Published in the October 2014 issue of Todays Hospitalist
AS HEAD OF HOSPITAL MEDICINE at University of Virginia (UVA) in Charlottesville, George Hoke, MD, received an unusual request last March from his credentialing committee: Come up with a plan to ensure that all group members would be board certified in hospital medicine as a requirement for hospital privileges.
Instead, Dr. Hoke sent the committee a clarification. He explained that there is no such thing as board certification in hospital medicine, only the option of recertifying with a focused practice in hospital medicine for doctors who have worked as hospitalists for at least three years.
As for requiring focused practice recertification for all group members, Dr. Hoke pointed out that such a policy wouldn’t allow him to hire doctors straight out of residency, a real handicap for recruiting. It would also prevent him from hiring hospitalists who choose other routes to recertify, such as palliative care or general internal medicine, and limit his options for bringing moonlighters on board.
In response, “the committee has put the issue on hold and allowed us to continue as is,” Dr. Hoke reports. “But I think the topic will definitely get revisited in another year or so.”
Dr. Hoke’s back and forth with his credentialing committee comes at a time of confusion and uproar within medicine around maintenance of certification (MOC). While some have long grumbled about recertification’s costs, rigors and lack of evidence, that dissatisfaction flared into angry blowback this year in response to new MOC requirements announced in January by the American Board of Internal Medicine (ABIM).
Among the new requirements drawing heat: Doctors whose certification was grandfathered in 1990 must begin completing MOC components. According to Dr. Hoke, the most “contentious debate” before UVA’s credentialing committee is whether grandfathered doctors should comply with that new requirement.
A bigger issue for hospitalists is the fact that instead of being able to wait until the end of their 10-year recertification cycle to complete the various MOC elements, doctors are now required to do “some MOC activity every two years,” according to the ABIM Web site. They must also earn 100 points toward maintenance of certification every five years, as well as complete a patient safety and patient voice module.
For doctors who don’t comply with those new two- and five-year timelines, their profiles on the ABIM Web site will (starting in 2015) reflect that they are not “meeting maintenance of certification requirements.” Hospitals that require doctors to maintain certification might very well start pressuring them to comply with those requirements or put their privileges in jeopardy.
ABIM did announce in July that it may review some of those decisions. That announcement came after the board met with representatives from more than two dozen specialty societies, including the Society of Hospital Medicine (SHM).
Executives from the American College of Physicians (ACP) have characterized the new requirements as “an important tipping point” in catalyzing longstanding complaints about MOC, while the endocrine association is threatening to explore alternative certification mechanisms. Meanwhile, an MOC protest movement has gathered steam. Since July, more than 4,600 doctors have signed a petition of noncompliance with ABIM’s MOC process, pledging to opt out of MOC unless significant changes are made.
Another petition drive launched in March by the same group “Physicians for Certification Change “is asking ABIM to drop its new requirements. That petition has garnered more than 18,500 physician signatures. Online comments from doctors on the petition site level charges against “Big Medicine” and the “certification industrial complex.”
Hospital medicine is maintaining a low profile in the dissent. But hospitalists have plenty of ideas on how recertification should be changed.
Many want the process streamlined and made more relevant. Others are going further, asking their hospital administration to rethink the need for MOC beyond initial board certification. While ABIM has responded in print and on its Web site to many of the objections raised, we talked to several hospitalists to sample what hospital medicine thinks about MOC and to find out how individual hospitalists plan to respond.
“I totally support the concept that physicians should be continually educating themselves to make sure they’re up to date,” says Dr. Hoke. “The ‘how’ is the hard part.”
Hospitalists: “less libertarian”
While Dr. Hoke has heard all the chatter about the pushback on ABIM, he’s not surprised that hospital medicine isn’t in the thick of the fight.
“Just by the nature of our practice, we’re used to other people scrutinizing our work and looking at our data on performance,” says Dr. Hoke, pointing to MOC’s practice assessment and quality improvement components. “As a group, we’re probably less libertarian than physicians in general.”
Then there’s the fact that, as a workforce, hospitalists are fairly fragmented in terms of recertification. While most see the launch of focused practice in 2010 as a real achievement, hospitalists haven’t universally embraced focused practice, at least not yet. In the 2014 Today’s Hospitalist Compensation and Career Survey, 11.7% of full-time adult hospitalists reported having taken and passed the focused practice exam, while 41.5% said they planned to pursue focused practice to recertify. But 46.8% reported not having signed on for focused practice for MOC “and said they had no plans to do so.
