1. Rhode Island Physicians for Quality Care (RIPQC) (Master Slide Set)

2. Who We Are An ever growing group of 20 physicians from various specialties including: President: Debbi McInteer, MD Vice President: Howard Schulman MD Secretary: Heather Hall MD Treasurer: Lisa Frappier DO Councilors: Karmela Chan MD, Edward Donnelly MD, David Kahn MD, David Kroessler MD, Peter Margolis MD, Kazi Salahuddin MD, Ronald Stewart MD, Andrew Tompkins MD

3. Why We Formed From The Fight Against MOC: The Spark that Unites Physicians “Physicians are docile. We are programmed to put the greater good above our own. We train mercilessly, work tirelessly, and bend faithfully at the alter of those we have vowed to heal.” Accordingly, physicians have been far too accommodating. Rather than rock the boat, we have accepted the spew and encroachment that has come from almost every direction. Lawyers will sue. Politicians will mandate and legislate. Technologists will code and program And by and large, we have accepted each bitter pill as it has sucked away the very marrow of enjoyment and professionalism of our field. We have spent our own precious hours learning how to document better, feeding a tort system that shows no signs of being consumed by its own wanton wastefulness. We have slaved over relentless forms and check marks, each new piece of paper the love child conceived in an orgy of governmental vigor. And we have hunkered down in front of computer systems stoked by nonsensical technology ignoring the very patients they were created to serve... The result has been a great emigration away from clinical medicine. Maintenance of certification has become the spark that has finally ignited the beleaguered physician. Faced with a nonsensical health care system mired in administrative minutia, we have found a rallying cry that symbolizes all that trampling we have endured over the last few decades.“ http://www.kevinmd.com/blog/2015/02/fight-moc-spark-unites-physicians.html 3

4. Our Mission We strive for RI physicians to be free of any additional purposeless bureaucracy that keeps them from their primary mission of caring for the citizens of RI. We believe staying current with the best medical practices is essential for quality care and that CME provides education in both established knowledge and cutting edge research. We believe in a physician's freedom to choose their educational direction based on their particular practices in order to maximize the use of their educational time. We oppose the increasingly involuntary status of the ABMS MOC ® which has not been proven to indicate a physician’s overall competence or protect patients. We believe the ABMS MOC ® can be used as a voluntary educational tool only if all board certifications are restored to lifelong certifications. We are against linking ABMS MOC ® and board certification with licensure and the practice of medicine.

5. Current Goals Create a formal resolution against ABMS MOC® Create a resolution against linking ABMS MOC® with MOL Create competition with the ABMS for continuous board certification Oppose efforts to link MOC® to MOL, including the Interstate Medical Licensure Compact which defines a physician as one who hold specialty certification by an ABMS member board,

6. What we have been doing Spreading our message and enlisting support across many specialties through networking, creating a Facebook Page, and soon a website, to facilitate communication Creating on-line petitions for others to support our goals Joining the movement for alternate pathways to maintain board certification and reaching out to hospitals and payers Opposing efforts to define a doctor as one who “holds specialty certification… recognized by the ABMS (or AOA Board),” in the 2015 Interstate Medical Licensure Compact (Bill #H5571) by meeting with local senators Reaching out to RIMS and DOH

7. Is There Data Supporting MOC? ABIM/ABMS argue there are data supporting the value of MOC. However, close examination of the reports cited by ABIM/ABMS reveals they support the opposite conclusion.

10. Initial Certification vs. MOC? initial certification exam provided almost all the studies in the literature evaluate board certification, not recertification or MOC Initial ABMS certification is earned, for the most part, by spending several years in an ACGME credentialed training program. The initial certification exam provided by the ABMS is simply the “final exam” which is obviously a much smaller part of the educational process. Should it be surprising that successfully completing 3 years of training in an ACGME credentialed cardiology fellowship makes a doctor better at treating MI’s? It is absurd to equate the busywork of MOC…clicking on computer modules for 10-20 hours each year…to the many years of training required for initial certification

11. One of the few studies examining lapsed certification found no impact on patient outcomes following coronary intervention

16. Study limitations: Non-randomized Propensity matching followed by a regression analysis Beware of unmeasured confounders Exercise caution interpreting small differences

18. Statistician's comment: Highly adjusted analysis Propensity matching followed by regression analysis

21. Should we worry about Conflict of Interest in a Non-Randomized Trial? Were the endpoints pre-specified? Was the small difference in cost discovered after looking at multiple potential endpoints? Were there any differences favoring the grand-fathered cohort that were not published?

