James J. Amos, MD
Clinical professor of psychiatry, University of Iowa Carver College of Medicine
Dr. Amos has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
If you’ve recently become a board certified psychiatrist, you’re probably aware of the Maintenance of Certification (MOC) program. MOC was created in 2000 by the American Board of Medical Specialties (ABMS) for their 24 specialty boards, including the American Board of Psychiatry and Neurology (ABPN). It was designed to address a perceived need by the public for greater accountability from physicians in terms of continuous quality improvement, competence, and protection of the public.
Maintenance of Certification Psychiatrists who were board certified after 1994 are required to participate in ABPN’s 10-year MOC program (which the ABPN abbreviates “10YR-MOC”). During each 10-year cycle, all diplomates are responsible for demonstrating they are keeping up to date with their medical knowledge and practice (more information is available at http://bit.ly/118UTe9; see also TCPR, October 2010).
There are 4 MOC program components for diplomates to fulfill.
Part I: Professional Standing. This component involves maintaining an unrestricted medical license.
Part II: Self-assessment (SA) and Continuing Medical Education (CME). The self-assessment requirement involves ABPN-approved SA activities, which cover knowledge and best practices and provide feedback to guide CME. You’re required to do two self-assessment activities over a 10-year MOC cycle (one in years one through three, the other in years six through eight), averaging eight CME credits per year. For the CME requirement, you must earn 30 category 1 CME credits per year.
Part III: Cognitive Expertise. This component involves a computer-administered examination required every 10 years. You can only sit for the exam if you’ve completed all other MOC requirements. One set of completed MOC activities suffices for multiple certificates. At present, the examination fee is $1500 for 10YR-MOC candidates, although the ABPN will pay for one cognitive exam for candidates in the C-MOC program (explained in greater detail later in this story). If you have multiple certificates, you’ll pay extra for exams in those areas—ie, the psychiatric subspecialties like child and adolescent psychiatry, forensic psychiatry, and geriatric psychiatry. In 2013, the total cost for two or three modules is $2575 and $3300, respectively.
Interestingly, child and adolescent psychiatry (CAP) diplomates can choose to participate in MOC only in CAP. Their certification in general psychiatry would then expire. CAP is the only ABPN subspecialty with this option. All other subspecialties have to maintain the general psychiatry certificate in order to maintain the subspecialty certificate. There will be a random audit of diplomate applicants prior to allowing them to sit for exams.
Part IV: Performance in Practice (PIP). This is the most controversial and labor-intensive component. It comprises three PIP units over the 10-year MOC cycle, each of which includes a clinical module and a feedback module. The modules have to be preapproved by the ABPN.
For the clinical modules, the diplomate needs to gather data from at least five patients in a similar category, eg, major depression. You need to assess at least four quality indicators and compare your performance to practice guidelines developed by peers. Then you must identify improvement opportunities, change your practice accordingly, and recollect data within two years on either the same or different patients. The cycle includes three different time periods for doing this; during years one through three, years four through six, and years seven through nine.
Feedback modules require diplomates to personally solicit opinions from at least five peers and patients that they can personally select. A peer could be a social worker, according to the ABPN. Feedback should be obtained in the areas of medical knowledge, patient care, interpersonal skills, practice-based learning, professionalism, and systems-based practice. The ABPN requires only that you document your collection of feedback—not that you did anything about it. Auditors will not ask for any paperwork that includes protected health information.
If you’ve certified or recertified in the last ten years but you’re behind on any of these measures, there’s still time to catch up. The ABPN website contains a chart showing what you need to do and when (http://bit.ly/118UTe9).
Other health professionals who have somewhat similar maintenance of certification processes include some nurse specialists (see http://bit.ly/17gDkfF) and physician assistants (see http://bit.ly/Hmf03m), but their requirements are—for now, at least—much less complex.
Changes Afoot in 2012 If you passed your initial certification or MOC (“recertification”) exam in 2012 or later, you’re required to enroll in the ABPN’s Continuous Pathway MOC Program (C-MOC) (http://bit.ly/15c3eEO). If you passed in 2011 or earlier, you may elect to do so. As with the 10YR-MOC, C-MOC requires an unrestricted medical license and the successful completion of a “cognitive exam” every 10 years. It also requires the following activities in each three-year cycle or “stage”:
24 self-assessment CME hours
90 total CME hours
1 PIP unit
To sign up, physicians can register for their Physician Folio on the ABPN website (www.abpn.com). Participation in C-MOC costs $175 per year (amounting to $1750 over 10 years, at current rates), which covers the cost of one MOC cognitive exam per 10-year cycle. Modular examinations will incur additional fees, as noted previously.
