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ABP Outlines MOC Changes & Long-Term Direction

15.02.25-Bottom Line

The ABP’s Mission and the Current Discussion on MOC

The current intense debate about the meaning of certification is important and healthy for the profession. The ABP position begins with its mission statement. Certification should be based on “standards of excellence that lead to high quality care.” In addition, the Board “provides assurance to the public that… a pediatrician fulfills … core competencies." What follows is a discussion of the components, vision, and criticisms of MOC in light of our mission and the values expressed in the Bottom Line.

Life-Long Learning (MOC Part 2)

“What do I need to know?”
Continuous improvement of our Part 2 activities requires better dialogue with diplomates about what information amidst the growing avalanche of papers a busy pediatrician should know. The Question of the Week (QOW) series has been very effective in this environment and widely praised by general pediatricians. Similarly, in collaboration with the AAP and interested specialty societies, we will build an interactive platform for posting the top articles in a given field. You will be able to rank and comment on the submissions--or offer suggestions of your own. Not only will this dialogue help you to know what literature pediatric experts consider to be important but it will also allow us to link life-long learning (MOC Part 2) with knowledge assessment (MOC Part 3) more effectively.

The MOC Exam (MOC Part 3)

“Change the exam…”
During the past year, we’ve been planning a major conference on the Future of Testing (FOT) that will take place May 15-16 in Chapel Hill. The participants include a diversity of practitioners and leading experts in the field of testing and medical education, who will grapple with all the issues you have raised, including the use of test centers, access to electronic searchable resources (ESRs), alternative testing methods such as simulation or work-place based assessment, and more.

2015 Future of Testing Conference

The results of this conference will guide future decisions about the MOC exam, with the goals of ensuring that it is fair, valid, reliable, and reflective of contemporary practice. I first raised the question of opening the exam to online resources in my December 2013 and March 2014 blogs. Depending on the evidence reviewed at the conference, the ABP may pilot the use of online resources or alternative testing formats. You will soon be able to follow the conference through a dedicated website, which will feature resources and articles used in the conference sessions, summaries, video clips, and more.

“There is no need for the test center. The old open-book exam was a better learning experience…”
I, too, learned a lot working through the ABP diskette from a different era. However, balancing promotion of learning with assessment of medical knowledge is only one of the complex issues the Future of Testing conference will address. Another issue most pediatricians are not aware of is the so-called 10-Year Rule. In fact, ten states have a requirement that a physician must have passed a proctored exam within the preceding 10 years in order to receive a license. The initial certifying exam fulfills this requirement for recent training program graduates, but some physicians in mid- or late-career seeking to (re)enter practice in one of these states have relied on the current proctored MOC exam to fulfill this requirement. The alternative is the National Board of Medical Examiners’ Special Purpose Examination (SPEX), which is a general practice exam (i.e., not just pediatrics) that also includes basic science topics. We will all need to consider very carefully whether having the SPEX exam as the only alternative to receive a mid-career license in these states is in the best interest of pediatrics.

“The exam does not reflect my practice…”
I understand this concern. Our examination committees (consisting of practicing pediatricians) write questions to reflect current practice, but they must also address rare conditions that could harm a child if missed. The current measles outbreak is a telling example. Almost no one’s practice had encountered measles in the last 25 years. And yet, the first pediatrician to encounter an ill-appearing child with the characteristic rash needed to be able to make the diagnosis. The content outlines for each exam guide their construction and are readily available on the ABP website. To allow us to better understand the nature of your practice, we will create a mechanism for you to rank and comment on components of the outlines.

“Help me know what I don’t know…”
I suspect I’m not alone in having been amazed at some of the questions I got wrong on my MOC exam. A review of one’s exam results is a teachable moment for all of us. Over the past year, ABP has greatly enhanced the feedback you receive after an exam. Click here for a sample of the recently improved exam report, which would have told me the specific areas where I missed questions and thus helped me to construct an effective study plan to fill those gaps.

Quality Improvement (Part 4)

“It’s too complicated and not relevant to what I do…”
e at ABP agree that as part of our own continuous improvement, we need to simplify the process and make it easier for diplomates to focus on meaningful quality improvement projects. In addition to the many activities already offered by the ABP, several new pathways have been developed over the past year and will roll out beginning in May. Our declared intent is that all certified pediatricians have access to quality improvement offerings reflective of their daily practices.

For General Pediatricians:

  • MOC Part 4 credit for establishing a Patient Centered Medical Home (PCMH)
    General pediatricians have suggested that the ABP award credit for achieving accreditation of a PCMH. We listened and have created a pathway for diplomates with National Committee for Quality Assurance (NCQA) PCMH accreditation to satisfy the entire Part 4 requirement for a 5-year cycle. Approximately 8,000 primary care pediatricians have established a PCMH to date, and the number is growing rapidly. This MOC activity aligns with both federal and private payer incentives. The application for this pathway will be ready by May. For other PCMH certifications that require demonstrated quality improvement, the component QI projects can be submitted for Part 4 approval.
  • Quality Improvement Programs for Small Groups
    I know most small practices do not have their own QI infrastructure. And if you finished training more than 10 years ago (like I did), you never received any formal training in QI. Therefore, our MOC committee, which includes general pediatricians in private practice, has designed a much simplified program application form for small practices (<10 people). The fee will be nominal, and the pathway will be available by May. Our MOC coordinators will be able to walk you through the process. It reflects our genuine desire to award credit for work you are already doing that improves the care of children.

Many small practices rely on the AAP or subspecialty societies for assistance with QI infrastructure. The ABP will continue to work closely with the Academy and societies to create a QI platform for small groups and find other ways to eliminate barriers to QI participation.

