Thank you for the invitation to speak. Just to warn everybody, most of my talks are usually 20% entertainment and 80% content, so there might be a little humor in some of the slides. So these are some irrelevant financial disclosures. I'm a neurologist, by the way, not a hepatologist or GI specialist. I'm also the Director of Legislative Affairs for the National Board of Physicians and Surgeons, so I'm going to be talking quite a bit about that and how we came about. Also a facial hair disclosure. Are any of you familiar with Movember for prostate and testicular cancer awareness? So some years I take it a little bit further than others, so this mustache is a little bit tamer than what I've had in previous years. So we'll skip through some of these slides, and I think our first two speakers did a great job, and I would like to say what a great job the ABMS and ABIM has done over the years of providing initial certification. It's a herculean task to really do that, and that's why the NBPS requires it, which we'll talk about. So I think it's a great service that they do to the medical community. As you know, residencies and fellowship programs are highly variable in terms of the knowledge that the students or trainees receive, and so it's nice to have a standardized format that we can assure the public that they walk out of their training programs with that core fund of knowledge. So this is the timeline which you're all aware of. Prior to October 1st, 1994, there were lifetime certificates. It was a celebrated rite of passage to pass your exam. After that time, the 10-year exams came out, which we all kind of agreed with and said, okay, that's fine. Every 10 years we'll take an exam, although many of us did feel it was kind of hypocritical to hold one group of physicians exempted from taking the exam and then another group having to do it, which discreetly it is discriminatory based not only on age but also sex and race, because there's a larger and growing number of minorities and women in practicing medicine. And of course, the irony is to hold people further out of training to a higher standard or a different standard than people who've been out of training for longer. So I'm grandfathered just as my grandson. Yeah, Grandpa, who needs MOC when you have pecks of steel? So in 2007 is when the MOC or maintenance of certification programs came about. Not only was it the exam and the CME, but there were these SA and PIP modules, and one of the websites actually said the change from recertification to MOC strengthened the program and guaranteed that physicians were current in ways not immediately available for testing. So the term guaranteed kind of struck me. That's kind of a strong term to be using. Any Star Trek fans here? Yeah, so we have Jim here. Can you handle this, Bones? Dammit, Jim. Starfleet terminated my contract because I did not buy my MOC modules on time. Hashtag the real Brooke McCoy. So we don't have much to do with our time between patient care, having to see more patients in shorter time, research, educating trainees, EHR compliance, CME, ICD-10, institutional compliance modules, as well as, of course, family and social commitments. And I liken this to a hot dog eating contest. You know, in the literature there's talk about coping strategies, career counseling, meditation and yoga, but how about less hot dogs? And in my opinion, hot dogs are administrative burdens which necessarily do not improve the care that we give our patients. So I attended an information session myself back in 2014 and everybody in the audience was asking, who came up with these modules? What's the evidence that it supports the improvement of patient care? And I could just cherry pick patients and colleagues to say, you know, I'm a good doctor and fill out some of the surveys and also it's quite expensive. And in my opinion, starting MOC was like introducing a drug without doing any testing about safety or efficacy and just introducing it to a large population and keeping your fingers crossed. The efficacy would be a lack of studies justifying some of the negative effects, which we'll talk about, including physician burnout. And again, a lot of the people pushing these were grandfathered physicians who really didn't have to do it, as well as salaried employees. So at that point, I'm going to skip through some of these slides. I decided to take action. I started a petition with 1,500 neurology signatures and 15 letters and even the American Academy of Neurology chimed in saying, and again, the request was just to remove some of the modules, keep the tenure exam, that's fine. The AAN chimed in saying that the modules were onerous and really didn't improve practice. The APA very quickly jumped in and said the same thing. And then back in March of 2015, the ABPN said, we're not going to be changing anything. And the AVMS chimed in similarly saying, we have no plan on changing anything. And at this point, many of us felt like the tail was wagging the dog and that these organizations were telling physicians what to do without actually listening. Now this is a chart that I added in, which is actually a factual chart. The turquoise there is the growth of administrators over the same time period, while yellow is the growth of the number of physicians. When people wonder where our healthcare dollars are going, you can't ignore these numbers. So on one of the ABIM 990 forms, it showed that there was a $39.8 million cost of products and services and $125.7 million went to some of its senior officers. And for me, the ABPN CEO made almost $3 million while officers were making six-figure salaries. Now I'm a firm believer that if you leave the practice of medicine to work with the boards, I think you should really make no more than what you would have made in clinical practice, not double, triple, or even quadruple that number. That's a nice chunk of change. Are they looking for new board members? So this is a slide, which I didn't believe when I first saw it, but these are some of the overseas holdings of the ABIM from their 990 form in 2015, totaling $6.5 million. So you have to wonder, where is a lot of this excessive revenue going? There's a JAMA analysis in 2013 that looked at some of the member