1. Maintenance of Certification: Then, Now and Looking Ahead Robert Shor MD, FACC Chair Board of Governors ACC October 2015

2. MOC
Where were we?
Where are we now?
Where do we go from here?

3. MOC: Where were we?
January 2014 Changes

4. MOC Jan 2014 Changes Part 1-the initial certification exam
Part 2-Knowledge based questions
Part 3-the 10 year secure exam
Part 4-PIMS (Practice Improvement Modules)
Part 5 & 6-to be defined but include patient satisfaction.

5. MOC The January 2014 changes:
Everyone needs to participate-even those certified before 1990
Now a 5 year and NOT a 10 year cycle
100 points every 5 years-20 part 2, 20 part 4 and 60 either part 2,3 or 4.

6. What 2014 Brought…
The ABIM announced major changes to its MOC process in January

7. The surveys were instrumental in crafting and influencing ACC policy.
MOC
The surveys were instrumental in crafting and influencing ACC policy.

8. Your ACC Listened …
and developed a three-pronged approach focused on –
Serving as a source of information about the changes for members
Providing tools and resources to help members more easily meet the new requirements
The ACC finds itself in the eye of the MOC storm.
With 25,799 cardiovascular disease diplomates on the ABIM rolls—of which 74% are enrolled in MOC—part of the College’s responsibility is to ensure that members have the tools and resources they need to meet new requirements, but also to ensure that processes that don’t work are modified.
According to 2015 survey conducted in April, members remain opposed (68%) to the new ABIM MOC requirements, however the number strongly opposed has dropped from what was recorded a year ago. Favor toward MOC rises 10 percentage points with 14% in favor of MOC.
Advocating on behalf of members for changes to the MOC process
Cardiology Magazine, January 2015

9. ACC Actions Included
Letters of opposition and recommendations to ABIM based on member survey results and feedback
In-person leadership meetings with ABIM in collaboration with internal medicine community
Continuous leadership updates via the ACC in Touch Blog, JACC and all-member s
Development of MOC Resource Hub on ACC.org

10. As a result of the ABIM changes in MOC the ACC convened 2 Task Forces to look at ways to work with ABIM to promote reforms to the MOC process and a second TF to look at alternatives to ABIM to provide MOC.

11. As a result of pressure from various constituency groups , and in large part the ACC, the ABIM and Rich Baron sent out the “We got it wrong” letter.
Changes have been made, but I believe more meaningful changes to the MOC/lifelong learning process using validated metrics is needed.

13. The ACC convened 2 Task Forces on MOC which over several months developed principles regarding the ACC position on MOC (Maintenance of Certification) and lifelong learning and Maintenance of Competence.
The Task Forces presented their recommendations to the BOT at the August annual BOT Retreat. What follows is the information from the TF’s and the BOT recommendations.

14. Maintenance of Certification and Recertification (ACC/F) Task Force #2
Reviewed discussions with:
ABIM
Alternative Boards: Neurosurgery and Neurology
Input from Key Stake Holders
“Break away” ABMS Board
Independent Boards such as Nuc, echo

15. Maintenance of Certification and Recertification (ACC/F) Task Force #2
Reviewed discussions with:
NBPAS-Dr. Teirstein
Patient Perspective
Payers
Cost
Certificate of Continuing cardiovascular Development Program(C3PD)

16. Summary of Elements that TF #2 feels should be included in ongoing certification:
The current initial certification process is felt to be acceptable
Expansion of MOC part II to include elements from LifeLong Learning Clinical Competency Statement (completed in August 2015)
Elimination of MOC III/Ten year test, allowing instead, credit for ongoing prescribed education/confirmation of successful completion

17. Summary of Elements that TF feels should be included in ongoing certification:
Further exploration (during 2 year ABIM grace period) of options for MOC IV, patient safety and patient voice: TF feels that part IV and patient voice should be integrated into existing ACC, hospital and practice programs in such a way that it is not burdensome to physicians.

18. Task Force #2-MOC-Unresolved issues
Cost
Will failure of subspecialist to certify in general cardiology preclude such practice
Will failure of subspecialist to certify in general cardiology preclude such practice?
Any new board will require acceptance by medical staffs (and possibly payers)

19. Task Force #2-BOT issues
If recertification elements acceptable to ABIM, recommend not initiating new board
If elements not accepted by ABIM, present same to ABMS for consideration of new board outside of ABIM

20. ACC BOT MOC TF Motions August 2015
#1: The BOT recommends that the 10 year exam be replaced with a new externally validated process for maintenance of competence and the ACC work with ABIM to develop this.  No time line or "drop dead" date for action was given, rather conveying a sense of urgency for response. ABIM subsequently presented its 2020 proposal.

21. ACC BOT MOC TF Motions August 2015
#2: The BOT decided that the ACC will continue its work toward an alternative Board pending ongoing discussions with ABIM.  This is the purview of Task Force #2.  Task Force #1 will be rolled in to TF#2.

