REPORT OF THE COUNCIL ON MEDICAL EDUCATION

CME Report 7-A-07

Subject: Specialty Board Certification and Recertification (Resolution 302, A-06)

Presented by: Melissa K. Thomas, MD, PhD, Chair

Referred to: Reference Committee C (Edward C. Tanner, MD, Chair)

1 Resolution 302 (A-06), Specialty Board Certification and Recertification, submitted by the 2 Minnesota Delegation and referred to the Board of Trustees, asked that our American Medical 3 Association (AMA): 4 5 Study the issues surrounding certification and recertification by medical specialty boards 6 including, but not limited to, their appropriateness as measures of competency, the varying 7 methods and criteria used by specialty boards for recertification, and third party payers’ 8 requirement of board certification as a condition of participation in their networks. 9 10 At Reference Committee C, testimony was mixed though all speakers were supportive of lifelong 11 continuing competency. Several speakers suggested that these issues have already been studied or 12 will be studied by the American Board of Medical Specialties (ABMS) and its member boards in 13 connection with their respective specialty societies, so it should not be necessary for the AMA to 14 invest resources to look at this issue. Many of the speakers suggested referral because of the many 15 variables involved, including a sizeable fiscal note, and in an effort to limit the size and scope of 16 the potential study. Also noted was that the term “recertification” had been replaced with the term 17 “Maintenance of Certification” (MOC). 18 19 Existing AMA Policy 20 There are multiple AMA policy statements related to certification and recertification that support 21 these concerns. These policies include: 22 23 H-230.986 “JCAHO Recognition of Specialty Boards Recognized by American Board of Medical 24 Specialties and AMA and AOA” (AMA Policy Database) in which the AMA recommends that 25 medical staffs should have flexibility in determining which, if any, specialty board certification will 26 be used as a criterion to delineate clinical privileges. 27 28 H-275.933 “Specialty Board Recertification Requirements for Employment” in which the AMA 29 opposes specialty board recertification as a sole condition of employment. 30 31 H-275.936 “Mechanisms to Measure Physician Competency” which asks the AMA to review and 32 propose improvements for assuring continued physician competence, including but not limited to 33 performance indicators, board certification and recertification, professional experience, continuing 34 medical education, and teaching experience; and (2) opposes the development and/or use of 35 "Medical Competency Examination" and establishment of oversight boards for current state CME Rep. 7-A-07 -- page 2

1 medical boards as proposed in the fall 1998 Report on Professional Licensure of the Pew Health 2 Professions Commission, as an additional measure of physician competency. 3 4 D-275.971 “American Board of Medical Specialties - Standardization of Maintenance of 5 Certification Requirements” in which the AMA pledges to work with the American Board of 6 Medical Specialties to streamline Maintenance of Certification (MOC) to reduce the cost, 7 inconvenience, and the disruption of practice due to MOC requirements for all of its member 8 boards, including subspecialty requirements. 9 10 D-275.977 “Update on the American Board of Medical Specialties Program on Maintenance of 11 Certification (MOC),” which states that the AMA will: continue to monitor the progress of 12 Maintenance of Certification (MOC) and its ultimate impact on the practice community; encourage 13 the Physician Consortium for Performance Improvement, the American Board of Medical 14 Specialties, and the Council of Medical Specialty Societies to work together toward utilizing 15 Consortium performance measures in Part IV of MOC; and encourage the ABMS Maintenance of 16 Certification Task Force to develop and adopt recommendations for re-entry into clinical practice 17 and entry into Step IV of MOC for diplomates not involved in direct patient care. 18 19 D-275.987 “Internal Medicine Board Certification Report–Interim Report,” in which the AMA 20 encourages specialty societies to work with their respective ABMS member board to implement 21 and evaluate MOC, to continue to assist physicians in practice performance improvement and to 22 continue to monitor MOC implementation. 23 24 H-275.996 “Physician Competence” which urges the American Board of Medical Specialties 25 (ABMS) and its constituent boards to reconsider their positions regarding recertification as a 26 mandatory requirement rather than as a voluntarily sought and achieved validation of excellence; 27 (2) urges the Federation of State Medical Boards and its constituent state boards to reconsider and 28 reverse their position urging and accepting specialty board certification as evidence of continuing 29 competence for the purpose of re-registration of licensure; and (3) favors continued efforts to 30 improve voluntary continuing medical education programs, to maintain the peer review process 31 within the profession, and to develop better techniques for establishing the necessary patient care 32 data base. 33 34 H-405.972 “Recertification Alternatives” which asks the AMA to continue to support the 35 development and validation of alternatives to recertification by standardized testing. 36 37 H-405.973 “Board Certification” which asks the AMA (1) to continue to work with other medical 38 organizations to educate the profession and the public about the board certification process; and (2) 39 that, when the occasion arises that equivalency of board certification must be determined, the 40 Essentials for Approval of Examining Boards in Medical Specialties be utilized for that 41 determination. 42 43 H-405.974 “Specialty Recertification Examinations” which encourages the ABMS and its member 44 boards to continue efforts to improve the validity and reliability of procedures for the evaluation of 45 candidates for certification; and (2) recommends that the holder of a certificate without time limits 46 should not be required to seek recertification. 47 48 H-405.975 “Recertification Exam for the American Board of Medical Specialties” in which the 49 AMA actively encourages those specialty boards that issue time limited certificates to include CME Rep. 7-A-07 -- page 3