25. Not a meta-analysis. It’s an “equivocal” literature review 24/29 studies listed attempt to correlate clinical outcome with certification not re-certification or MOC 5/29 studies listed do attempt to correlate outcome with MOC grades but no studies attempt to correlate outcomes with the dichotomous endpoint of MOC participation Written by ABIM affiliate

26. Do we really need more data? In the debate I keep hearing calls for more “data.” “More data” - sounds good from the podium, looks good in print. But, think about it. What kind of data quality will ever be achievable? Level A? Are we really going to randomize physicians to MOC vs no MOC? Can we blind the doctors? Unfortunately, the data will always be registry data with massive bias. In my opinion, asking for more data, is a cop out…it just kicks the can down the road.

27. ABIM makes the argument ‘CME is too passive” Personally, it’s hard to imagine anything more passive than sitting at a computer, clicking away on MOC modules that may not be current or even relevant to your particular practice Continuing Medical Education and MOC®

28. Continuing Medical Education and MOC CME is a better approach to lifelong learning. Organizations providing recognized CME programs are regulated by a rigorous accreditation body (ACCME) requiring each CME offering provide an educational gap analysis, “needs assessment," speaker conflict of interest, course evaluations and many other performance standards. Accredited CME must be independent of commercial interests MOC focuses on established knowledge while CME can include future innovations that keep the physician on the "cutting edge." CME offerings are highly competitive and provide choice. If physicians do not perceive value in a particular CME offering, they will go elsewhere. This contrasts with the monopoly ABIM has on MOC.

29. The 10 Year Recertification Exam Very controversial. Some think a test is important Arguments against: The exam questions are often not relevant to physician’s practice. Questions often relate to parts of their specialty they do not practice. The questions are often outdated. Most of the studying is done to learn the best answer for the test, which is very often not the current best practice. Testing often uses “Guidelines” as gold standard but there is a long history of Guidelines changing and often reversing Closed book tests are no longer relevant. We care for patients with our colleague’s input (ie conferences, the Heart Team, curbside consults etc) and we are connected to the internet all day long There are no re-certification or MOC programs outside the U.S.

30. Don’t Pilots have to maintain currency? Our flight reviews are required every two years. They involve at least one hour of ground flight training and one hour flying with a certified instructor (selected by the “applicant”) It is very practical There are no written exams or computer modules, you cant fail Cost is about $100-200 every two years. Commercial requirement is a more intense one week experience, but still based in practice, not written exams Its NOT a waste of time. If every two years a doctor (whom WE selected and respected) worked side by side with us for a day…we would LOVE it

31. The Cost of ABMS MOC® MOC® is worth little to Physicians MOC® is worth a lot to ABMS and its partners

32. MOC® is Worth a Lot to ABMS

33. And to Its Partners Many organizations, like ACP and ACC make money from selling MOC study and testing materials

34. Costs (for one specialty) begin at $190 – 256/year plus module fees. Costs increase significantly if you have boards in multiple specialties On top of this are costs for review courses, travel to review courses Time away from practice What about the cost?

35. Value is Virtuous ABIM IRS Form 990 tells the story ABIM annual revenue is $55M (that’s per year) Directors are very well paid We have all had to tighten our belts in medicine Patients are NOT demanding MOC…but they ARE demanding better “value”…better care, lower costs Recently, most physicians, have spent an enormous amount of time cutting costs in their practices and hospitals Physicians are now asking for a better value from the ABIM.

38. The Revolt In 2011, Change Board Recertification is formed in reaction to the developing “discriminatory and costly burden of MOC to physicians, patients and healthcare” In 2013, the Association of American Physicians and Surgeons files a civil suit against the ABMS citing anti-trust laws and misleading information about physician skills based on their participation (which is still ongoing)

40. ABMS and ABIM are currently under fire in the lay and scientific press!

41. These events also may portend a permanent change in the balance of power between US physicians and other parts of the medical system such as insurance companies or employers. The authority of the specialty boards has turned out to be more a matter of entrenched assumptions than actual fact. Physicians have learned they have real clout and that organized effort can overturn something many saw as inevitable. This is a potent lesson, and physicians are good at absorbing new knowledge. Look for this to be the first of many doctor-led revolts.