22. ACC BOT MOC TF Motions August 2015
#3: The BOT appoints Patrick T. O'Gara MD,MACC and William J Oetgen MD, MBA, FACC to serve as liaisons for ABIM continued communications.  Both have worked closely and well with the ABIM leadership.

23. ACC BOT MOC TF Motions August 2015
#4: Will work with ABIM to research into best practices for maintenance and demonstration of competence with eventual link to patient outcomes, cost and cost effectiveness.  We wish to define what actually makes sense for our members and improves outcomes.

24. ACC BOT MOC TF Motions August 2015
#5: Recognizing that elements of Part IV and patient experience are federally mandated, these should be integrated into existing ACC hospital and practice programs.  Elements are apparently imbedded in MACRA and we are trying to recognize and get credit for  the work we all do regularly and integrate this in to our normal workflow.

25. Where are we now?

26. ACC Input to ABIM Has Created Change:
Reversal of the double jeopardy provision
Decoupling of the initial board exam from MOC participation
Streamlining the ability for practitioners to get both CME and MOC Part II credit
Delaying MOC Part IV
The ACC has been tremendously instrumental in making real change occur surrounding MOC. These include:
Reversal of double jeopardy provision which ABIM announced in July This means it is eliminating the requirement to maintain underlying certification in a foundational discipline in order to remain certified in a subspecialty. For cardiology, this means that those specializing in interventional, electrophysiology, adult congenital and advanced heart failure will no longer need to pass both the general cardiology and sub-specialty boards.
Decoupling board certification exam from MOC participation in August This means the ABIM is reversing its policy requiring physicians who have passed the initial Certification exam in 2014 or later to have enrolled in the Maintenance of Certification (MOC) process in order to be listed as board certified. Effective immediately, physicians who are meeting all other programmatic requirements will not lose certification simply for failure to enroll in MOC. This decision is a direct result of ACC's efforts over the last two months seeking an expedited resolution of this issue by ABIM.
Streamlining the ability for practitioners to get both CME and MOC Part II credit. This means the ABIM will provide more opportunities for physicians to earn Maintenance of Certification (MOC) Part II points for activities with a self-assessment component that have traditionally been designated as CME credits only. Specifically, ABIM indicated it would develop ways to recognize most forms of CME approved by the Accreditation Council for Continuing Medical Education (ACCME), thus “allowing new and more flexible ways” for physicians to demonstrate self-assessment of medical knowledge. The ABIM provided an update on these efforts and announced an official collaboration with ACCME that will expand the options available to physicians to receive MOC credit by enabling CME providers, like the ACC, to offer more lifelong learning CME-MOC options. The ACC, along with other cardiology and internal medicine association stakeholders, has been diligent over the last two years in our efforts to encourage ABIM to expand MOC Part II options available to physicians and reduce redundancy with CME, as well as allow societies to more easily offer lifelong learning activities for MOC. This move is a direct result of these efforts and is a big step forward in our ongoing work to represent the needs of our members and to collaborate with the ABIM in their efforts to “ensure that ABIM and MOC evolve to better reflect the changing nature of medical practice.”
Delaying MOC Part IV

27. Most Recent ABIM Actions
April 2015: ABIM announces plans to provide increased opportunities for physicians to earn MOC through self-assessment activities previously categorized as CME credits.
July 2015: Requirement for underlying certification discontinued
August 2015: ABIM announces official collaboration with ACCME to expand options for MOC credit by enabling CME providers to offer more lifelong learning CME-MOC options
August 2015: ABIM announces no loss of certification for failure to enroll in MOC (if other requirements, including 5 and 10 year milestones met)
ACC’s Education Team will continue to
work with ABIM to clarify the changes.

28. ABIM’s Assessment 2020 Task Force Report Developed to:
Develop a vision for future of assessment
Stimulate discussion among stakeholders
In September 2015, The American Board of Internal Medicine (ABIM) released a report entitled “A Vision for Certification in Internal Medicine in 2020,” that was drafted to inform the reshaping of ABIM’s Certification and Maintenance of Certification (MOC) programs. The report, developed by the Assessment 2020 Task Force which assembled in 2013, aims to “develop a vision for the future of assessment in internal medicine and associated subspecialties”  and to “stimulate discussion” around the future of certification. It is in line with many recommendations from the ACC.
In line with many of the ACC’s recommendations!

29. My take on the ABIM 2020 Task Force Proposal
*more frequent lower stakes exams AND secure exams of some sort.
*Uncertain cost, but can't imagine it would be cheaper -TBD
*replaces MOC Part 2

30. My take on the ABIM 2020 Task Force Proposal
*The recommendations seem far more expansive and intrusive on initial review, but much of the detail remains unclear.
*I'm not sure Parts IV, V and VI have been abandoned or rather shelved till alternative methods of measurement can be determined.

31. Summary of MOC Changes October 2015
The prior changes from the ABIM:
MOC Parts 4,5 and 6 are on hold for 2 years
You still need 100 points in 5 years.
You CAN use PIMs (Part 4) to obtain these points fairly painlessly
You will be listed as “participating in MOC”, NOT “In Compliance with MOC”.

