Maintenance of Certification: Myths, facts, and FAQs

This article's views do not necessarily reflect those of Contemporary Pediatrics. -The Editors

Certification by the American Board of Pediatrics (ABP) provides a standard of excellence by which the public can select pediatricians and pediatric subspecialists. The ABP is continually trying to improve the process by which diplomates maintain that certification. To accomplish this, the Board accepts criticism on all aspects of the Maintenance of Certification (MOC) program. This article will address some of these criticisms and myths and explain what MOC is, how it works, and what it will accomplish.

Myths about MOC

“The Boards are corporations that are only in this to make money.”

There are a few certifying organizations that are profit-making enterprises, but the ABP is not one of them. Founded by pediatricians in 1933, the ABP is nonprofit and governed completely by pediatricians. More than 250 distinguished pediatricians in clinical practice, education, and research volunteer their time to develop and verify test questions and advise on MOC activities so that pediatricians can continue to be self-regulating, a privilege that should be jealously guarded. Otherwise, outside agencies (eg, insurance companies, government agencies) would develop regulations for pediatricians to follow.

The work of initial certification and MOC is done by the 4 pediatricians employed by the ABP, a staff of about 100, and 250-plus volunteers, nearly all of them pediatricians. A few others are specialist representatives and public members. Every involved pediatrician, including those with permanent certificates, must meet MOC requirements.

The ABP is acutely aware of the cost to diplomates-certified pediatricians-and works hard to steward the resources it has. The fees cover costs of developing, administering, evaluating, and reporting the results of the nearly 50 examinations that are administered by the ABP, as well as credentialing; resident and fellow tracking and evaluation; development and approval of MOC activities; and other functions essential to certification and MOC. The ABP maintains reserves based on generally accepted accounting practices, equal to about 2 times annual operating expenses.

“There is no proof that MOC is beneficial.”

It is widely known that there is a substantial gap between what medicine/healthcare could do and what it does do. This is the “quality chasm” identified by the Institute of Medicine more than a decade ago,¹ and numerous studies have documented the decrement in physician knowledge over time. The creation of systems of accountability (including MOC) is part of the response to those identified gaps. It is axiomatic that physicians need to keep current and that quality improvement is a fundamental requirement of practice (although 1 critic told ABP with a straight face that he only needed 1 hour a year to keep up).

The criticism is that the way MOC has been implemented does not accomplish these purposes. However, these are the goals of MOC, and all 24 of the Boards that are members of the American Boards of Medical Specialties (ABMS) are working hard to create programs that will improve the health and welfare of patients. Although there are no randomized trials to prove it, there is a large amount of evidence that participation in MOC is correlated with higher quality and better outcomes, and the constant changes in the program represent efforts to continuously improve it.²

“MOC takes too much time.”

Diplomates are asked to participate in 3 to 5 Lifelong Learning Activities, Part 2, that must involve a self-assessment over the course of 5 years. Each of these activities takes between 2 and 5 hours to do. The maximum time commitment for 5 activities for Part 2 would be 5 hours per year.

For Performance in Practice, Part 4, diplomates are asked to participate in 2 quality improvement activities over the course of 5 years. The activities vary in time commitment, and many people do much more just in the course of their daily work than these activities require. If someone wants to know the bare minimum time commitment (not taking into account the benefits of the activities for themselves and their patients), then the total time commitment for Part 4 would be approximately 5 hours per activity, for a total of 2 hours per year.

Someone who takes his or her responsibility seriously for ongoing, continual learning and improvement within the context of daily work would choose to spend more time. Although this would not be required by the MOC process, it is certainly time the Boards want to recognize with MOC credit.

“The exam doesn’t reflect MY practice.”

No longer do professionals, parents, or the public believe that passing an exam once in a career is enough to demonstrate to all that a doctor will always be current. However, diplomates sometimes do object to the format of the exam and the lack of ability to use outside resources available to them in everyday practice. The ABP, along with all the other certifying boards, is working hard to address these very legitimate concerns.

Exam questions are selected from a large pool of questions that are based on the exam content outlines posted on the public part of the ABP website. (Go to www.abp.org, then search for “Content Outlines.”)

Pediatrics is a vast specialty with many different kinds of practices, so no one exam will reflect anyone’s practice perfectly. For example, ABP has received complaints that there is too much neonatology and just as many complaints that there is too little neonatology. The MOC exam is more clinically oriented than the initial certification exam, and because it is given to diplomates who have passed the initial certification exam, the high pass rate (varying from 92% to 98%) is not surprising.