43. ABIM backs off

44. ABIM Apologizes - a good first step Part IV is suspended. Very good decision Other changes, however, are not meaningful: Changing public reporting language of diplomat status, freezing fees, and promises to consider further changes We are still left with parts 2 and 3 that are onerous, time wasting and expensive (self assessment modules and repeat secure testing) The self-admitted poor roll-out of MOC by ABIM illustrates the need for alternative certifying organizations. Different physicians have different needs. One size does not fit all. Applications for NBPAS tripled after there apology. Physicians are not satisfied

45. ABIM Changes its Policy (for now) “After listening to members of the community—especially program directors and society leadership—and hearing their thoughts around this issue, the ABIM Board of Directors unanimously agreed that ABIM needed to change this policy. Effective immediately, diplomates who are meeting all other programmatic requirements will not lose certification simply for failure to enroll in MOC. What does this mean for diplomates? Diplomates who lost certification solely on the basis of failure to enroll in MOC or to pay MOC fees have now had their certification status updated to “Certified.” There is no further action they need to take. Diplomates who wish to be reported as “Participating in MOC” must be enrolled in the MOC program, be current with their payments and be meeting ongoing program requirements.” Richard J. Baron MD, MACP August 4, 2015

46. The Scramble Continues 9/16/15, Medscape Medical News reports that ABIM considers replacing the 10-year recertification exam with shorter and more frequent testing It is not addressing the other elements of MOC and it remains to be seen how frequently and how costly this exam will be 46

47. The need for an alternative Irrespective of how the MOC issue is resolved by ABMS, the process of evaluating MOC has shed enormous light on how medicine is regulated in the United States In the past, ABMS has made contributions to patient care by providing initial physician certification exam. But it is also clear that ABMS is a private, self appointed credentialing organization. ABIM has grown into a big >$55M business, unfettered by competition, with zealous economic goals, selling proprietary, copyrighted products It is time for other organizations to compete with ABIM and offer alternative credentialing options.

48. An Alternative to ABMS MOC®

49. The NBPAS Advisory Board Members are physicians who value patient care, research, and life long learning. Board members (all unpaid) believe continuous physician education is required for excellence in patient care. NBPAS Board Members: Paul Teirstein, M.D., President NBPAS, Chief of Cardiology, Scripps Clinic John Anderson, M.D., Past President, Medicine and Science, American Diabetes Association, Frist Clinic, Nashville, TN David John Driscoll, M.D., Professor of Pediatrics, Mayo Clinic College of Medicine Daniel Einhorn, M.D., Immediate-Past President, American College of Endocrinology; Past President, American Association of Clinical Endocrinologists Bernard Gersh, M.D., Professor of Medicine, Mayo Clinic College of Medicine C. Michael Gibson, M.D., Professor of Medicine, Harvard Medical School Paul G. Mathew, M.D., FAHS, Director of Continuing Medical Education, Brigham & Women's Hospital/Harvard Medical School, Department of Neurology Jordan Metcalf, M.D., Professor and Research Director, Pulm. & Crit. Care, Oklahoma University Health Sciences Center J. Marc Pipas, M.D., Professor of Medicine, Dartmouth Medical School Jeffrey Popma, M.D., Professor of Medicine, Harvard Medical School Harry E. Sarles Jr., M.D., FACG, Immediate Past President for the American College of Gastroenterology Hal Scherz, M.D., Chief of Urology- Scottish Rite Children's Hospital, Assoc Clinical Professor of Urology Emory University Karen S. Sibert, M.D., Associate Professor of Anesthesiology, Cedars-Sinai Medical Center, Secretary, California Society of Anesthesiologists Gregg W. Stone, M.D., Professor of Medicine, Columbia University College of Physicians and Surgeons Eric Topol, M.D., Chief Academic Officer, Scripps Health; Director, Scripps Translational Science Institute Bonnie Weiner, M.D., Professor of Medicine, University of Massachusetts Medical School Mathew Williams, M.D., Chief, Division of Adult Cardiac Surgery, New York University Medical Center

50. NBPAS Fees and Application NBPAS is a not for profit 501(c)3 organization The fee is $84.50 per year ($169 for two year certification), irrespective of the number of specialty applications. This one fee covers two years and all specialties desired. Physicians in or within 2 years of training qualify for a reduced rate of $29 for a two year certification ($14.50/year). Fees are used for staff, IT, offices, equipment and marketing. The fee will be adjusted in future years, determined by our expenses. The application requires less than 15 minutes to complete. NBPAS currently offers certification in most non-surgical specialties Go to NBPAS.org to view the website, apply for certification, leave comments and help us educate administrators and the public. www.NBPAS.org

