The American Board of Medical Specialties has a stronghold on setting standards for physician certification, a near monopoly built over years of partnerships with insurance companies and hospitals. Most private insurance companies require physicians to prove board certification, although Medicare does not, and many hospitals require certification as well.
Physicians have abided by the certification, for the most part, for decades; however in the 1990s the board implemented a maintenance of certification program requiring physicians under a certain age to obtain re-certification throughout their careers. Older physicians were "grandfathered" in under previous lifetime certification guidelines.
Under MOC requirements, physicians are assessed every two years and must pass an examination in their specialty every 10 years. However, the data on whether certification improves patient safety and outcomes is unclear; in a meta-analysis of 33 studies on the topic, 16 reported a significant association between certification and positive outcomes while 14 found no association and three found negative association.1 The certification process may cover elements of a surgeon's specialty he or she doesn't typically see in practice and take considerable time and resources to complete. MOC fees could range from $2,715 to $3,335 per physician in addition to time lost for preparation and taking the exam.
And physicians are fighting back.
Organizations across the country, including the American Association of Physicians and Surgeons, Practicing Physicians of America and Association of Independent Doctors all oppose the MOC requirements, and Paul Teirstein, MD, founded the National Board of Physicians and Surgeons to combat re-certification requirements. Individual physicians are writing their legislators against MOC as well.
"NBPAS was founded to provide meaningful continuous board certification for physicians," says Dr. Teirstein. "Most physicians support initial ABMS/AOA member board certification but believe the current MOC requirements are onerous, expensive and do not provide meaningful benefit to patient care."
The resistance against MOC is taking less formal means as well; a Facebook group created to stand against MOC has 50,000 physician members and Westby Fisher, MD, who regularly uses Twitter to send updates on anti-MOC legislation at the state level, has 17,000 followers.
"There is much that needs fixing in healthcare today and physicians have historically been too busy to get involved," says Dr. Fisher. "The internet is changing that though. Facebook and Twitter had proven themselves to be disruptive forces in business, and medicine is no different."
MOC is particularly challenging for hospital-employed physicians, who need the certification to remain employed. "For employed physicians, it's just a matter of time before lawsuits by physicians against the ABMS and their hospitals occur because they are restricted from earning a living after years of practice solely on the basis of this corrupt, proprietary and monopolistic recertification system," said Dr. Fisher.
At least 17 states have seen proposed legislation to ban mandatory MOC requirements, according to Medscape, and the movement is growing.2 Bills in some states would prevent hospitals and payers from requiring current certification while others regulate voluntary certification programs to lower standards. ABMS has taken the stance that MOC keeps patients safe, and anti-MOC legislation would put them at risk because physicians may not keep their certification current.
The anti-MOC movement feels differently.
While ABMS has made modifications to initial MOC requirements, such as allowing remote proctoring and online assessments as well as attempting to customize the approach to different physicians and specialists, many physicians continue to stand against MOC in principle, if not in practice.
"The rainmakers seem to be daring hospitals to make them do MOC and refusing, for now. The large majority of doctors are more compliant, roll their eyes, pay the fees, then gripe about the whole unnecessary endeavor," says Dr. Fisher. "They are typically employed and have to do MOC to keep their credentials to practice in that setting. The real crisis comes when a physician fails their recertification exam after 10, 20 or 30 years of practice, irrespective of whether they're employed or not."
When physicians are unable to achieve recertification, they are professionally embarrassed and may lose their hospital privileges, insurance payments and patient base. For all specialties, the MOC failure rate is 13.2 percent. Opponents also raise the issue of revenue generated by certification and recertification, which makes fighting against the requirements more difficult.
"We have been lobbying for change for over two years but the ABMS member boards still require physicians prepare for tests that have little relevance to their practice and result in well over $100 million in fees to the board members," says Dr. Teirstein. "The ABIM, just one of the 24 ABMS member boards, reports $27 million in MOC fees on their IRS Form 990 and that was three years ago when only about half of their diplomates were required to participate in MOC; the other half was grandfathered. As the grandfathers retire, MOC fees will certainly top $50 million for ABIM, and there are 23 other member boards also collecting MOC fees."
Dr. Teirstein doesn't expect ABMS to change its policies without a "major fight" but reports that if and when ABMS developed "meaningful and reasonable MOC requirements" then NBPAS would disband. Members of NBPAS are currently unpaid for their efforts.
In September, Ohio legislators introduced a bill against MOC — House Bill 273 — and the battle has heated up in states across the country. Dr. Fisher delivered a testimony in front of the Ohio Health Committee during a hearing on Oct. 11 where he presented support for the bill, which restricts hospitals and insurance companies from preventing experienced physicians from practicing based on maintenance of certification. He testified on previous MOC legislation and corruption surrounding MOC funds. He also addressed physician shortages and the impact MOC has on medical professionals.
"Hundreds of Tweets and emails I receive each year speak to the reality of the tremendous negative effect [MOC has] on decent, highly respected colleagues too embarrassed to go public with their failure, many of whom quietly leave medicine," he said in his testimony. "The Maintenance of Certification profit-making machine is creating a physician brain drain and a shameful exodus of too many good people."
Several states are attempting to push legislation to remove the MOC requirement on physicians, but the fight has not been easy. Hospitals and payers have joined forces, supported by massive lobbying efforts, to halt any anti-MOC bills. In 2016, for example, Medscape reports Oklahoma became the first state to pass anti-MOC legislation, known as the Right-to-Care law, which intended to eliminate MOC as a stipulation for physicians to receive hospital privileges and licenses. This victory for the anti-MOC camp soon turned sour as hospitals found various loopholes in the language to still mandate MOC as a requirement. Arizona, Kentucky and Michigan also tried to pass anti-MOC legislation in 2016, to no avail. MOC opponents in Tennessee suffered a similar loss in April when they succeeded only in removing MOC requirements for a medical license.
But Georgia anti-MOC legislation made it through the muck. In May, the state became the first to officially remove MOC requirements for some hospital's staff privileges, medical licensure and payer membership, according to Medscape.
So what should we expect in the future? Maryland, Missouri, North Carolina, Texas, Alaska, California, Maine, Massachusetts, New York and Rhode Island all currently have anti-MOC legislation in the works. Dr. Teirstein reports NBPAS will continue to offer a meaningful alternative to ABMS/AOA board certification and fight against MOC legislation. Dr. Fisher expects NBPAS to grow and is using PPA as a grass roots consortium of physicians, combating MOC.
1. Teirstein P. Boarded to Death—Why Maintenance of Certification Is Bad for Doctors and Patients. N. Engl J Med. 2015; 372: 106-8. doi: 10.1056/NEJMp1407422
2. Medscape. The War Over MOC Heats Up. http://www.medscape.com/viewarticle/881274_1. Accessed Oct. 10,