1 young physicians with such certificates in the decision-making process for any design of plans for 2 recertification. 3 4 Background: The American Board of Medical Specialties and the Concept of Maintenance of 5 Certification 6 Although specialist certification may indicate competency at the time of examination, it is 7 important to maintain this level of competency during the course of practice. Robert Steinbrook, 8 MD, in a November 2005 issue of the New England Journal of Medicine, reported an inverse 9 relationship between physician performance and years of service. ABMS, as the organization that 10 establishes standards for physician specialty certification and recertification, redefined as 11 Maintenance of Certification (MOC), has the responsibility for issuing 37 general and 92 12 subspecialty certificates throughout the United States. 13 14 MOC focuses on four components: (1) evidence of professional standing; (2) evidence of 15 commitment to lifelong learning and periodic self-assessment; (3) evidence of cognitive expertise; 16 and (4) evidence of evaluation of performance in practice. Six areas of competence are addressed: 17 patient care, medical knowledge, practice-based learning and improvement, interpersonal and 18 communications skills, professionalism, and systems-based practice. In addition to creating an 19 infrastructure for ongoing assessment, ABMS is working to establish nationwide consensus 20 regarding standards of quality specific to each medical specialty. Each ABMS member board 21 determines the competencies for its individual specialty and will collaborate with regulatory and 22 other organizations to establish these standards. 23 24 Part I: Professional Standing. Requires physicians to maintain an unrestricted license to practice 25 medicine. 26 27 Part II: Lifelong Learning and Self-Assessment. Requires evidence of participation in 28 educational programs and meeting specialty-specific standards integrated with practice 29 performance. Many of the member boards ask for a specific number of hours of AMA Physician’s 30 Recognition Award continuing medical education credit, usually specialty specific. 31 32 Part III: Cognitive Expertise. Provides evidence through clinically relevant examinations that 33 physician specialists have the knowledge necessary to provide quality patient care. This 34 component is achieved by a proctored, secure examination, most often computer-based. The 35 questions should be based on fundamental knowledge, practice related knowledge, and the practice 36 environment. 37 38 Part IV: Practice Performance Assessment. Requires physician specialists to assess the quality 39 of care they provide compared to peers and national benchmarks, then apply the best evidence or 40 consensus recommendations to improve that care using follow-up assessments. The assessment of 41 performance uses a balanced set of measures, including clinical processes and outcomes, patient 42 satisfaction, and the efficient and appropriate use of resources. This component demonstrates some 43 variability among the member boards with the requirements ranging from patient and peer 44 assessment, use of evidence-based guidelines, quality improvement, to office-based record review. CME Rep. 7-A-07 -- page 4