“Hospitalists who have another certificate “be it nephrology or palliative care “will probably maintain them, and hospitalists will remain split in terms of recertification,” says Jeffrey Frank, MD, quality director for CEP America, a physician-owned company based in Emeryville, Calif., that staffs EDs, hospitalist programs and urgent care centers. While some hospitalists see focused practice as much-deserved recognition, Dr. Frank believes that others may perceive it as “pigeonholing them” and potentially making it more difficult for them to accept a position in outpatient care.
Deadlines and standards
As for ABIM’s new requirements, Dr. Hoke “who plans to recertify in focused practice in 2018 “finds them troublesome.
“What I do for recertification is not going to be the primary means by which I get CME and stay up to date,” he says, noting that one complaint about the new requirements is that ABIM is trying to monopolize the CME process. “Primary CME for me is going to university conferences, attending national meetings and reading journal articles, so telling me I have to do ABIM’s CME every two years is troublesome.”
Plus, Dr. Hoke points out, the new ABIM schedule just adds to a list of bureaucratic deadlines doctors already have to meet.
“You’ve got licensure every two years, your DEA, your hospital credentialing, with my institution and state needing me to provide proof of CME,” says Dr. Hoke. “Why do I have to report CME to three different parties, including ABIM, in three different ways? Isn’t there a standardized way we could do this so there’s less administrative waste?”
But not everyone feels so negative about the new timelines. Hospitalist Kareem Hinedi, MD, now practices in Dhahran, Saudi Arabia, as part of Johns Hopkins Aramco Healthcare “a position for which he has to maintain ABIM certification.
Before he started practicing abroad, Dr. Hinedi says he worked as a hospitalist in Oregon where, at the time, he did not have to fulfill any CME requirement for state licensure. (That changed in 2009, and doctors in Oregon must now report 60 CME credits every two years to be licensed).
“At least, recertification standardizes across states what people are required to do for CME, which is probably a good thing,” he says. As for the new two- and five-year ABIM requirements, “I don’t have much of an issue with having to be more proactive earlier on.”
Dr. Hinedi, who doesn’t need to recertify until 2016, plans to take the focused practice exam next year. His big complaint so far is that so few board review courses are geared toward focused practice. Last month, SHM sent out a call to authors to help create vignette-style questions for a focused practice exam prep tool.
Cathleen Ammann, MD, a hospitalist at Wentworth-Douglass Hospital in Dover, N.H., was among those to take and pass the inaugural focused practice exam in October 2010. For Dr. Ammann, both preparing for the exam and completing the various MOC elements were positive experiences.
She found the exam to be relevant and says that studying for the test helped her “internalize information” much more than if she was just attending a conference for CME. While she found the PIM selection at that time to be limited “”many were office-based and not possible for hospitalists to do,” she says “she’s encouraged that ABIM plans to make more available.
“I do not join the ranks of people,” says Dr. Ammann, “unhappy with ABIM requirements.”
Seref Bornovali, MD, a hospitalist with a solo practice at West Chester Hospital in West Chester, Ohio, passed the focused practice exam last fall.
He too is “really glad I took the exam,” Dr. Bornovali says. “I believe it’s made a difference in my practice.” He also continues to use techniques he picked up from ABIM’s patient safety modules.
But as for the PIMs, “they didn’t have much to do with performance or improvement,” says Dr. Bornovali. Other MOC exercises were also excruciating, he notes, such as distributing and collecting surveys from patients and referring physicians.
“You have to survey a large number of patients who are receiving surveys from the hospital already,” he explains. “The rate of return was so low that several weeks later, you had to find another group of patients.” As for referring physicians, “the survey is so long, I just had to call and beg them to write something, just to get it done.”
Making MOC more manageable
Another problem Dr. Bornovali had completing practice improvement modules for MOC stems from the fact that he’s a private practitioner, not a hospital employee.
“Many of the quality improvement modules assume that hospitalists have an integral relationship with hospital administration, with access to quality and performance data,” he says. “But I don’t have that relationship with the hospital.”
Hospitalists who do have that relationship, however, want a more streamlined process for submitting quality improvement data. That would go a long way, some say, to making the MOC process more manageable.
