Co-authored by Justin Pollock, M.D.
Credentialing has been important to physicians’ careers from the earliest days of medical practice. As far back as 1000 BC, the ancient Persian cult of Zoraster outlined its process for physician “licensure”. A candidate had to prove himself by successfully treating three heretics. If all three died, he was denied the right to practice medicine, but if all three lived, he was considered fit to practice for “ever and ever.”
Most of us would agree on the importance of a systematic physician licensing and certification system to establish consistency and safety in medical care. Unfortunately, the best means of achieving those goals is hotly debated and constantly evolving.
The American Board of Anesthesiology (ABA) is set to roll out MOCA 2.0, its newly redesigned maintenance of certification program, on January 1, 2016, in response to physician pushback against the original version. We’ll explain what’s new, what will stay the same, and why physicians in many fields demand revamping of the whole recertification system.
How did MOCA begin?
A medical license granted by the state does not indicate whether a doctor is qualified to practice in a specific medical specialty. Board certification is an additional qualification indicating that the physician has been approved by one of the 24 member boards of the American Board of Medical Specialties (ABMS).
Board certification was initially a lifelong credential. But in 1999 the ABMS began to require physician recertification every ten years through a new Maintenance of Certification (MOC) program. The American Board of Anesthesiology (ABA) followed suit, decreeing that anesthesiologists who achieved board certification in 2000 and beyond must participate in Maintenance of Certification in Anesthesiology (MOCA).
The ten-year MOCA recertification process is designed around four components:
- Professionalism and Professional Standing, requiring possession of a valid state medical license;
- Lifelong Learning and Self-Assessment, requiring accumulation of CME credits;
- Assessment of Knowledge, Judgment, and Skills (formerly Cognitive Expertise), requiring demonstration of up-to-date knowledge;
- Improvement in Medical Practice (formerly Practice Performance Assessment), requiring completion of practice-relevant improvement activities.
Since its inception, the MOCA process has been deeply controversial, with some groups extolling its emphasis on lifelong learning and high standards. Others criticize it as unnecessary, unsupported by quality evidence, expensive, and cumbersome, pointing out that all the ABMS boards have a powerful profit motive for advocating MOC programs. The total cost for 10-year MOCA recertification can reach $3,500-4,500, varying with travel costs and the (now optional) choice of a simulator session.
Does MOCA improve patient care?
Anesthesiologist Paul Kempen, MD, an outspoken MOCA critic, analyzed all the 2011 physician impairment data from the Ohio State Medical Board and found only two instances of disciplinary action against physicians due to incompetence out of 42,000 licensed physicians, an incompetency rate of 0.005%. The studies that claim to demonstrate the positive impact of physician board certification on patient care are mainly observational in nature, were funded by the agencies running the certification process, and have been charged with significant conflicts of interest.
Not surprisingly, surveys of physician attitudes towards the value of MOC and MOCA produce largely negative results. A 2010 poll asked physicians if they would recommend a fictitious physician with time-unlimited certification to enroll in a MOC program, and 63% of the 2,500 respondents said no. A 2013 ABA survey reported that anesthesiologists do indeed value board certification and parts of the MOCA process. However, respondents voiced concerns about the cost, complexity, and the lack of evidence that MOCA improves clinical care. Many anesthesiologists also felt that the written examination covered topics not relevant to their current practice.
MOCA and quality
Every anesthesiologist has a responsibility to keep up with innovations and technology. As healthcare focuses more and more on a patient-as-consumer model and on quality improvement, continuous board certification is surfacing as a popular metric for physician quality.
The ABMS website tells patients that board certification is highly important, and provides a search engine to verify physician certification status and MOC participation. The ABA website offers a similar link for anesthesiologists and MOCA. Not surprisingly, a 2010 ABMS survey reported that 95% of patients prefer for their physicians to participate in MOC. In 2012, CMS agreed to provide a 0.5% reimbursement incentive to physicians actively participating in a MOC program. While seemingly voluntary, board certification has a large impact on physician marketability, and recent graduates are particularly compelled to participate.
Taking a step further, some states have started pilot projects to evaluate Maintenance of Licensure (MOL). These programs would add new requirements to physician licensure, demonstrating participation in lifelong learning and professional development. While MOL does not yet require board certification or recertification, the Federation of State Medical Boards has made it clear that MOC participation will fulfill all MOL requirements.
Physicians are pushing back. More than 1000 anesthesiologists signed an online petition calling for the ABA to change and simplify MOCA. In response to escalating physician outcry and charges of financial mismanagement, the American Board of Internal Medicine (ABIM) formally admitted that its MOC program needs a makeover. The ABIM suspended some costly and arduous requirements for the next two years, and plans to redesign the entire program.
The ABA isn’t ignoring its critics either. In 2013, the ABA reduced the CME requirement from 350 Category 1 credits to 250. In April of this year, the ABA eliminated the written examination, a heavily criticized component of recertification, and replaced it with an online learning tool, the “MOCA Minute”. Launched as a pilot program in 2014, the “MOCA Minute” is intended to provide quick but intensive learning. The ABA will offer a variety of options to fulfill MOCA requirements, varying in affordability and time commitment. The simulation course, once a requirement of “Improvement in Medical Practice”, is now optional.
The updated MOCA program, called MOCA 2.0, is set to begin next year. The ABA says it has been designed to allow anesthesiologists to specify areas of clinical practice and tailor activities specifically to their areas of interest. The ABA website now includes a way for anesthesiologists to provide feedback about MOCA, and encourages “constructive criticism”.