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AAN's Call for Repeal of MOC Part IV Awaits Action from Credentialing Board

ARTICLE IN BRIEF

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THE AAN said it cannot support the Part IV requirements of maintenance of certification because they are onerous and there is no evidence that they improve physicians practice and the quality of care they provide.

The AAN has asked that Part IV of the MOC requirements be dropped out of concern that they are onerous and do not reflect practice standards that are meaningful for neurologists. But the leaders of both the American Board of Psychiatry and Neurology and the American Board of Medical Specialties have not expressed willingness to drop these requirements.

Leaders of the medical boards that set requirements for maintenance of certification (MOC) are resisting a call by the AAN and hundreds of neurologists to drop Part IV of the MOC requirements, which many consider onerous.

While expressing sympathy with the view that some of the requirements can be burdensome, particularly for neurologists in small practices, leaders of both the American Board of Psychiatry and Neurology (ABPN) and the American Board of Medical Specialties told Neurology Today that they and their boards have already worked hard to make MOC requirements as flexible as possible. In the end, however, they emphasized that there is no getting around the need for physicians to demonstrate continued improvement in their medical practice.

“I cannot imagine that the AAN, with its tremendous commitment to patient safety and quality improvement, would ever truly call for an end to the improvement in medical practice requirements,” said Lois Margaret Nora, MD, JD, an AAN member who is the president and chief executive officer (CEO) of the American Board of Medical Specialties, in a telephone interview. (The American Board of Medical Specialties oversees physician certification in the US, and is comprised of 24 member specialty boards, including the ABPN.)

For their part, AAN leaders said the Academy remains committed to practice improvement and quality measures. But they are concerned that Part IV of the MOC standards — those covering “Improvement in Medical Practice,” or PIP (for “Performance in Practice”) — do not reflect those standards in a meaningful way.

“The problem with the Part IV requirements for many of our members is not just that they're onerous and time-consuming,” Catherine M. Rydell, CAE, executive director and CEO of the AAN, told Neurology Today. “We do not have convincing research showing that Part IV is effective in improving physicians' practice and the quality of care they provide. As a result, we can't support them. We just don't think Part IV is doing what it is intended to do.”

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DR. TERRENCE L. CASCINO: “The AAN has tried to make Part IV as easy as possible with its high-quality NeuroPI courses, but still some members find that Part IV is time-consuming and interferes with other aspects of patient care. Unfortunately for a number of neurologists in practice, theyre having charts pulled by hand and it takes a lot of time. MOC Part IV doesnt seem very meaningful to them without convincing research showing that Part IV is effective in improving practice and quality of care.”

MIXED RESPONSE TO THE REQUEST

On Feb. 24, AAN President Timothy A. Pedley, MD, FAAN, announced in a letter to members that the Academy's Board of Directors had decided to call on the ABPN to revoke or eliminate Part IV of the MOC standards.

“The AAN is urging repeal of Part IV of MOC and is calling on ABPN to respond positively to this request,” Dr. Pedley stated in his letter.

“This decision of the AAN Board of Directors to call for revocation of Part IV is an independent decision,” he wrote. “We believe that one of our most important roles is to advocate responsibly on behalf of our members. But it is also important to remember that the AAN is an independent association with no control over ABPN, the American Board of Medical Specialties, or the MOC rationale and process.”

The response so far, at least in public remarks, has been mixed.

In a brief telephone interview conducted a week after Dr. Pedley's letter was released, Larry R. Faulkner, MD, president and CEO of the ABPN, said that his board is simply not authorized to unilaterally repeal standards set for all medical specialties by the American Board of Medical Specialties. “As always, we certainly welcome any constructive feedback,” he said. “But simply wiping out part of the requirements is not something we at the ABPN believe we have the authority to do. The American Board of Medical Specialties sets the standards, and unless they decide to change them, we don't have a choice but to follow them. Within the American Board of Medical Specialties framework, however, we will continue to advocate for MOC standards that are as reasonable and flexible as possible.”

On March 2, the American Board of Medical Specialties released a position statement on its website stating that it “remains fully committed to all of the elements of MOC.”

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DR. TIMOTHY A. PEDLEY wrote in a letter to the AAN membership: “This decision of the AAN Board of Directors to call for revocation of Part IV is an independent decision. We believe that one of our most important roles is to advocate responsibly on behalf of our members. But it is also important to remember that the AAN is an independent association with no control over ABPN, the American Board of Medical Specialties, or the MOC rationale and process.”

FRAMING THE DEBATE

The current debate over Part IV of the MOC requirements went public last year when AAN member Paul G. Mathew, MD, FAHS, launched a petition calling for its elimination through a website he established, www.endmoc.com. Dr. Mathew, who is director of Continuing Medical Education at the Brigham and Women's Hospital and Harvard Medical School and a staff neurologist with the John R. Graham Headache Center in Boston, said more than 900 neurologists, as well as numerous state neurological societies and chairs of academic departments, have e-signed the petition.

While applauding the AAN for issuing its call to drop Part IV, Dr. Mathew disagreed with Dr. Faulkner's view that the ABPN lacks authority to do so.

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DR. ANN HENDERSON TILTON: “Its a balance. Theres a lot of public pressure on physicians to prove that theyre continually improving their performance. But anything the American Board of Medical Specialties could do to lighten the load on neurologists would be totally embraced.”

“I think he's really passing the buck,” Dr. Mathew said. “I think the ABPN can and should drop Part IV.”