CEP America, for instance, has 17 hospitalist programs staffed by 225 hospitalists. “As an organization, we provide data and have very robust site leaders and site support,” says Dr. Frank. He plans to create practice improvement modules that the hospitalist partners in his company can use for MOC. “Groups should be able to submit their data as a whole to ABIM for several individual physicians,” Dr. Frank explains, “but I don’t think ABIM is there yet.”
Yet some physicians are convinced that MOC needs a much more radical overhaul. Ryan Nagy, MD, who finished his med-peds residency in 2012 and certified in both internal medicine and pediatrics, is the medical director of a new hospitalist program set up by 4M Emergency Systems, a staffing company, at Saint Elizabeth Boardman Health Center in Youngstown, Ohio. As far as he is concerned, the new requirements are really hard to parse out and the entire MOC process is too cumbersome.
“Generic modules that teach to a test that itself is somewhat arbitrary is not really a way to improve practice,” says Dr. Nagy, who has signed the Physicians for Certification Change petition. “Instead, you want physicians to be double-checking what they’re doing for the patients they’re actively seeing.”
Rather than finishing practice assessment and medical knowledge modules produced by a board or medical society, for instance, he thinks the CME credits he earns for using UpToDate in his practice should count toward MOC.
“I’ve got probably 40 or 50 CME credits for the last six months just because I’m reading,” says Dr. Nagy. “That’s what CME should be directed toward: improving patient care.”
Should MOC be required for privileges?
Dr. Nagy also offers up this alternative version of recertification. “My solution would be to cut the cost of the exam, cut the exam itself in half and do the exam every five years as opposed to every 10,” he says.
Doctors would need to submit “one keystone project every five years” on clinical care, practice assessment or patient safety. And “you would still have to keep up with CME, which I think is very important,” Dr. Nagy adds. “But doing all this extra stuff for certification is beyond what most people consider reasonable. I wonder if the cure is worse than the disease.”
In the meantime, he and other colleagues have approached their hospital’s credentialing committee.
“As a group, we’re trying to decide whether we even want to participate in maintenance of certification at all,” Dr. Nagy says. “We’re trying to work with the administration to figure out if recertification is really necessary or if board certification alone is what’s needed.”
According to Dr. Nagy, the internists and internal medicine subspecialists on the credentialing committee “have spoken up, saying they feel that maintenance of certification is really not practical until a more definitive benefit is shown.” Committee members who are surgeons, on the other hand, are pushing to keep maintenance of certification mandatory.
The committee has delayed its decision for a few months to gather more opinions from local physicians. And what will Dr. Nagy and his colleagues do if the committee decides that maintenance of certification is required on top of initial certification?
“Then we will all enter the maintenance of certification program,” he says.
Working toward a “two-way street”
Dr. Frank from CEP America, who doesn’t have to recertify until 2020, doesn’t have a problem with hospitals mandating maintenance of certification.
“Anything that helps maintain the impression that doctors are continuously learning,” he says of MOC, “is good for the industry.” But he admits he is “sitting on the sideline, watching ACP battle with ABIM” and waiting for ABIM to clarify its new MOC cycles.
In the wake of objections raised, ABIM has said it plans to broaden the kinds of educational efforts doctors can use for MOC credit and include more activities they may already be doing in their own practice.
That would be a welcome change, says Dr. Hoke. “The rigidity of having to do practice improvement modules through ABIM may not adequately take into account how individual hospitalists practice,” he says. That makes the current process “perhaps not flexible enough to be useful. We want recertification to be useful to docs, not just a hoop to jump through so you can put ‘board certified’ on the Web.”
Dr. Ammann echoes that sentiment, saying she’d like the practice improvement modules expanded to include topics that hospitalists are already working on.
She’d appreciate, for instance, a PIM related to geographic rounding. “It would be nice to have a two-way street,” says Dr. Ammann, “where we as a specialist body could actually move our data forward and develop best practices through recertification projects.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Decision time for pediatric hospitalists
WHILE HOSPITALISTS WHO TREAT ADULTS have had the option of recertifying with a focused practice in hospital medicine since 2010, pediatric hospitalists are still trying to decide what kind of recertification pathway to push for.
Among pediatric hospitalists, a 2011 survey found that 33% supported a focused practice pathway similar to what the American Board of Internal Medicine provides, while 30% supported establishing pediatric hospital medicine as a distinct subspecialty complete with a two-year fellowship. Another 17% thought that residency programs should incorporate a hospital medicine track.