32. The Most Recent Changes to MOC
Reversal of the double jeopardy provision
Decoupling of the initial board exam from MOC participation
Streamlining the ability for practitioners to get both CME and MOC Part II credit
The ACC has been tremendously instrumental in making real change occur surrounding MOC. These include:
Reversal of double jeopardy provision which ABIM announced in July This means it is eliminating the requirement to maintain underlying certification in a foundational discipline in order to remain certified in a subspecialty. For cardiology, this means that those specializing in interventional, electrophysiology, adult congenital and advanced heart failure will no longer need to pass both the general cardiology and sub-specialty boards.
Decoupling board certification exam from MOC participation in August This means the ABIM is reversing its policy requiring physicians who have passed the initial Certification exam in 2014 or later to have enrolled in the Maintenance of Certification (MOC) process in order to be listed as board certified. Effective immediately, physicians who are meeting all other programmatic requirements will not lose certification simply for failure to enroll in MOC. This decision is a direct result of ACC's efforts over the last two months seeking an expedited resolution of this issue by ABIM.
Streamlining the ability for practitioners to get both CME and MOC Part II credit. This means the ABIM will provide more opportunities for physicians to earn Maintenance of Certification (MOC) Part II points for activities with a self-assessment component that have traditionally been designated as CME credits only. Specifically, ABIM indicated it would develop ways to recognize most forms of CME approved by the Accreditation Council for Continuing Medical Education (ACCME), thus “allowing new and more flexible ways” for physicians to demonstrate self-assessment of medical knowledge. The ABIM provided an update on these efforts and announced an official collaboration with ACCME that will expand the options available to physicians to receive MOC credit by enabling CME providers, like the ACC, to offer more lifelong learning CME-MOC options. The ACC, along with other cardiology and internal medicine association stakeholders, has been diligent over the last two years in our efforts to encourage ABIM to expand MOC Part II options available to physicians and reduce redundancy with CME, as well as allow societies to more easily offer lifelong learning activities for MOC. This move is a direct result of these efforts and is a big step forward in our ongoing work to represent the needs of our members and to collaborate with the ABIM in their efforts to “ensure that ABIM and MOC evolve to better reflect the changing nature of medical practice.”
Delaying MOC Part IV

33. The Most Recent Changes to MOC
Reduce fees
Possible suspension of the 10 year secure exam (Part III): the New 2020 Task Force report
The ACC has been tremendously instrumental in making real change occur surrounding MOC. These include:
Reversal of double jeopardy provision which ABIM announced in July This means it is eliminating the requirement to maintain underlying certification in a foundational discipline in order to remain certified in a subspecialty. For cardiology, this means that those specializing in interventional, electrophysiology, adult congenital and advanced heart failure will no longer need to pass both the general cardiology and sub-specialty boards.
Decoupling board certification exam from MOC participation in August This means the ABIM is reversing its policy requiring physicians who have passed the initial Certification exam in 2014 or later to have enrolled in the Maintenance of Certification (MOC) process in order to be listed as board certified. Effective immediately, physicians who are meeting all other programmatic requirements will not lose certification simply for failure to enroll in MOC. This decision is a direct result of ACC's efforts over the last two months seeking an expedited resolution of this issue by ABIM.
Streamlining the ability for practitioners to get both CME and MOC Part II credit. This means the ABIM will provide more opportunities for physicians to earn Maintenance of Certification (MOC) Part II points for activities with a self-assessment component that have traditionally been designated as CME credits only. Specifically, ABIM indicated it would develop ways to recognize most forms of CME approved by the Accreditation Council for Continuing Medical Education (ACCME), thus “allowing new and more flexible ways” for physicians to demonstrate self-assessment of medical knowledge. The ABIM provided an update on these efforts and announced an official collaboration with ACCME that will expand the options available to physicians to receive MOC credit by enabling CME providers, like the ACC, to offer more lifelong learning CME-MOC options. The ACC, along with other cardiology and internal medicine association stakeholders, has been diligent over the last two years in our efforts to encourage ABIM to expand MOC Part II options available to physicians and reduce redundancy with CME, as well as allow societies to more easily offer lifelong learning activities for MOC. This move is a direct result of these efforts and is a big step forward in our ongoing work to represent the needs of our members and to collaborate with the ABIM in their efforts to “ensure that ABIM and MOC evolve to better reflect the changing nature of medical practice.”
Delaying MOC Part IV

34. What is your ACC Doing at this point?
We continue to reiterate and emphasize to ABIM our previously stated positions regarding meaningful, simplified, less expensive Maintenance of Competence and Lifelong learning.
We continue to work with ABIM to forward our goals on behalf of our patients and members.

35. What is your ACC Doing at this point?
We continue to have dialogue with other Medical Societies.
We continue to keep open the option of establishing a separate and new Board recognizing the costs and potential issues.
We recognize the efforts ABIM has made so far.