Certification Boards

But the discontent abated somewhat in February after ABIM conceded that it had made mistakes and started changing MOC requirements based on feedback from the internal medicine community. But these changes may not be enough.

Last week, however, tensions flared again with online publication of a study in which MOC costs were analyzed. The study's objective was to estimate the total cost of the 2015 version of the MOC program and the incremental cost relative to the 2013 version.

The study, published in the Annals of Internal Medicine, found that the estimated cumulative costs for the 2015 MOC will be $5.7 billion over 10 years, $1.2 billion more than the 2013 MOC. The clincher is that 90% of those costs are opportunity costs—revenue lost because of the time it takes physicians to meet the certification requirements.

Internists will incur an average of $23,607 in MOC costs over 10 years, ranging from $16,725 for general internists to $40,495 for hematologists-oncologists, the study shows.

It points out that "Subspecialists face higher costs than general internists, primarily because they take additional certification examinations that generate more fees and a greater time outlay."

A Substantial [Cost] Underestimate
"Our study highlights that the key driver of MOC costs is the physician time required to complete MOC activities, which accounts for nine of every 10 dollars spent on MOC," the study states. The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year; this is a substantial underestimate precisely because it overlooks time costs. Efforts to decrease the cost of MOC should therefore focus on reducing demands on physician time."

Paul Teirstein—The Doc Behind the Mutiny Against the MOC

Richard J. Baron, MD, president and CEO of the ABIM, a member of its board of directors, and an internist and geriatrician with more than 30 years of community practice, understands that physicians are busy professionals. "We want to minimize the way in which they experience hurdles with the program and congruent professional self-development," he told me. "We have already implemented many of the suggestions mentioned in the article."

I asked Dhruv S. Kazi, MD, one of the study's authors, why he and his fellow authors decided to do the study in light of the ABIM concessions. "It occurred to me it was an historic opportunity to inform the conversation," he said.

Then I asked if he was satisfied with ABIM's ongoing efforts to meet internists concerns. "The changes announced in February are definitely a step in the right direction in helping the time burden," Kazi acknowledges. One of ABIM's reforms, allowing more of state required continuing medical education to be counted toward MOC, is helpful, he says. But the study calls for "increasing integration with existing continuing education activities."

Baron argues that the study's authors are not familiar enough with the wide range of CMEs that are now accepted toward MOCs.

Can't They All Just Get Along?
Kazi's biggest objection to the MOC requirements is that there is no hard evidence to prove that the cost in money and time actually improves the quality of patients' care. "There is plenty of evidence within healthcare to demonstrate that just doing something because you think it is effective is not good enough," he says.

Of course, ABIM disagrees. Baron says that a study published last year in the  Journal of the American Medical Association looked at the connection between MOC and costs and demonstrates that MOC can lead to savings.
 
Kazi dismisses the study's value: "In clinical medicine we seek high-quality of evidence of efficacy and safety. Policy interventions, particularly when they are expensive, should be held to the same evidentiary standards."

If sound evidence were available proving that the current MOC requirements was worth the costs, made physicians more knowledgeable, and improved patient care, Kazi says he would be satisfied and no longer object to it.

ABIM and the internal medicine community need to figure this out, and quickly.  Patients don't have much sympathy for physicians complaining about lost money and time, especially when it could impact patients' health.