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Physicians Rail at Recertification Requirements

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   June 19, 2014

Medical doctors are facing revamped board recertification requirements that are "expensive, burdensome, and detract from the care of the patient," says David Fleming, president of the American College of Physicians.

A physicians association representing some 120,000 practicing internists is up in arms over groundshaking new rules for board certification, known as maintenance of certification or "MOC."

Many of the new recertification requirements, which took effect Jan. 1, "are not evidence-based, but are expensive, burdensome, and detract from the care of the patient," says David Fleming, president of the American College of Physicians.

The new rules are so "logistically and emotionally burdensome," he says, that they "may drive smaller practices out of business."

The traditional recertification exam, a "secure" set of 200 multiple choice questions doctors must pass once every 10 years, now has a failure rate of 22% for those who take it the first time. For those who took it for the first time five years ago, only 9% failed, Fleming says.

Not only are many of the questions on the exam irrelevant, Fleming contends, but "the core general medicine questions that we were used to having in the past are no longer there. Instead, there's a lot of esoteric information you were expected to memorize, like knowledge of clinical situations and diseases that you never see."

The rules are perceived to be so onerous, that 10,000 internists have signed a petition calling for many of the new criteria to be killed.

Doctors are additionally concerned about new transparency policies that reveal to the public which doctors meet interval requirements, and which ones don't. "There's an insinuation that good doctors pass their boards, and bad doctors don't," Fleming says.

'Huge Stakes'

General guidelines for the new certification are now required by the American Board of Medical Specialties for all 24 boards, each of which tailors specific certification requirements for its group of specialty practitioners.

For internists, the largest group, board certification comes from the American Board of Internal Medicine, which certifies 200,000 internists or one in four physicians in the United States.

But it is the way the ABIM has interpreted its mandate from the ABMS, and tailored its own rules, that has internists fired up. "The ABIM's requirements are as rigorous or more rigorous than many other certification boards," Fleming says.

For example, the new rules require doctors to survey patients' charts, to assure that certain services have been provided, such as foot exams for all patients with diabetes. The effort may involve hiring more staff.

"We're not saying they shouldn't have to do this, but the problem is the way it's being rolled out, with very tight expectations that are burdensome for many practices. We don't think it should be part of the recertification process," Fleming says.

Fleming says that for internists, the need to maintain board certification is critical, more so than for many other specialties and it is becoming even more important for payment determination.

Proof of certification is often required by insurance groups to be considered a preferred provider, and it's increasingly tied to credentialing for staff privileges within healthcare systems.

"In some states, and more in the not too distant future, it's tied to licensure. There are huge stakes here" for doctors who can't meet criteria, Fleming says.

Why the MOC?

Before 1990, physicians who passed their board certification exams the first time were certified for life. Certification for most physicians had to be renewed with a passing grade on an exam every 10 years, starting in 1990. By 2001, however, it became increasingly important that besides the exam, internists had to have certain knowledge and skill, and training in an ongoing way.

The new requirements stem from years of discussion and a general acceptance that the old ways just weren't appropriate anymore.

"Our board realized that a lifetime credential is simply not credible, because we know over time physicians lose skills, and that knowledge changes," says ABIM President and CEO Richard Baron, MD.

It's important for older doctors too, he says, many of whom have been grandfathered under the old rules.

"All the boards decided to move toward a program where you didn't have the credential for life, one which had ongoing expectations for physicians to keep up to date during their practice careers, to maintain knowledge, and take on various other responsibilities that frankly, 20 years ago, physicians didn't have," Baron says.

Waited 'Til The Last Minute

"The board had an expectation that doctors would keep up continuously over each 10 year period, but most waited until year 8.5 and then did what was meant to be 10 years worth of programs in 1.5 years," Baron says. "They complained. 'Boy, it's so demanding all these things you're making us do and we don't have time.' "

So the ABIM put its foot down, saying that by January, 2014, doctors would have to satisfy certain performance and education criteria in a series of cycles rather than procrastinate until the last few months to do it all.

ABIM says it is listening to the doctors, and Baron issued this response to the petition in April. But so far, it is not about to budge, Baron says.

Much of the objection is coming from older doctors whose training did not include measuring and improving performance "as a core part of what you do as a doctor. And now, knowledge and expectations for what a doctor should do are changing."

Baron says that in the last 10 years, studies show enormous gaps between what doctors think they do and what they actually do for their patients, and that's why chart review is now being required to assess care.

"Take the foot exam for patients with diabetes. We know that in doctor's office A it's done 90% of the time, but in B, 5%," but both doctors will think they're doing it all the time.

"They don't reliably think of their jobs as meeting the needs of a diabetes population, but just those for one patient at a time, or those I saw from 9 a.m. to noon." It's not that they're bad doctors, but maybe for a patient with severe arthritis, taking the shoes off for the exam was too much trouble. Or maybe you skipped the exam because you were running late on the schedule."

To the cries that the cost is too high, Baron says that it isn't. To satisfy MOC criteria for one internal medicine certification, the cost is $1,940 for ten years, or $194 per year. For an endocrinologist, it's $2,560 for 10 years, or $256 per year.

The bottom line, he says, is that tighter credentialing and certification criteria is something that must happen now. "What the public wants is a doctor who is credentialed in a way they know that is someone who is keeping up with their discipline."

Recent articles in the Annals of Internal Medicine explain the issue from the ABIM's perspective and the ACP's.

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