51. NBPAS is a new alternative for continuous physician certification. NBPAS relies on ACCME accredited CME for life- long learning instead of computer modules and repeat testing. This grassroots movement is now in discussions with hospitals, physician groups and payers to accept NBPAS continuous certification To date, 12 US Hospitals have accepted NBPAS, we have just started these discussions n RI

52. What’s wrong with MOC? The majority of available data indicates MOC has no impact on patient outcomes The overwhelming majority of physicians believe the medical knowledge modules and recertifying exams are onerous, and a poor use of their time. Even the ABIM now agrees that the patient safety modules and practice improvement modules should be suspended. MOC is costly for physicians and has become a money-making enterprise

53. Arguments against the 10 year Recertification Exam –The exam questions are often not relevant physician’s practice. Questions often relate to parts of their specialty they do not practice. –The questions are often outdated. Most of the studying is done to learn the best answer for the test, which is very often not the current best practice. –Testing often uses “Guidelines” as gold standard but there is a long history of Guidelines changing and often reversing –Closed book tests are no longer relevant. We care for patients with our colleague’s input (ie conferences, the Heart Team, curbside consults etc) and we are connected to the internet all day long –There are no re-certification or MOC programs outside the U.S.

54. NBPAS Criteria for Certification NBPAS supports the initial ABIM certification criteria and secure test NBPAS strongly objects to the ABIMS’s requirements for MOC NBPAS supports choice. Physicians who believe they benefit from MOC, should participate in MOC Life-long learning is not one size fits all. No single program will meet everyone’s needs. NBPAS provides physicians with an important alternative. The next slide provides the complete NBPAS criteria for continuous certification

55. CME Vs MOC for Life-long Learning Why ACCME accredited CME is a better approach to lifelong learning. Organizations providing recognized CME programs are regulated by a rigorous accreditation body (ACCME) requiring each CME offering provide an educational gap analysis, “needs assessment," speaker conflict of interest, course evaluations and many other performance standards. ACCME accredited CME is NOT permitted to be influenced by industry. MOC focuses on established knowledge while CME often goes further, offering new and future directions that keep the physician on the "cutting edge." CME offerings are highly competitive and provide choice. If physicians do not perceive value in a particular CME offering, they will go elsewhere. This contrasts with the monopoly ABIM has on MOC.

56. ■ Candidates must have been previously certified by an American Board of Medical Specialties member board. ■ Candidates must have a valid, unrestricted license to practice medicine in at least one US state. Candidates who only hold a license outside of the U.S. must provide evidence of an unrestricted license from a valid non-U.S. licensing body. ■ Candidates must have completed a minimum of 50 hours of continuing medical education (CME) within the past 24 months, provided by a recognized provider of the Accreditation Council for Continuing Medical Education (ACCME). CME must be related to one or more of the specialties in which the candidate is applying. Re-entry for physicians with lapsed certification requires 100 hours of CME with the past 24 months. Physicians in or within two years of training are exempt. ■ For some specialties (ie interventional cardiology, electrophysiology, surgical specialties), candidates must have active privileges to practice that specialty in at least one US hospital licensed by a nationally recognized credentialing organization with deeming authority from CMS (ie Joint Commission, HFAP, DNV). ■ A candidate who has had their medical staff appointment/membership or clinical privileges in the specialty for which they are seeking certification involuntarily revoked and not reinstated, must have subsequently maintained medical staff appointment/membership or clinical privileges for at least 24 months in another US hospital licensed by a nationally recognized credentialing organization with deeming authority from CMS (ie Joint Commission, HFAP, DNV). Complete criteria for NBPAS certification:

57. The MOL Issue The Federation of State Medical Boards has wanted to link MOC type activities to licensure for some time The Federation of State Medical Boards (FSMB) has significant collaboration with ABMS and has tried and failed to link MOC with MOL

61. The Interstate Medical Licensure Compact The FSMB now proposes the Interstate Medical Licensure Compact And is financially supporting this effort

62. 62

63. The FSMB claims it s a simple bill to ease physician licensing across states and support telemedicine, however, the bill defines a physician as one who “holds specialty certification or a time-unlimited specialty certificate as recognized by the ABMS (or AOA)” Such a definition could be the beginning of linking MOC to MOL 63