Regulatory capture is an economic term which refers to when a regulatory agency uses policies or laws to advance its own political and economic agenda. Of all the regulations and policies that have burdened the practice of medicine, few have been more injurious than the American Board of Medical Specialties’ Maintenance of Certification (ABMS MOC) program.
On the surface, the MOC seems like a nice thing. It affords its "diplomates” the opportunity to publicly demonstrate their commitment to lifelong learning and improvement in their chosen field of practice.By documenting that physician specialists certified by the ABMS boards are maintaining their necessary and required skills and knowledge, the process ensures that diplomates are providing quality patient care in their specialties.
Perhaps most importantly, MOC represents an opportunity for physicians to take a leadership position in the national movement to improve health care quality and patient safety, through performance assessments founded on objective clinical standards and measurable outcomes.
The MOC has been coined the “new gold standard” of specialty board certification by the ABMS. However, when it is examined more closely, many concerns come to light. It is full of onerous tasks that are, in many instances, duplicated by other regulations and policies.
There are six core physician competencies that need to be documented to ensure physician proficiency—some of the ABMS member boards have suspended some of the MOC requirements until December 31, 2016. Some of the modules required to maintain ABMS certification include: practice assessments, practice improvement, capturing the patient voice, patient safety, and self-assessment.
MOC controversy and concerns
When you look at the requirements for the patient safety, practice assessment, and patient voice modules, not only are they very time-consuming, they closely duplicate Meaningful Use and PQRS reporting, but with slightly different requirements. For example, all have a component requiring coordination of care, patient and/or caregiver surveys, medication safety and reconciliation,preventative care, and screening requirements.
Seventeen state medical associations and numerous national specialty societies have voiced the following concerns regarding the process:
- The majority of available data indicates MOC has no impact on patient outcomes The majority of physicians believe the medical knowledge modules and re-certifying exams are onerous and a poor use of their time
- MOC is costly for physicians, takes valuable time away from their practice, and has become a money-making enterprise for a select few
- ABMS is a private, self-appointed organization that has no checks and balances against self-interests.
In response to the regulatory capture, or creep of the ABMS, an alternative certifying organization for medical specialties was created by leading academicians who examined the evidence the ABMS put forth justifying the MOC, and they found it lacking. This organization is called the National Board of Physicians and Surgeons (NBPAS). Membership support and recognition of the NBPAS is growing rapidly in light of the more conservative approach to requirements for maintenance and certification. While it still requires initial certification through an ABMS-approved board, the NBPAS requires only that its certified physicians earn at least 25 hours of CME per year by an organization recognized by the Accreditation Council for Continuing Medical Education (ACCME).
Members of the NBPAS Board of Directors include some of this nation’s best known medical practitioners and academicians from institutions like the Mayo Clinic, Harvard Medical School, Columbia Medical School, and other powerhouses in the field of medicine. In an article written for the NewEngland Journal of Medicine, Dr. Teirstein, the head of the NBPAS, reviewed the studies cited to justify the MOC by the American Board of Internal Medicine (ABIM).
“In fact, close examination of the reports cited by the ABIM reveals that the data are ambiguous at best,” according to Teirstein. “In a meta-analysis of 33 studies, 16 described a significant association between certification status and positive clinical outcomes, 14 found no association, and three found a negative association. Moreover, the authors of the meta-analysis concluded that the research methods of most published studies on this topic are inadequate.”
“This new board [NBPAS] is not just about breaking the ABIM monopoly,” he continued, “but is also part of an effort to put the right people in charge of the profession’s future. Medicine has been controlled by individuals who are not involved with the day-to-day care of patients. It is time for practicing physicians to take back the leadership.”
The controversy over the requirements for MOC brought attention to the lack of accountability or transparency of medical boards, the ABMS, and their different political agendas. The internal politics of the ABMS and constituent boards make it increasingly difficult for new specialties to be recognized. In fact, there have been no new specialties recognized by the ABMS since 1991.
The impact on phlebology
Phlebology is an area of medicine that is affected by the politics of the ABMS and its constituent boards. Phlebology has a distinct subject matter, broad professional support, and a single evaluation standard. It has an ACGME-approved training fellowship. However, to get wider adoption of its distinct training, it would benefit greatly from ABMS recognition of the American Board of Venous and Lymphatic Medicine (ABVLM). The ABMS constituent boards have somewhat competing interests with the ABVLM. For now, this tension makes the constituent boards less likely to support ABVLM recognition or training.
The fate of the new area of practice specialties may also change. Either ABMS will adapt to the reality that there are new areas of medical specialization that have developed since 1990, or another certifying board will eventually fill the void.
Disclosures: Dr. Wright is a diplomate of the ABVLM, the ABIM and the NBPAS