There has been a significant amount of outrage over the past few months of the maintenance of certification process. The anger has not only been targeted towards the ABIM, but also towards the other specialty boards. Pediatrics, for example, now requires ABP approved quality improvement (QI) projects that have been widely criticized.

While these MOC requirements are a major nuisance for most, the implications may actually run much deeper. A number of doctors are opting out of medicine and citing increasing maintenance of certification requirements as a major contributing factor.

There are many articles denouncing MOC and a few articles defending MOC. But neither side of the discussion has proposed a workable middle ground solution.

There are a few facts to consider:

• The current MOC requirements are overly burdensome.
• Many of the MOC requirements show no actual improvement in patient outcomes and the studies that do show improvement come from biased sources.
• The public, as well as the majority of physicians, do consider some type of periodic assessment to be necessary.
• Insurance companies and hospitals will continue to demand some credentialing mechanism. Removing all credentialing requirements is not an option.

The in-between solution would be something that satisfies the public, insurance, and hospitals, while being easy, high quality, and affordable to physicians. The National Board of Physicians and Surgeons (NBPAS) may be the beginning of a new viable structure. At $169 for a two-year certification, the NBPAS is certainly affordable for the internal medicine specialties, but lacks the assessment component that the insurers and hospitals need.

An alternative moving forward would be for the NBPAS to partner with any number of the existing online question banks to provide a digital self-assessment exam that could be accessed at any time by a physician. This would overcome the current hospital and insurance objection of not having a recertification assessment while making the process extremely easy for a physician.

There are a few reasons why this would be a good way forward:

• Online self-assessment is already an accepted standard. Digital case-based questions with evidence-based rationales are the format of many of the existing approved MOC activities.
• Digital self-assessment providers already have widespread adoption. Board prep companies have hundreds of thousands of MDs and DOs on their platform for certification, recertification, and MOC credits, and could bring a lot of weight to the fledgling NBPAS or help transform long-established boards.
• Total cost to the physician would significantly decrease. The focus would shift from big testing center contracts and board profit centers to medical knowledge and ongoing assessment. Cost to the physician could decrease from thousands of dollars to less than $500 per assessment period.
• More flexibility for physicians. All physicians are crunched for time, and a digital assessment model would allow physicians to complete assessment activities when it’s best for them — not when the board mandates it.
• The digital assessment would provide the validation needed for insurance and hospital buy-in.

The American Board of Anesthesiology is already trending in this direction with its MOCA 2.0 pilot, particularly with MOCA Minute™ which takes out the assessment exam altogether. Under the new model, anesthesiologists need to answer 120 questions per year, typically one every few days. This enables physicians to answer questions on the go instead of cramming once every ten years, which the ABA hopes is less burdensome on physicians.

And the benefit for the ABA is clear. It gets to test a continuous assessment model, while dramatically increasing the number of data points for assessment — 1,200 instead of 200 over the 10-year cycle. Whether this is an improvement overall remains to be seen, but at the very least credit is due to the ABA for trying an alternative model.

Right now, nearly everyone is dissatisfied. It’s time to start proposing alternate solutions that work for the public as well as for doctors. The more viable competition that we bring to the ABMS the more likely it is that better options will emerge. It’s on us to carry this forward.

Andrea Paul is chief medical officer, Boardvitals.com.

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