The ABP is currently engaged in a collaboration with testing experts and colleagues from other Boards to understand the best way to evaluate cognitive knowledge. The blog abpeds.wordpress.com from ABP Chief Executive Officer David G. Nichols, MD, MBA, addressed this topic on March 12, 2014, and comments from readers are welcome.

"There is no Quality Improvement (QI), Part 4, activity that relates to me or my practice."

When the self-assessment and QI requirements were added to MOC in the early 2000s, there were relatively few approved activities, and the subject matter was geared to the ambulatory primary care pediatrician. For many diplomates, this was certainly a legitimate complaint. As part of ABP’s improvement activities, there are now hundreds of approved activities, with more coming online every week.

In collaboration with a group of specialists, ABP has developed several new online modules geared to pediatricians taking care of children with serious chronic illness. Also, ABP is now strongly focused on giving credit for QI activities that are based in practices, institutions, and collaboratives through its project approval and portfolio programs and working on easier, more streamlined ways for diplomates to receive credit for QI work they originate.

“MOC is just a part of the disaster that is Obamacare.”

Several critical bloggers have stated that MOC is a creation of the Affordable Care Act (ACA). Obviously, this is not true because MOC has been around for much longer than the ACA. For physicians who treat Medicare patients, one option for reporting some quality measures is through a MOC program, thus simplifying reporting requirements, but that is not the only option for reporting and it is not relevant to pediatric patients.

Now the details: How does MOC work?

Each diplomate has one 5-year MOC points cycle, during which the diplomate must earn 100 MOC points that apply simultaneously to all  his or her certificates, regardless of the number of certificates the diplomate holds. In addition, each diplomate has a 10-year exam cycle for each certificate he or she holds. The points and exam cycles are separate, and the cycles usually do not coincide.

The 5-year cycle

At the time of initial certification in general pediatrics, new ABP diplomates are automatically enrolled in their first 5-year MOC cycle, with cost of the first MOC cycle included in the fee for the initial certification exam.

Once enrolled in MOC, diplomates must fulfill a set of MOC requirements every 5 years; thus the 5-year, 100-points cycle. These requirements include:

• Maintaining valid, unrestricted medical licensure (Part 1);

• Completing approved self-assessment and continued learning activities (Part 2);

• Completing approved performance in practice activities (Part 4).

During the last year of the 5-year MOC cycle, once all requirements are completed, diplomates must re-enroll in MOC so that there is no lapse in certification.

So you’re somewhere in your various MOC cycles. How to do you find out what credit you've already received, when activities are due, and when you need to sign up for another exam?

Each diplomate has a personal portfolio on the ABP website that shows exactly what he or she needs to do and by when, and that also includes links to further information. Log on to the ABP website at www.abp.org to check for your specific requirements. Also, so that you don’t inadvertently miss a deadline, the ABP will send you periodic reminders, usually via e-mail but sometimes with an old-fashioned paper letter. As you get closer to your due date, these communications will become more frequent. As soon as your requirements are met, the reminders stop.

Q. I need Part 2 points. What activities are available?

The ABP has approved more than 200 (120 currently active) Part 2, Lifelong Learning and Self-Assessment activities, 55 of which are available at no additional charge on the ABP website. Part 2 activities earn continuing medical education (CME) credit, also at no additional charge. Diplomates may earn Part 2 points in any area of interest, whether certified in a subspecialty or not, and those points will count toward the total points needed. Many CME courses are now offering Part 2 credit as part of their programs as well.

Q. I need Part 4 points. What activities are available?

The ABP has approved more than 400 Part 4, Performance in Practice activities, 15 of which are Performance Improvement Modules available at no additional charge on the ABP website. An additional 7 are American Academy of Pediatrics (AAP) Education in Quality Improvement for Pediatric Practice (EQIPP) modules that will be available from the AAP at no additional charge later this year.

For diplomates already involved in QI, organizations can apply for approval of their QI projects and ABP will award credit to all diplomates who participate meaningfully in the project. Larger institutions can become portfolio sponsors, with the ability to approve multiple projects within the institution. Currently, there are more than 50 institutional portfolio sponsors with many more in the pipeline.

Finally, if you have published a qualifying QI project or presented it as a poster, you may be able to receive credit. Contact the Board if you need help obtaining credit for QI work you are already doing. Additional ways to earn Part 4 credit are “under construction” at the ABP.

