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…

7. MOC-Maintenance of Certification The new changes are from the ABIM, NOT the ACC. –The ACC is working to provide solutions –AND trying to work with the ABIM to make the process easier, more palatable to our members and less costly.

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

9. 2015 MOC Familiarity Q. How familiar are you with all of the recent changes that the ABIM has made to its certification / recertification process? Similar to last year, almost all members are aware of the MOC changes and they report being familiar with the particulars with half being very familiar with all of the changes and two-in-ten saying they are not familiar. 9 2014 2015 Total Very Familiar 56%54% Total Not Familiar 19%19%

10. 2015 MOC Favorability Q. Do you favor or oppose the new ABIM MOC requirements? 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. 10 2014 2015 Total Favor 4%14% Total Oppose 87%68%

11. MOC Effect on Future Plans Q. Have these recent MOC requirements affected your planning for the future, specifically thoughts of retirement, part-time practice or transitioning out of the practice of cardiovascular medicine? One-third of members (32%) continue to report that the recent MOC requirements are affecting their future planning, particularly earlier retirement or transitioning out of practice. Two-in-five (41%) say that their planning is not affected by MOC changes while 17% are not sure. 11 2014 2015 Total Yes 32 % 32 %

12. MOC Effect on Future Plans - by Tenure Q. Have these recent MOC requirements affected your planning for the future, specifically thoughts of retirement, part-time practice or transitioning out of the practice of cardiovascular medicine? 2015 In training (n=226) 2015 1 – 7 years (n=451) 2015 8 - 14 years (n=534) 2015 15 - 21 years (n=638) 2015 22 - 28 years (n=689) 2015 29 or more years (n=793) 2015 Not in practice (n=43) No, this has not affected my future plans 43%51%47%41%37%35%23% Total Yes 13%14%22%32%42%45%15% Yes, plan to retire earlier 8% 15%20%26%27%5% Yes, plan to retire later 2%<1%1% 0% Yes, plan to transition out of practice 3%5% 8%10%11%5% Yes, plan to work part time 0% 1% 3%5%6%5% Other, please specify 12%10%9% 6%7%28% Not applicable 4%1%3%1% 2%28% Not sure 29%23%17%16%14%10%7% Not surprisingly, cardiologists who have been in practice longer, are more likely to report that their future plans have been affected by the recent MOC requirements, with at least one-quarter saying they will retire earlier than planned. 12

13. Recommended MOC Process Revisions Q. If you were tasked with revising the MOC process for cardiologists, which of the following would you recommend? Please select all that apply. Having ACC assume certification (51%) and removing MOC as a requirement (40%) remain the most desired MOC revisions followed a close third by removing Part 4 (36%). 13

14. 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 Advocating on behalf of members for changes to the MOC process Cardiology Magazine, January 2015

15. 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 emails Development of MOC Resource Hub on ACC.org

16. 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.

17. ACC Sends Letter to Members on Aug. 20, 2014

18. ACC’s Initial Recommendations to ABIM Creation of dual pathways for recertification Harmonization of CME with MOC credits Recognition of ongoing, hospital-based quality improvement and patient surveys as qualifying for MOC accreditation Elimination of the “double jeopardy” faced by those who have to pass both the general cardiology and sub-specialty boards Reduction of fees Improvement in ABIM web site Research into the value of MOC

19. 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.

21. 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.

22. ACC 2 MOC Task Forces: TF1: To look at ways to work with ABIM to promote reforms to the MOC process TF2: To look at alternatives to ABIM and to provide lifelong learning and Maintenance of Competence.

23. Task Force #1-MOC TF Charge Facilitate ACC-ABIM communication Prioritize MOC issues for ABIM consideration Determine whether meaningful changes to MOC process can be made over a reasonable time frame

24. Maintenance of Certification and Recertification (ACC/F) Task Force #1 Ground rules: Defining the needs of the members in the context of public welfare and how we can “co-create” a new standard for MOC. A Board would need to be at arms length from ACC and thus working with ABIM existing structure is appealing. Four parts of the Physician Charter on Professionalism are particularly relevant:

25. Maintenance of Certification and Recertification (ACC/F) Task Force #1 Ground rules: The principle of the primacy of patient welfare The commitment to professional competence The commitment to improving quality of care The commitment to professional responsibilities

26. Task Force #1-Future Considerations Use of ACC competence statements for practicing cardiologists to inform design of MOC activities Research into best practices for maintenance and demonstration of competence with eventual link to patient outcomes, cost and cost-effectiveness Identify ACC members (in addition to WJO) to maintain liaison with ABIM

27. 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

28. 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)

29. 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

30. 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.

31. 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)

32. 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

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. Where are we now?

39. 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

40. 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.

41. ABIM’s Assessment 2020 Task Force Report Developed to: Develop a vision for future of assessment Stimulate discussion among stakeholders In line with many of the ACC’s recommendations!

42. 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

43. 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.

44. 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”.

45. 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

46. The Most Recent Changes to MOC Reduce fees Possible suspension of the 10 year secure exam (Part III): the New 2020 Task Force report

47. 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.

48. 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.