The Evolving RequirementsRecommendations for Physician by penniesneverknow


									The Evolving Paradigm -Tying
Physician Demonstration of
Continuing Competency to
Maintenance of Licensure

  Does the emperor have any clothes?

      Linda Van Etta, M.D., FACP
            March 7, 2009
Concerns about poor quality of
healthcare in U.S.
   IOM reports- 1999, To Err is Human
    followed by Crossing the Quality Chasm
   consumer groups-Consumers Union,
    public reporting
   TJC-national patient safety initiatives

                 Is the problem due to physician incompetence?
Increasing “concerns” about
physician competency
   Perception of decreased physician skills and
    knowledge during practice life
   Perceived need for physicians to provide
    enhanced demonstration of competency
    periodically during their careers-CME not
   Perception that current state medical board
    requirements for MOL are inadequate to
    assure competence
What is physician
   The ability to answer knowledge
    questions on a secure exam?
   The ability to diagnose patients and
    prescribe appropriate treatment?
History/evolution of physician
training and certification
   1840s-physician “trade schools”
   1845-Nathan Davis, NY, proposed
    nationwide professional association
   1847-AMA founded
   1876-AAMC
   1889-Johns Hopkins Hospital, Osler’s
    textbook, medical school-first
History/evolution of physician
training and certification
   1910-Abraham Flexner, Carnegie
    Foundation on quality of medical
    education-only 5 found acceptable
   1912-FSMB created
   1914-AMA Council on Medical
    Education-institutes program of hospital
    internships, approved facilities
   1915-NBME
History/evolution of physician
training and certification
   1916-board of ophthamology
   1924-board of otolaryngology
   1930-board of OB/Gyn
   1932-board of dermatology and
   1933-boards unite to form ABMS
History/evolution of physician
training and certification
   1937-AHA created
   1940’s-1970’s-evolving councils regarding
    graduate medical education (GME)
   1965-Medicare Bill, GME now public policy
   1981-ACGME formed
   2000-2002-ACGME endorses six general
    competencies to assess residents (also
    adopted by ABMS)
Six core competencies
   Patient care
   Medical knowledge
   Interpersonal and communication skills
   Professionalism
   Systems-based practice
   Practice-based learning and
ABMS (American Board of
Medical Specialties)
   Founded 1933
    24 member boards
   38 specialty, 108 subspecialty
   Certify “85%” of licensed U.S.
   1970’s- moved towards time-limited
   ~ 850,000 certificates
   5-100% of certificates time-limited,
    depending on specialty
   ~ 60% of total are time limited at present
   Life-time (non-time limited) certificate holders
    can volunteer to recertify, but most have not
   cannot legally break the life-time certificates
ABMS-Maintenance of
certification (MOC) program
   January, 1998- “white paper”, David
    Hahrwold, M.D. for exec committee
   March, 1998-taskforce on competence
    formed-MOC proposed
   All 24 board started MOC as of 2008
    with full implementation by 2016
   Replaced the single, secure exam for
ABMS/MOC-4 parts
   Professional standing
   Lifelong learning and self-assessment
   Cognitive expertise (secure exam)
   Practice performance assessment
Horowitz article-Neurology,
   Sheldon Horowitz, M.D.-ABMS executive for
   “linkages of participation in MOC to improved
    physician performance and patients outcomes
    are not yet available”
   “all four parts of MOC are essential, but Part
    4 is the heart and soul of the program as it
    involves looking directly at patient care and
    patient outcomes”
Horowitz article
   “As MOC establishes links to other
    programs, such as maintenance of
    licensure, pay-for-performance, and
    recognition programs, diplomates with
    non time-limited certificates will be
    more likely to participate in MOC.”
Horowitz article
   “A number of efforts to accomplish this
    coordination are under way. ABMS and
    its Member Boards are working to tie
    physician participation in Medicare and
    other government-controlled health
    care programs to MOC.”
Horowitz article
   “ABMS also is working with the
    Federation of State Medical Boards so
    that participation in MOC may
    eventually fulfill some new, more
    stringent requirements for renewing a
    state medical license.”
   70 member state medical boards
   Presently, state medical boards require
    payment of a fee and most require CME to
    renew a state medical license
   FSMB board of directors and the CEO, Jim
    Thompson, M.D. launched 2 national
    initiatives regarding maintenance of
    competency and the possibility of tying MOC
    to maintenance of licensure (MOL)
2 FSMB MOC/MOL initiatives
   Special FSMB committee on MOL- formed in
    2003 with report to HOD at annual meeting in
    May, 2008
   Physician Alliance for Physician Competency
    (PAPC)-now renamed the National Alliance for
    Physician Competency- members include the
    FSMB, member medical boards, ABMS, AMA,
    AARP, NBME, etc- has held periodic summits,
    meeting since March, 2005
   “burning platform”
Minnesota BMP-MOC/MOL
   Meeting since August, 2006
   Stakeholders on taskforce-BMP, U of M,
   Data mining of MN licensees-discovered
    only 70% are board certified
   Presentations by ABMS, FSMB,
    Canadian MOC/performance review
    program, etc
Goals of the MBMP MOC/MOL
   conclude that the current requirement
    of 25 CME credits per year is an
    adequate demonstration of continuing
    competency, if not
   recommend an alternative way for
    licensees to demonstrate continuing
Any new requirements should
   Be available to all licensed physicians and
    osteopaths, all eligible
   Acceptable to the public, regulators, and
   Practice relevant, fair, and validated
   Non-punitive
   Not onerous or duplicative
   Not dissuade physicians from practicing in
                                         Minnesota Primary vs Non-Primary Care Physician
                                                 Certification Term by Age Group