Diplomates who certified or recertified in 2011 or earlier are already in the 10YR-MOC program but have the option to enroll in the C-MOC program after passing their next examination. Why, you might ask, should you do this now? For one thing, ABPN has moved to an annual program fee instead of one large examination fee every 10 years. Also, MOC activities are now tracked on a more continuous basis (three year cycles), not just every decade. Further details about the MOC and physician folios can be found at www.abpn.com/moc and www.abpn.com/folios respectively. The ABPN welcomes questions about the process in order to improve it; send email to email@example.com.
Maintenance of Licensure In a related development, the Federation of State Medical Boards (FSMB) proposes Maintenance of Licensure (MOL) as a framework for license renewal which “supports a physician’s commitment to lifelong learning” (www.fsmb.org/mol.html). If everything goes forth as planned by the FSMB, sometime in the “coming years” you may not be able to renew or obtain a medical license without participating in MOL.
The FSMB is a nonprofit organization representing the nation’s 70 state medical boards (including boards in US territories and some states’ osteopathic boards), with whom it is working to develop a nationwide MOL system. Pilot projects are underway in several states to study and implement MOL. At present, no exam is required for MOL; in fact, the FSMB is not clear what will ultimately be required, except that physicians must “demonstrate skills and knowledge in their areas of practice on an ongoing basis.”
It’s possible that you may be required to jump through the MOC hoops described previously, not only to maintain your board certification, but also your license. The FSMB believes there is enough research evidence to support imposing MOL; a bibliography of studies purportedly showing this can be found at www.fsmb.org/MOL.html.
Arguments Pro and Con Proponents of MOC and MOL point to high profile cases of egregious safety violations by physicians as clear indications for shared accountability among physicians and regulatory agencies (Dyer C, BMJ 2001;323(7306):181). As a case study, they point to the Bristol Royal Infirmary inquiry, undertaken by the National Health Service (NHS) in the United Kingdom to investigate the deaths of 29 babies at that hospital in the late 1980s and early 1990s. It uncovered a lax approach to patient safety, secrecy about physicians’ performance, and a lack of accountability, which led the NHS to implement a system for its physicians called “revalidation,” similar to MOL.
Here in the US, the Centers for Medicare and Medicaid Services’ Physician Quality Reporting System (PQRS) MOC Program began paying a 0.5% incentive payment (0.5% of total Medicare billings) in 2012 to physicians participating in a qualified MOC program (Kues JR, Curr Psychiatry 2013;12(2):17–20).
Opponents cite the high costs of MOC and lack of evidence to support the assumption that certification or recertification provides for better patient outcomes (Buscemi D et al, J Comm Hosp Int Med Persp 2013;2:1–6). In 2011, a referendum critical of the ABPN’s MOC PIP requirements was supported by 80% of APA voters but it failed to pass because only 25% of members cast a ballot, far fewer than the 40% needed.
I’m personally opposed to the MOL and the MOC in its present form. That doesn’t mean that I’m opposed to the principle of continuous improvement in skills and knowledge base. In fact, I’ve been trying to walk the tightrope between member specialty boards, which have the difficult job of translating the ABMS guidelines for MOC processes into working protocols, and physician groups who are vehemently opposed to the MOC in any form. To that end, I’ve submitted a resolution to block the implementation of MOL in my home state of Iowa, which the Iowa Psychiatric Society is co-sponsoring. The Iowa Medical Society House of Delegates has forwarded my resolution for discussion by the IMS Reference Committee. You can read more on my website at http://bit.ly/10HjNUV. Similar discussions are happening in other states.
TCPR’s Verdict: MOC and MOL have their weaknesses and challenges. However, psychiatrists need to understand MOC as it is currently designed, and to reflect on it, seek ways to improve it, reform it if necessary, and continue to look for practical ways to help health professionals provide safe patient care that is not only competent, but excellent.