Tuesday, June 03, 2014

Why Do Hospitals Side With Maintenance of Certification?

With the recent 22% percent failure rate of the most recent Maintenance of Certification (MOC) testing offered by the American Board of Medical Specialties/American Board of Internal Medicine, I was puzzled as to why any hospital systems would want to support the proposed Maintenance of Certification changes imposed 1 January 2014.  After all, wouldn't hospitals risk of looking like they have substandard physicians on on their staff if they failed to pass their MOC exam? Do hospitals really really side with the ABIM's leadership that MOC testing is for public good?  Or might there another motive why hospitals support the MOC process?

To reach an understanding of this issue, I asked a senior member of our staff who has served many policy roles within the leadership of the American College of Physicians, the Illinois Chapter of the American College of Cardiology, and served as a founding fellow of the Society of Cardiovascular Angiography and Interventions (SCAI), Joseph V. Messer, MD, MACC.  Joe is widely respected in the cardiovascular policy circles and has worked extensively on such things as "Appropriateness Use Criteria" and performance measures for cardiology. He carries a unique understanding of the challenges inherent to bureaucratic methods to measure quality care and (importantly) the limitations of creating such systems.  Joe is a luminary in many respects and thought hard about the question I posed him.  His response was both eloquent and insightful.  With his permission, I am publishing his response to me so others might enjoy Joe's perspective on why hospital systems want to "align" with the MOC process. Here is what he wrote:
Wes, your question yesterday at our Cath Conference started me thinking. Since I have decided not to go the MOC route, haven't given it much thought. Here are my ideas:

Both the Feds and the Hospital Systems prefer a single payer system. Several years ago at an ACC conference, the CMS representative told me their goal was to pour all the money into a single funnel and let healthcare systems worry about the distribution, providing a significant source of "handling" fees for the systems.

CMS and hospital systems seek alignment. The "funnel" analogy is one example. Further, CMS has very limited authority to define and require demonstration of quality from providers. They will encourage the hospital systems to handle this role, and will provide the $$ for same - thus more revenue for hospital systems, not unlike current support for residence and fellow training programs.

As we move toward a single payer system, hospital systems will continue their effort to control physicians - the most important of the distribution recipients in healthcare other than the systems themselves. By ultimate controlling MD's they can take a larger piece of the pie for themselves. Increasingly impotent physicians will have little recourse, since the public consumer now values convenience and low cost over quality.

Supporting MOC assists the hospital systems in controlling MD's. Systems will use public opinion, in part, as a tool in this effort. Hospital systems will vigorously claim that MOC assures higher quality. By requiring and advertising that all system employed MD's are MOC certified the systems will have another weapon against the "private practice" MD, many of whom will not pursue the MOC course, many of whom will be "concierge MD's" and the most vocal opponents of hospital systems.

Ultimately, I believe the hospital systems want to control the certification process. By supporting the MOC initiative they will likely destroy the ABIM as it loses its physician support because of MOC. The specialty societies are lukewarm at best about MOC's and I hear increasing criticism of ABIM for its ulterior financial motivations. Some specialty societies are receiving similar criticism for the fees they charge for educational materials crafted to meet MOC requirements. Thus, ACC and others may well suffer with the ABIM for not vigorously opposed MOC in its current form.

Marginalizing the special societies has already begun. It is very clear that employed cardiologists find less interest in the ACC. The largest grant the ACC has ever received just went to two Chapters - Wisconsin and Florida - to test local, grassroot proposals for health care financing. ($15.8 million over 3 years). National ACC supported this project for a while, but then fell away when the leadership lost interest. My concern here is that the ACC/AHA/STS/HRS/SCAI remain key supporters of quality, appropriate use and performance measurement. If they are significantly weakened by all of these issues - MOC, physician employment, decreased specialty influence in CMS and Congress, the hospital systems will surely move into the vacuum to control education and quality definition to their advantage.

But, when all is said and done, I doubt that the incoming crop of physicians care. In a recent survey (2-3 years ago) the primary motivation of medical school applicants was "job security".
Ugh.  Depressing.  Sadly, I think he's correct.

Thanks for your insights, Joe - 



Steve Parker, M.D. said...

I am grateful I am "grandfathered" as life-long certification (at least for now).

The MOC malarkey is a reason for young folks to avoid medicine as a career.

Do lawyers, bureaucrats, and politicians do this to themselves?

RD said...

Dr. Wes,

For students who have spent their entire conscious being struggling upstream like salmon through a torrent of educational endeavor, seeing the necessity of independence of is difficult. One more test seems like no big deal. More importantly, they don't understand the full weight of responsibility that practicing medicine entails, and how important it is to have the freedom to do the right thing for your patients. Truthfully, I didn't appreciate until I stepped out of an academic environment to independent practice, myself. We need leadership to show the way and overcome these challenges. Your work on this point is invaluable, sir.

Dr DW said...

Dr Parker, grandfathered does you no good. You will be listed as "not meeting MOC requirements" unless you participate and pay up.

K Murray Leisure MD Infectious diseases MA USA said...

MOC executives have no respect even for Board certified "grandfathers" from past decades. Experience means nothing. Pay up or die. Like Cosa Nostra, this unelected, unaccountable private testing industry monopoly fleeces us w regular "offers that you cannot refuse." Good questions as to why hospitals promote MOC so blindly? Unclear if hospital execs wished to shortcut the credentials process by letting MOC alone serve as a (false) standard of ongoing lifelong learning and professional excellence. Too bad for outstanding medical or surgical physicians who were superb in every way except that they declined MOC. Too bad for the hospital patients who lost access to these fine doc's only due to MOC peculiarities. Alternatively, did MOC/ ABIM backed lawyers and lobbyists work the dark side with hospital associations to provide sample medical staff bylaw templates that just happened to mandate MOC requirements among minor details? And were there special educational grants, kickbacks, or other arrangements from the ABIM and ABMS rendered to hosp execs in exchange for their unquestioning support of MOC programs? Just curious.

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