For Pediatricians with Access to QI Infrastructure

  • Receiving Part 4 credit for QI that’s already part of your practice – The Portfolio Program
    The ABP portfolio program allows an institution with QI infrastructure to manage and award MOC Part 4 credit directly to the pediatricians who participate in the institution’s QI programs. This program has grown dramatically in the past year and now covers 70 institutional sponsors, and many more will be added this year. For example, the Nemours Healthcare System has embedded QI data capture into its electronic health record such that participating pediatricians do not have to enter data twice. Now they receive reports as well as MOC credit—automatically.
  • Direct QI data transfer to ABP
    The leader of a major children’s hospital told me they had granular QI data on all pediatricians in its network that ABP should simply accept. We are interested in studying this approach and open to partnering with interested institutions.

Training Programs

Residents will be able to “bank” Part 4 credit that will become active as soon as they pass the initial certifying exam. Faculty who supervise resident QI projects can also receive Part 4 credit.

For all Diplomates

  • Expanding Eligibility for Part 4 Credit
    A list of the many current pathways to receive Part 4 credit is available online. I recognize however, that despite the above efforts to expand the pathways to Part 4 credit, some of you feel that they still do not fit your practice. We will be expanding MOC Part 4 credit eligibility to include the application of Quality Improvement principles, science and tools to an activity intended to improve the health of children. This activity should be highly relevant to any diplomate’s work. For example QI projects can involve clinical care, clinical research, basic research, education and policy work. Examples may include using QI principles, science and tools to:
    • Assess and improve the percentage of children 6-11 years of age who have annual physicals in one’s practice
    • Assess and improve enrollment in a clinical trial
    • Improve an educational program in a pediatric fellowship
    • Improve processes in a bench science laboratory
    • Implement a measurable change in state Medicaid programs
    • Improve processes in guideline development

As a first example of this approach, QI program developers (e.g., chief quality officers, department chairs, etc.) may receive Part 4 credit with attestation of the impact of their QI efforts, beginning in May.

It will take some time to put the remaining examples of expanded Part 4 eligibility in place. The ABP will reach out to professional societies and the American Board of Medical Specialties for input and I will be in touch later in the year to report on progress in this area.

“There is no evidence that MOC improves care…”

Projects Awarded MOC Part 4 Credit

I hear this often. MOC Part 4 credit has been awarded to thousands of pediatricians who collectively have improved the health and healthcare of tens of thousands of children. Click here to see just a few examples. Our 2014 Annual Report provides additional examples and lists publications about the effects of QI programs that have received Part 4 credit. Some of the more prominent examples include:

  • the dramatic reduction in central line associated blood stream infections (CLABSI) (Miller MR et al. Pediatrics 2011;128:e1077)
  • the drop in medical errors after introduction of a handoff bundle (Starmer AJ et al. NEJM 2014;371:1803)

    ABP 2014 Annual Report

  • the major improvement in inflammatory bowel disease remission rates (Crandall VW et al. Pediatrics 2012;129:e1030)
  • the Improvement Partnerships (private practices, state Medicaid agencies, AAP chapters, and children’s hospitals) in several states that have improved care for asthma, attention-deficit/hyperactivity disorder, autism, developmental screening, obesity, mental health, and medical home implementation among others (Shaw JS et al. Acad Pediatr 2013;13:S84).

Of course, it’s not the MOC per se that improves care; it is your dedication that leads to better care and outcomes. MOC offers a national standard of recognition for QI and has been shown to provide an incentive to improve practice. (Gorzkowski JA et al. Pediatrics 2014;134:747. Lannon CM et al. Pediatrics 2013;113(suppl):S187. Vernacchio L et al. Pediatrics 2014;134:e242.)

The Cost of Certification

“MOC costs are too high…”
The ABP Board of Directors reviews the fee schedule in detail every year and remains concerned about the costs of certification, particularly for young pediatricians just completing training. Last year, after close consultation with specialty societies, the ABP froze the 2015 initial certification fees. Extensive cost saving measures will allow the ABP to again freeze all fees for 2016. We remain committed to holding down costs and working to avoid or minimize fee increases.

The ABP's actual financials are available to view online for fiscal years 13 and 14, as well as the FY15 budgeted financials. A few observations:

  • The revenue is variable from year to year and depends on the number of individuals registering for the various certifying exams.
  • There was positive variance in FYs 13 and 14 due to a larger than expected number of enrollees and to efforts by ABP staff to hold down expenses.
  • The costs of MOC far exceed the MOC revenue. If the purpose of MOC were simply to make money, ABP would have discontinued it long ago.

View FY13 View FY14 View FY15

Decisions about Certification

In the midst of debate around MOC, a different model has emerged. The National Board of Physicians and Surgeons (NBPAS) now offers a certificate for individuals with a valid license, a history of initial board certification, and evidence of at least 50 hours of CME credit. The reliance on CME for maintaining certification mirrors the requirements for renewal of licensure. The ABP takes a different stance. Consistent with our mission and accountability to the public, we believe that standards of excellence require a periodic knowledge assessment and active engagement in improving the quality of practice. We recognize our responsibilities to you, our diplomates, to continuously improve every single aspect of MOC while holding down costs. We also must make the interactions around MOC seamless so that a diplomate’s time can be devoted ultimately to improving the health of children. Yet the various models of maintenance of certification reflect a legitimate debate, which needs thoughtful diplomate and public input, if we are to improve healthcare and outcomes for children.

This is what I think. Please let me know what you think.


David G. Nichols, MD, MBA
President and CEO