Q. I am not clinically active, but I wish to participate in MOC. What can I do?

Diplomates who are not seeing patients can complete practice improvement modules that contain simulated data. Currently these are offered both by ABP and by the AAP EQIPP program.

The 10-year cycle

Every 10 years, diplomates must pass an exam in each area in which they are certified to demonstrate that they continue to have the cognitive knowledge to meet the standards of care set by the ABP for certification.

Developing a certification exam is a lengthy and rigorous process that helps to ensure that the exams are valid, fair, and reliable. More than 250 pediatricians and pediatric subspecialists from both community and academic practice are involved in every step of the process, from determining content to writing and reviewing the questions to analyzing the results and setting a passing score.

The MOC tests are more clinically focused than the initial certification exams. The pass rates on MOC exams are above 90%, depending on the year and the area: general pediatrics or a pediatric subspecialty.

More information about taking the exams is available on the ABP website.

Q. I am a subspecialist. Do I need to maintain certification in general pediatrics if I maintain my subspecialty certification?

Maintaining certification in general pediatrics is not a requirement for maintaining certification in an ABP subspecialty. Some subspecialists may wish to maintain their certification in general pediatrics, but this is not an ABP requirement.

If you are certified in both general pediatrics and a subspecialty, you have only one MOC points cycle that applies to all your certificates. You will need to take an exam every 10 years for each certificate you wish to maintain. In addition, if you are meeting the requirements of MOC for another ABMS Board (such as internal medicine), the ABP considers this sufficient demonstration of self-assessment, lifelong learning, and performance improvement, and you are deemed to be meeting the requirements of Part 2 and Part 4 of MOC for ABP. The other ABMS Boards similarly provide reciprocal credit in recognition of ABP’s MOC program.

Q. What happens if I don’t get everything finished on time, or if I don’t pass the exam?

For diplomates with a time-limited certificate, if you do not fulfill your MOC requirements and re-enroll in MOC by the due date listed in your ABP portfolio, or if you do not pass the secure exam by the due date listed in your ABP portfolio, your certification will lapse. Pediatricians whose certificates have lapsed can apply for reinstatement and must complete specific requirements in order to regain certification.

Q. What about the fees?

The fee to re-enroll in one 5-year cycle of MOC in 2014 is $1230 (less than $250 per year). The fee includes access to ABP’s Part 2 and Part 4 activities and a voucher for one exam every 10 years. Diplomates maintaining more than one certificate do not pay any additional MOC fees, but do pay an additional reduced fee for their second exam.

The fees for exams and MOC must cover all of ABP’s costs; the ABP does not accept outside funding. Although ABP’s fees are among the lowest of the certifying Boards, the largest Boards are able to offer lower fees (especially for subspecialists) because they have so many more diplomates in their programs.

The ABP and its Board of Directors are committed to controlling certification costs while maintaining the quality of the certification process and recognize the financial burden of certification on physicians. For that reason, ABP works hard to be a good steward of diplomate fees while fulfilling its fundamental purpose of ensuring a high level of physician competence to produce the best possible healthcare outcomes for children.

In conclusion

Certification is more than a title and more than a degree. It is a demonstration of commitment to continuous improvement leading to opportunities for providing better care. Although ABP certification is voluntary, nearly all qualified pediatricians seek this recognition. Just as building the initial knowledge during formal training takes time and deliberate effort, building on that knowledge and developing genuine expertise following training requires conscious commitment to new learning and quality improvement.

Board-certified pediatricians meet the ABP’s standards of excellence by demonstrating their participation in ongoing learning and showing how they apply quality improvement in the care of their patients. The Board is continually trying to improve this process, sharing the ultimate goal of all pediatricians: to improve health and healthcare for children.

REFERENCES

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. Available at: http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx. Published March 2, 2001. Accessed July 23, 2014.

2. American Board of Medical Specialties. Welcome to the ABMS Evidence Library. ABMS web site. http://evidencelibrary.abms.org/. Accessed July 23, 2014.

Are you attending the American Academy of Pediatrics National Conference and Exhibition in San Diego, October 11-14? Visit the American Board of Pediatrics at Booth #12 where representatives will be on hand to meet with you and answer your questions about MOC.

Dr Moyer is vice president for Maintenance of Certification (MOC) and quality, American Board of Pediatrics, Chapel Hill, North Carolina.

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