ABU addresses concerns about cost, value of MOC

January 1, 2007

Chicago-In 2000, the American Board of Medical Specialties assembly voted to commit member boards to Maintenance of Certification for their diplomates holding time-limited certificates. The American Board of Urology will introduce its MOC program in 2007, but during its development, the ABU has received a number of complaints and questions about MOC from urologists.

At the 2006 American College of Surgeons Clinical Congress, Stuart S. Howards, MD, executive secretary of the ABU, addressed some of the most common concerns. Dr. Howards is professor of urology, University of Virginia, Charlottesville.

Why doesn't the ABU require grandfathered diplomates to enter into MOC? Urologists certified before 1985 are not required to be re-certified because there is a contract with these physicians that cannot be revoked. Legally, these urologists who have non-time-limited certificates cannot be required to enter into the MOC process.

Re-certification and MOC cost too much. Considering the finances of the ABU, there is no possible way to lower the fees. The trustees of the board are already providing their services without compensation and, over the past decade, the ABU annual operating budget has been close to breaking even, but it ended with a deficit of $119,000 for 2005. Clearly, the ABU cannot exist with a permanent operating deficit. While at the end of 2005, it had an endowment of $2.5 million, those funds are needed to cover expensive lawsuits, unexpected business expenses, or operating deficits that may arise in the future.

There is no need for MOC. Everything is fine as it is. It is true that the vast majority of urologists practice good medicine. However, the re-certification process uncovers a few who do not, and the ABU receives complaints from diplomates regarding peers who are substandard in practice or who are unethical. Re-certification and MOC allow the ABU to address these problems, which it is required to do by both its public service mandate and by the ABMS.

What does the American public think about board certification and testing of physicians? The American Board of Internal Medicine commissioned the Gallup Organization to conduct a public opinion poll to determine attitudes toward board certification of physicians. A total of 1,001 adults participated, and the results showed the vast majority felt that rigorous, frequent evaluation of practicing physicians is important. Ninety-five percent responded that re-certification is very important, and 85% thought physicians should be evaluated at least every 5 years. Many polled participants indicated that they would change specialists if their physician were decertified.

Why doesn't the ABU use practice-based evidence to evaluate diplomates? While ideal, there is currently no practical, reliable method for conducting physician clinical performance assessment. As outlined in an article by Landon et al (JAMA 2003; 290:1183-9), a number of technical barriers exist, including absence of evidence-based robust measures for outcomes, questions about choosing standards for delimiting acceptable performance, and sample size issues. The latter especially applies to urology because, for most major complicated procedures, the number of cases performed annually by a single practitioner is too small to allow statistical evaluation of outcomes.

Furthermore, because many procedures done by urologists have such good outcomes, it is difficult to identify statistically significant differences in complication rates. The fact that patients are not randomly assigned to physicians is another complicating issue. Some specialists handle a greater proportion of complicated cases than the average practitioner does. Risk adjustment methods for dealing with that type of inequality are imperfect.

What would happen if the ABU refused to implement MOC? The ABU would be removed from the ABMS and would no longer be considered a legitimate board. As a result, its diplomates would not be able to join the staff of most hospitals and would be excluded from payment by some third parties.

In addition, because the Federation of State Medical Boards passed a resolution in 2004 to support maintenance of licensure (MOL) and it in 2005 initiated a program for continuous monitoring of physician competence based on the individual's practice, diplomates could encounter problems with their state medical boards. It is expected that MOC will be sufficient for MOL when it comes into existence and that the Centers for Medicare & Medicaid Services may also accept MOC as proof of performance when the pay for performance program begins.