                            Primary Care Lifetime Certification                 Primary Care Time Limited Certification
                            Non-Primary Care Lifetime Certification             Non-Primary Care Time Limited Certification


# of Minnesota Physicians

                            1000                                               996

                            800                  777                                      804

                                                                550                             574
                            600                                          496        536
                                                   492                               562          453
                            400                                        447                  480
                                                                                                        314340       294
                                                                                    364                        222
                                                 264        235                                                       193
                            200                                                           225         175      169
                                    53               107                      225
                                                       6                               59                             24
                                        3 11      0
                                                                                   25                                   5
                               0        0
                                        1     3
                                    25-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70                             71
                                                                        Age Group
2008-intersection of the
MBMP/taskforce and FSMB
   Nov 2007-FSMB special committee on MOL
    issued draft report for comment (30 days)
   Jan 2008-MBMP spent majority of meeting
    discussing the draft report and forwarded
    comments to the FSMB
   Feb 6, 2008-taskforce had presentation from
    Carol Clothier, FSMB, on the now
    “restructured” report
MOL proposed standards for
demonstrating competency-FSMB
   Participation in an ongoing process of
    reflective self-evaluation, self assessment,
    and practice assessment including learning
    modules, CME, etc.
   Demonstration of medical knowledge thru a
    secure exam at least once every 10 years
   Accountability for performance on practice
    thru 360 evaluations, patient satisfaction
    surveys and collection and analysis of practice
MOL proposed standards-
   State medical licensing boards would need to
    monitor the compliance of their licensees,
    and discipline any physician out of
    compliance regardless of their competency
   At present only 36% of members boards are
    supportive of requiring physicians to provide
    enhanced demonstration of competence as a
    condition of license renewal/reregistration
    (FSMB survey, 2008)
   May 2008- FSMB annual meeting and HOD
   Members of the MBMP contributed significant
    dialogue about the MOL report
   HOD adopted the recommendations of the
    report, but recommended no implementation
    at this time but rather study of the
    implications of implementation. Report due to
    HOD, May 2009
2008-intersection of the
MBMP/taskforce and the FSMB
   June 5, 2008- taskforce reviewed the FSMB
    BOD and HOD report on MOL
   July 2008- Dr. Rebecca Hafter-Fogarty and
    Dr. Linda Van Etta were invited by the FSMB
    to participate in the 6th summit meeting of
    the NAPC. Draft of the Guide to Good Medical
    Practice-USA, version 1.0 reviewed and
NAPC-”Guide to Good Medical
   Mimics the core competencies of the ACGME
    and ABMS
   Recommends a MOC program for all
   270 bullet points a physician must uphold
    covering many aspects of care delivery
   “aspirational versus attainable” at present
2008-intersection of the
MBMP/taskforce and the FSMB
   Oct 9-10, 2008- Dr. Linda Van Etta attended
    the FSMB MOL taskforce meeting on models
    for MOL implementation-representatives of 13
    state medical boards invited.
   Oct 13, 2008- MBMP taskforce discussed
    Guide to Good Medical Practice document and
    forwarded feedback to the FSMB
2008- the FSMB
   October 11, 2008- Dr. Regina Benjamin,
    chair of the FSMB board of directors,
    accepts the resignation of CEO, Jim
    Thompson, M.D., effective October 31,
   Barbara Schneidman, M.D.- leaves the
    AMA to become the interim CEO of the
The future of MOC/MOL
   Will we continue down the current path
    outlined by the FSMB?
   Will the process be slowed or changed
    by the new leadership at the FSMB?
   Is this the right path?
Recommendations of the
MBMP taskforce
   no changes to the MOL requirements should
    be made at this time
   MBMP should closely monitor and influence
    the ongoing MOL initiatives at the FSMB
   Eventually all physicians will have time limited
    board certifications from the ABMS or AOA
    and will be enrolled in MOC programs
    resulting in enhanced demonstration of
Is the chosen surrogate valid?
   ABMS MOC programs have been
 “chosen” as the way for physicians to
 demonstrate maintenance of
 competency, but does

       MOC = MOC ?
Circulation-February 5, 2008
   Retrospective study of 8,127 diabetic
    patients treated for hypertension
   301 internists at primary care clinics
    affiliated with MGH and B&WH in
   “treatment intensification”
Circulation- Boston study
Better care (optimal hypertension control)
 by internists recently board certified:
    26.7% -recently board certified
     6.9% -last certified 31 years
Circulation –Boston study
First study that “analyzed a quantitative
  relationship between the length of time
  since the last board certification and
  quality of care”

Is 26.7% the level of quality we want to
“Does the emperor have any
 Will requiring physicians to participate in
 MOC programs as currently structured
 and tying that to MOL result in
 improved quality of care and patient
 Or, will it simply result in increased
 burdens on physicians?
 A “better path” for MOC/MOL
    the changes should be
         “evolutionary, not revolutionary”
    do away with the requirement for a “secure, high
    stakes” exam and focus on quality improvement and
    education modules (ABMS components 2 and 4)
   focus on system errors and system solutions, with feed back
    loops to physicians
   Harness EHR technology to help physicians improve episodes of
   Allow multiple organizations to develop learning modules that
    fulfill the MOL requirements, not just the ABMS
Recommended reading

   Guide to Good Medical Practice-USA, version
    1.0 (National Alliance for Physician
   FSMB-MOL committee report to HOD, May
   Horowitz, Sheldon-Maintenance of
    certification: The next phase in assessing and
    improving physician performance. Neurology
    2008; 71;605-609.

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