board revenues, and there was a $24 million surplus, and I'll just quickly read this quote because it is powerful. As non-profit organizations funded primarily by physician members, the ABMS member boards have a fiduciary responsibility to match revenue and expenditures. However, this is not the case for most boards with overall revenue greatly exceeding expenditures. Now when I read this, I thought this was going to be an angry private practice internal medicine or family practice doctor, but no, these were plastic surgeons that wrote this piece. So really, it does cover nearly every discipline of medicine. And when you talk about cost, this piece, which was written in the Annals of Internal Medicine, a single-boarded physician, it costs about $16,725 to comply with a 10-year cycle of MOC. When you look at the time lost from seeing patients, cost of prep materials, as well as the actual testing materials, and for a multi-boarded physician, in this case a hematologist oncologist, $40,495 to comply with a 10-year cycle of MOC. So it is quite costly. To look at it in another way, some hospitals are actually reimbursing physicians for the cost of MOC independent of their CME budget. So I'll just say one healthcare system, if there's 1,200 physicians times $2,000 per physician, that's $2.4 million that the hospital's paying in MOC fees, or $240,000 every single year. And in my opinion, that's money better spent by the hospital on the opioid crisis or other patient-centered activities. In addition, that doesn't take into account the revenue that the hospitals are losing based on not seeing patients during those times. And of course, that's in addition to conference time, CME, and personal time off. This is one of the 990 forms, which documents some of the salaries of some of the people at the AVMS. And as you can see, six-figure salaries ranging from the $300,000 and $400,000. And many of the people that are listed in these ledgers are the same people that are writing some of the articles. So I'll read one of the excerpts here. In general, physicians who are board-certified provide better care, albeit the results of modest effect sizes and are not unequivocal. Just that terminology, not unequivocal, it's kind of amazing to me. I'm not even sure what that means or how that got published. In addition, inserts are paid for to include this kind of material purporting that MOC significantly improves patient care. On the other hand, there are pieces that detail how there's really no significant difference between grandfathered physicians and MOC-compliant physicians. In this paper, they looked at 10 primary care performance measures and found no difference between these groups. And again, this was published in JAMA. Two critiques I've heard about MBPS, which again we'll talk about in a future slide, is that are you willing to forfeit your initial certification and continue to recertify with this other organization when in fact MBPS certification is an extension of your initial certification? And then if you're named in a lawsuit, would you be willing to claim that you're not board-certified? And I would argue that if you are negligent, no matter what piece of paper is hanging on the side of your office, it really doesn't matter. You're going to be found guilty. And I don't think any board will come running to your defense if you're being negligent. So we'll skip some of these slides here just in the essence of time. Just so all of you know, Medicare does not require maintenance of certifications. And many insurance companies do require maintenance of certifications. And because of that, then the hospitals and the medical centers then require maintenance of certification. So it's kind of a difficult cycle to break. There is a organization called the NCQA, which actually certifies insurance companies. And Margaret O'Kane is the founder and president. And as you can see, she is the president of the NCQA, but she's also a board member of the ABMS, which does draw into question that there might be some conflicts of interest there. And again, here's the 990 form and her salary listed there for you to see. So this article basically looked at one angry anesthesiologist who had just taken their 10-year exam. And after the 10-year exam, the continuous certification process was rolled out in anesthesia. And basically, he was told you have to pay your dues and you have to participate in the continuous certification, even though you just took a 10-year exam, which should alleviate you from having to comply for 10 years. And a lot of the same arguments applied here. He thought it was expensive. He just did this 10-year exam. And he was being tested on material like open heart surgery, chronic pain, and other things that had nothing to do with his actual practice. And after quite a bit of anger from him and anesthesiologists like him who just took the exam, finally, there was some back down and it was reported that they said, OK, you don't have to pay the fees for 10 years, but you still have to comply with some of the requirements. The ABPN for neurology did something similar with a MOCA 2.0, where you're expected to read articles and then answer some questions. So this is one slide I post to my neurology colleagues when I give talks to them. And I ask them, what is this slide? And nobody can really identify it. I then put this up and everybody yells, acoustic neuroma, completely irrelevant to practice. Very relevant to practice, which illustrates some of the material that's on some of the exams that really doesn't make sense. So board recertification is what the National Board of Physicians and Surgeons do. Again, we appreciate the work that the ABMS does with initial certification. It's critically important for the practice of medicine, and that's why we require it. You also need a valid license to practice 50 hours of CME over a 20-month cycle for selected specialties, particularly interventionalists, hospital privileges, and that no negative action has been taken, again, contrary to some people's opinions, we've actually turned down a number of people who've applied to be diplomats because we do have a pretty thorough screening process, and we note that some people have had actions taken