1 Implementation of MOC Across Specialties 2 ABMS policy has focused on implementing its MOC program through its member boards. They 3 created an ABMS “help services team of experts” to accelerate the adoption of MOC programs by 4 member boards. Topics central to MOC implementation include the identification and 5 development of alliances with external organizations (e.g., hospitals, ambulatory care 6 organizations, medical groups, large providers, commercial health plans, National Commission on 7 Quality Assurance, government) that incorporate MOC as a required part of their physician 8 performance evaluations. To date, each of the 24 ABMS Member Boards has gained ABMS 9 approval of its entire MOC programs (Parts I-IV). 10 11 Committees of the ABMS and the Future of MOC 12 Several ABMS committees are in place to monitor, evaluate and research MOC. They are: 13 14 1. Maintenance of Certification Task Force - This task force of the ABMS asks the member 15 boards to develop specific requirements and timelines for implementation of evaluation of 16 practice performance, to design policy to produce uniformity between the MOC programs of 17 member boards (taking into account necessary specialty-specific variations) and to establish 18 standards and methods for evaluating diplomates against the six general competencies. In 19 addition, this committee plans to recommend the creation of appropriate modifications and/or 20 improvements in the ABMS standards and guidelines for MOC, as well as the creation of 21 specific MOC requirements for retired/not currently practicing diplomates (including 22 requirements for return to clinical practice). 23 24 ABMS is focused on defining systematic research of the outcomes of the MOC programs and 25 using that information to improve the MOC programs of the boards. Furthermore, the ABMS 26 is seeking a central repository of boards’ experiences relating to state licensure revocation 27 decisions through the Disciplinary Action Notification Service (DANS) program. 28 29 Although the ABMS is attempting to define and implement processes to prove the value of 30 MOC, ABMS research currently does show an association between certification and physician 31 performance/patient outcomes. For the recertification exam, American Board of Surgery (ABS) 32 data indicate that physicians with disciplinary actions with DANS had a higher failure rate on 33 the 2005 recertification exam—14.8% as opposed to those without, 4%. Diplomates with lower 34 continuing medical education activity also had a higher failure rate. In regards to Parts II and 35 IV (Lifelong Learning/Self-Assessment and Practice Performance Assessment, respectively) 36 and an analysis of DANS data, a survey was recommended to be conducted. This survey would 37 consist of determination of self-assessment activities for Parts II and IV, and how this impacts 38 Practice Improvement. 39 40 In addition, the American Board of Family Medicine (ABFM) is using the database of the 41 Missouri Information for Community Assessment (MICA) for preventable hospitalizations for 42 24 disease processes, and plans to assess the impact of interventions with Part II (self- 43 assessment modules, clinical simulations) and Part IV (Web-based education module tools.) 44 Feedback from the American Board of Internal Medicine (ABIM) and the American Board of 45 Pediatrics (ABP) showed physician satisfaction with the MOC process. The ABP plans to 46 approve a ten-year project linking practice parameters that provide guidelines for care to 47 performance in various aspects of MOC. CME Rep. 7-A-07 -- page 5

1 2. ABMS Committee on Oversight and Monitoring of Maintenance of Certification (COMMOC) 2 - This committee will receive and review reports from each member board about its MOC 3 program and verify and document the compliance of individual member boards with the 4 implementation of its MOC program. It will also recommend methods for evaluating the 5 overall effectiveness of MOC as related to the purpose and mission of the ABMS. The 6 committee will provide recommendations and guidance to each member board with respect to 7 segments of its programs which are not adequately developed or being implemented. The 8 committee will be submitting a survey to the member boards regarding their self-assessment 9 programs and how it impacts practice improvement. 10 11 3. ABMS Committee on Research and Evaluation Procedures (COREP) - This committee will 12 develop and propose principles of evaluation for certification, recertification and MOC, 13 consider ways and means of improving the evaluation process, and aid and support the ABMS 14 staff in collecting and disseminating relevant information to the members. This committee will 15 identify and encourage research to improve the capacity to measure, assess and evaluate the 16 educational, scientific, clinical and professional qualifications and performance of physicians 17 engaged in the practice of medical specialties. Research priorities of the ABMS include the 18 funding of new research projects, collaborating with member boards and other organizations on 19 research projects, and other activities concerning research and development in certification. 20 21 In addition, as part of the ABMS strategic plan, it is committed to identifying appropriate metrics 22 and promoting research to demonstrate how MOC improves physician performance and patient 23 outcomes. Because few boards have an established research and evaluation program, it was 24 decided that the ABFM, the ABIM, the ABP, and the ABS would be key contacts to gather 25 additional information about research initiatives related to certification and physician performance. 26 The ABIM is also conducting research to assess the relationship between performance in MOC and 27 outcomes, processes and systems of care and the relevance of MOC for key stakeholders, including 28 physicians, health plans and health care system managers. 29 30 Employment, third party payers and the use of certification and MOC 31 Many health care organizations and institutions continue to use primary board certification for 32 purposes of initial employment or maintenance of employment. Because larger numbers of 33 diplomates now have time-limited certificates, there is concern that the employers may also 34 mandate recertification or MOC as a condition of continued employment. AMA policy in this area 35 does address the issue of recertification and opposes specialty board recertification or certification 36 as a sole condition of employment, (H-275.933 “Specialty Board Recertification Requirements for 37 Employment,” H-275.944 “Board Certification and Discrimination.”) In addition, the ABMS, in 38 its policy statement on “Delineation of Clinical Privileges,” states: “In making the determination of 39 what privileges a practitioner will be permitted to exercise, medical specialty certification or 40 subcertification should be considered as only one of the several valid and important criteria.” The 41 AMA has always supported the concept that multiple criteria should be used for assessing 42 employability of physicians. 43 44 Currently, no large-scale survey has been developed to address the issue of third party payers and 45 certification, but the ABMS is currently creating a survey regarding the use of certification and 46 MOC. The survey is a study of the use of certification and MOC status by hospitals, ambulatory 47 settings and health plans. The results should be available by the fourth quarter of 2007. In many 48 states, third party payers require physicians to complete residency training only. Some payers 49 require physicians trained after a certain period to be board certified or become board certified CME Rep. 7-A-07 -- page 6