While a slim majority of pediatric hospitalists gave a thumbs up to focused practice, a council of representatives from several pediatric associations that met in 2013 came up with another recommendation: pursuing subspecialty status. That council is now petitioning the American Board of Pediatrics for support. Under that plan, pediatric hospitalists currently practicing would be grandfathered in.
As for a focused practice option, the council of representatives felt it was a “non-starter,” says Weijen Chang, MD, a med-peds hospitalist who is site director of the hospitalist service at the University of California, San Diego in La Jolla, and who sits on the pediatric committee for the Society of Hospital Medicine.
Why so down on focused practice? “The initial data on how many adult hospitalists signed up for focused practice was viewed as less than encouraging by the American Board of Pediatrics,” Dr. Chang says. “But I think those numbers were very preliminary.” Many adult hospitalists, he points out, may be reluctant to enter such a new process in its first years.
Two groups within pediatrics have raised reservations about pursuing only the subspecialty pathway: community pediatricians and med-peds doctors. With the majority of med-peds physicians supporting a focused practice option, “we want to raise the issue again.”
So which of the two possible pathways “a subspecialty requiring a two-year fellowship or focused practice “is Dr. Chang rooting for? Actually, both.
“I think the group of pediatric hospitalists who will be leaders in the field and staffing big-city children’s hospitals will have done a two-year fellowship,” he says. “But there is absolutely no way a smaller community can retain and hold onto the pediatric hospitalist workforce it needs to take care of children in the hospital with that requirement.”
As Dr. Chang prepares to join his med-peds colleagues in advocating for a two-pathway solution, he’s getting first-hand experience with focused practice. Although he recertified in both internal medicine and pediatrics in 2009, he’s sitting for the focused practice in hospital medicine exam this month.
Focused practice figures
- 590 American Board of Internal Medicine diplomates have taken the focused practice in hospital medicine maintenance of certification (MOC) exam since 2010.
- 109 American Board of Family Medicine diplomates have taken the exam.
- Currently, 1,536 doctors are enrolled in the focused practice program.
- 232 doctors have signed up to take the exam in October 2014.
- Since 2010, the first-time pass rate for the focused practice exam has fluctuated between 86% and 89%. (For internal medicine, that rate dipped to 78% in 2013.)
- The cost to complete focused practice MOC is $2,060. That price includes all ABIM-produced modules.Maintenance of certification FAQsWhat new maintenance of certification (MOC) requirements did the American Board of Internal Medicine announce this year?
Recertifying physicians must now do some MOC activity every two years. In addition, they must earn at least 100 ABIM MOC points every five years, and that five-year total must include at least 20 points in medical knowledge and 20 points in practice assessment. Doctors must also complete a patient safety and patient voice module every five years. Right now, the ABIM’s Web profiles of doctors who still have time left on their current certification or recertification indicate that they are meeting MOC requirements.
But the clock is ticking on the new two- and five-year MOC deadlines. If physicians do not complete some MOC activity by the end of 2015, which will be two years since the new requirements were first announced, ABIM plans to note that those doctors’ profiles that they are not meeting MOC requirements.
What MOC practice assessment options do physicians have?
Recertifying physicians can choose among more than 20 ABIM practice improvement modules (PIMs), including a self-directed PIM to report a quality improvement project they’ve completed on their own. They can also choose among more than 50 approved quality improvement activities, most designed by medical societies. Approved activities include two from the Society of Hospital Medicine: Project BOOST and the glycemic control mentored implementation program.
Institutions and health care systems can also submit quality improvement projects to the Multi-Specialty MOC Portfolio program for approval. Once approved, physicians who are employees of or contracted with a sponsoring institution can submit data on that quality improvement activity to earn MOC points.
Are states moving to require maintenance of certification for maintenance of licensure?
In a July 28 letter, ABIM wrote that it “does NOT support using MOC as a requirement for any maintenance of licensure program.”
And according to a spokesperson for the Federation of State Medical Boards (FSMB), no states have moved to require MOC as a condition for licensure. Further, the FSMB is not aware of any state boards that are considering making it mandatory.
In several states, however, doctors can let their state medical board know that they are participating in maintenance of certification and be exempt from having to report CME when renewing their license. According to the ABIM Web site, those states include Idaho, Minnesota, North Carolina, Oregon and West Virginia.