against their license and we do not recertify them. These are some of the institutions and some of the specialties that are represented by the National Board, and we actually did a journal club looking at, we had two outside reviewers who were independent and took a look at some of the literature that's reported supporting MOC. The vast majority of it actually purports the importance and value of initial certification, and a lot of the literature that's out there supporting MOC is relatively weak. So as time goes on, more and more societies are actually endorsing MBPS as a viable alternative. These are some of the state societies from the neurology perspective, and even the AMA has weighed in saying that maintenance of certification should not be a requirement to practice, and I'm told that in addition to resolutions, they've been some action may happen in the near future. Also many of you know, in a parallel way, states are passing their own legislation saying that maintenance of certification should not be a requirement to practice. Oklahoma was the first, followed by Texas. In Texas, the law basically says that you cannot require MOC unless the entire medical staff has voted in favor of that, not a group of administrators, not a credentialing committee, but actually the entire medical staff. And numerous other states have also passed similar laws. In my state of Massachusetts, the key sponsor for the bill is actually the Massachusetts Medical Society. So when the people that put out the New England Journal of Medicine say it's a reasonable idea to support this bill, I think that should carry some credence. I've lobbied there as well as in Rhode Island, sorry, New Hampshire and Rhode Island. So a couple things that have come up when I've done some of this testifying on a state level, MOC is a voluntary process, which is what the ABMS purports, then why are they fighting bills that just want to have pro-competition so that physicians will have a choice between MBPS and ABMS. Public safety is at risk. Again, we did talk about how there are already safeguards in place like mid-year reviews and things like that, but also when there are malpractice issues, the vast majority of those physicians, if not all of them, are MOC certified anyway, so I don't think that's much of a safeguard. And then this idea of you don't know what you don't know. I would argue that everybody attending this liver meeting has probably learned some new things about liver disease that they didn't know before entering and that testing you or giving you a quiz on it is not going to make you learn that material any better than just attending the lectures. Physicians need to know cutting-edge material. I would say cutting-edge material is what appears in journals. If you want cutting-edge material to appear in an exam, it really has to be a gold standard and for things to become the gold standard typically takes years. So what's tested on the exam really can't be called cutting-edge material. It's not that expensive. We already went over the numbers and these things, just because of time, I don't want to run into. The Department of Justice not too long ago issued an opinion letter on this very subject. Many of you, are you familiar with JACO? How many people? So JACO was the only organization that CMS, the Centers for Medicare and Medicaid, were accepting for credentialing facilities. And then CMS actually said, you know, it's actually bad to have a monopoly and allow one organization to do all the certification for facilities. So they've actually opened it up and there's a couple of different organizations now that are certifying facilities which CMS will recognize. And the Department of Justice said something similar. If you do not have competition, you'll actually stifle innovation and it could actually harm the practice. So like I said, I fully support ABMS initial certification. That's why NBPS requires it. And it's really an important thing that the ABMS does. On the other hand, MOC is expensive, time-consuming, and has no convincing evidence that it improves patient care. MOC is often irrelevant to specialties and subspecialties. I'm a headache specialist. So for me to have to learn about MS and ALS and all these different things really does not apply to my practice. But it's something that I'm required to do under ABPN. MOC harms patient access to healthcare because already when there's such long times for people to see specialists, you're adding three to four weeks every single year a lot of the time. And over time between every single physician, that's a lot of time that patients are waiting. And also it does lead to early retirement. People that are on the verge do end up doing that. MOC does contribute to physician burnout because it's yet another responsibility with more pull-down menus and things that don't necessarily improve practice. And really it is not tailored to the physician's learning needs and assessment. So I'll end with this. Initial certifications like buying a brand new car, you're really happy with the car. Routine maintenance and oil changes in the form of CME, discussing cases with colleagues. And I read this in one piece. The adage of the wise old doctor who improves with experience is not true. Doctor skills tend to deteriorate after their formal training is over. I mean that couldn't be further from the fact that doesn't take into account when we look up up-to-date and check things on our phone and attend conferences, which really reinforces all the CME that we do. The MOC recertification exam is like a used car, although your car runs fine anyway. Every 10 years we're going to ask you to buy a new car. And then finally the modules I liken to a bicycle. Although you own a car, you'll still need a bicycle and you'll be required to make yearly payments. The chain might be broken, the tires may be flat, but you have to pay for it anyway. So I'll take questions and apparently Dr. Frieda is the first question. Is board recertification going to affect non-physician providers? I hope this does not affect my acupuncturist. So thank you for your time, I appreciate it.

maintenance of certification

physicians

MOC challenges

physician burnout

alternative certification board