1 within 24 months of employment. Some initial pilot programs are being considered requiring 2 certification or MOC on a state-by-state basis. No national mandates have been developed, though 3 the ABIM has developed web-based quality improvement tools to assist diplomates to report 4 practice performance to health plans, insurance companies, and hospitals. 5 6 AMA Involvement in the ABMS Process 7 Since 1934, medical specialty boards have been approved jointly by action of the ABMS and the 8 AMA Council on Medical Education through the Liaison Committee for Specialty Boards (LCSB). 9 The function of the LCSB is to receive and evaluate applications for approval of new medical 10 specialty boards according to the current version of the Essentials for Approval of Examining 11 Boards in Medical Specialties. In addition, AMA representatives attend the ABMS General 12 Assembly, have one delegate vote in the Assembly, and sit on various committees of the ABMS. 13 14 Summary and Recommendations 15 The issues surrounding primary certification and MOC by medical specialty boards can be 16 complicated, as examination programs strive for a parallel relationship between physician 17 competency and patient care/clinical outcomes. Since MOC is proceeding at different phases for 18 different specialties, it would be important to continue to monitor its progress and let the ABMS, 19 their respective committees and Member Boards be responsible for the research initiatives, surveys 20 and outcome studies as the ABMS has the appropriate resources for implementation. AMA 21 involvement on ABMS committees and in its Assembly could provide input and feedback to the 22 AMA. 23 24 The Council on Medical Education recommends that the following recommendations be adopted in 25 lieu of Resolution 302 (A-06) and that the remainder of the report be filed. 26 27 1. That our American Medical Association reaffirm policies: H-230.986 “JCAHO 28 Recognition of Specialty Boards Recognized by American Board of Medical Specialties 29 and AMA and AOA,” H-275.933 “Specialty Board Recertification Requirements for 30 Employment,” H-275.936 “Mechanisms to Measure Physician Competency,” H-275.944 31 “Board Certification and Discrimination,”D-275.971 “American Board of Medical 32 Specialties - Standardization of Maintenance of Certification Requirements,” D-275.977 33 “Update on the American Board of Medical Specialties Program on Maintenance of 34 Certification (MOC),” D-275.987 “Internal Medicine Board Certification Report – 35 Interim,” H-275.996 “Physician Competence,” H-405.972 “Recertification Alternatives,” 36 H-405.973 “Board Certification,” H-405.974 “Specialty Recertification Examinations,” 37 and H-405.975 “Recertification Exam for the American Board of Medical Specialties.” 38 (Reaffirm HOD Policy) 39 40 2. That our AMA continue to monitor the progress by the ABMS and its member boards on 41 implementation of Maintenance of Certification (MOC) and encourage ABMS to report its 42 research findings on the issues surrounding certification, recertification and MOC on a 43 periodic basis. (Directive to Take Action) 44 45 3. That an update report be prepared for the AMA House of Delegates no later than 2010. 46 (Directive to Take Action) CME Rep. 7-A-07 -- page 7

1 4. That the AMA encourage dialogue between the ABMS and its respective specialty 2 societies to work on development, implementation, and monitoring of MOC that meets the 3 needs of practicing physicians and improves patient care. (Directive to Take Action) 4 5 Fiscal Note: Less than $500.