The debate has grown more intense since Feb. 3, when the American Board of Internal Medicine (ABIM) announced that it was immediately suspending its own Part IV requirements for at least two years in response to negative feedback from its diplomates. At press time, the Board of Trustees of the American Psychiatric Association, the sister organization under ABPN certification governance, also formally asked the ABPN to drop the Part IV MOC requirements, citing concerns about the limited evidence-base for the measures.

“The ABPN can and should take similar action on behalf of its diplomates regardless of what the American Board of Medical Specialties mandates, as the American Board of Internal Medicine has done,” Dr. Mathew said.

David Johnson, MD, chair of the ABIM Board of Directors, told Neurology Today, “It's a tough topic and one that has engendered a lot of emotion. Every physician I know really wants to be the best he or she can be. What the ABIM wants to do is have a program that's relevant, rigorous, and not redundant.”

Terry L Cascino, MD, FAAN, a professor of neurology at the Mayo Clinic in Rochester, MN, and the president-elect of the AAN, recently decided to step down from his simultaneous position on the ABPN Board of Directors to focus on his role as president of the AAN's 29,000 members, and to avoid the perception of a conflict of interest.

“I'm very proud of the work I've done on both boards,” said Dr. Cascino. “Up until the American Board of Internal Medicine made its announcement, the Part IV issue appeared to be mitigable. But it's now become a serious issue for many of our members.”

While supporting the goal of continuing quality improvement in practice, Dr. Cascino said that demonstrating such improvements is particularly burdensome for neurologists in small practices.

“Not everybody works with an institution where they have ongoing quality-improvement programs they can participate in,” he said. “Nor are many neurologists using the sort of electronic registries used by surgeons to measure practices and outcomes, which can seamlessly generate reports. The AAN has tried to make Part IV as easy as possible with its high-quality NeuroPI courses, but still some members find that Part IV is time-consuming and interferes with other aspects of patient care. Unfortunately for a number of neurologists in practice, they're having charts pulled by hand and it takes a lot of time. MOC Part IV doesn't seem very meaningful to them without convincing research showing that Part IV is effective in improving practice and quality of care.”

Ann Henderson Tilton, MD, FAAN, a professor of clinical neurology at Louisiana State University Health Sciences Center in New Orleans and chief of the LSU Section of Child Neurology, said she remained hopeful that the American Board of Medical Specialties would find a way to be responsive to neurologists' view that the Part IV requirements are unduly burdensome.

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DR. LOIS MARGARET NORA: “We did a lot of listening. I suspect that because the new standards are relatively young, the AAN is not aware of that flexibility. Once we have done a better job of making sure our latest standards are known to the AAN, I hope this discussion will be reframed as working to improve the implementation of the standards rather than to terminate them.”

“It's a balance,” said Dr. Tilton, who is also chair of the ABPN Board of Directors. “There's a lot of public pressure on physicians to prove that they're continually improving their performance. But anything the American Board of Medical Specialties could do to lighten the load on neurologists would be totally embraced.”

That view was strongly echoed by Dr. Mathew, who said the lack of proof that Part IV modules improve practice was what led him to oppose the requirements.

“This MOC reform advocacy started for me at the last AAN Annual Meeting, when I attended a re-certification session run by the ABPN,” he said. “When neurologists in the room asked what evidence there was to show that fulfilling these requirements can improve performance, they had very vague answers with no scientific merit.”

Explaining the timing behind the decision to release the AAN letter calling for Part IV to be revoked, Dr. Pedley said that the ABIM's suspension of its own Part IV requirements was like pouring gasoline on a smoldering fire.

“That ignited a tremendous degree of resistance from AAN diplomates,” he said. “The AAN heard what its members were saying, and we agree with them. When something like this affects huge numbers of our members, we have to listen.”

SUPPORT FOR OTHER MOC REQUIREMENTS

At the same time, however, Dr. Pedley and other members of the AAN Board of Directors were quick to emphasize that they continue to support the other MOC requirements, as well as the need for neurologists to continually improve the performance of their practice.

“There are some physicians, including some neurologists, who want all MOC stopped,” he said. “I think that is irresponsible. I believe we owe it to our patients and the communities we serve to demonstrate that we are providing the best possible care. The only legitimate question is how you demonstrate that.”

Dr. Nora of the American Board of Medical Specialties pointed out that the latest revisions to the MOC guidelines were only implemented this past January, following an extensive review with the involvement of all 24-member specialty boards and other stakeholders, including medical specialty societies.

“We did a lot of listening,” she said. “I suspect that because the new standards are relatively young, the AAN is not aware of that flexibility. Once we have done a better job of making sure our latest standards are known to the AAN, I hope this discussion will be reframed as working to improve the implementation of the standards rather than to terminate them.”

The AAN is aware of the new American Board of Medical Specialties standards and has met with Dr. Nora and ABPN leaders several times to discuss the issues and standards over the past year. But as to whether the American Board of Medical Specialties will accept the AAN's call for dropping the Part IV requirements altogether, Dr. Nora said, “I don't see us moving on that.”

LINK UP FOR MORE INFORMATION:

•. AAN Letter on MOC Part IV http://bit.ly/MOC-AANLetter
    •. ABMS Position Statement on MOC http://bit.ly/ABMS-MOCposition
      •. ABMS Standards for MOC http://bit.ly/ABMS-certification
        •. AAN NeuroPI courses http://tools.aan.com/practice/pip/