ABIM Overhauling MOC

Yesterday, the American Board of Internal Medicine (ABIM) announced proposed changes to their controversial Maintenance of Certification (MOC) (1). One of the biggest changes is an alternative path to recertification. For most physicians, that would mean they would not have to take the long-form test every 10 years, but instead would have a series of more frequent, but less onerous, assessments. To determine the MOC content ABIM will be using physician crowd-sourcing to determine what knowledge is essential for various physicians and what is most relevant to their practices. ABIM is also changing the format for scores so that physicians get more detailed feedback.

ABIM’s MOC program has been controversial (2). MOC has been viewed by most physicians as being irrelevant to their daily practice and a burden (3). This led to the formation of National Board of Physicians and Surgeons which is challenging ABIM’s monopoly on physician internal medicine certification (4).

ABIM claims that MOC is still the best way of assuring physician knowledge and skills in a particular field (1). Two studies were cited. One asserts that the cost of care for Medicare beneficiaries is 2.5% lower among physicians who were obliged to complete MOC than among those who were not (5). The second states death and emergency coronary artery bypass grafting is lower when patients undergoing percutaneous coronary interventions are treated by board-certified interventional cardiologists (6).

However, Paul Teirstein, MD, chief of cardiology and the director of interventional cardiology at Scripps Clinic in La Jolla, California takes issue with ABIM’s assertion. "There's no evidence that MOC, recertification or take-home computer modules improve patient outcomes," he told Medscape Medical News (7). "This is a money-making operation for [ABIM]. It's a tollbooth, and there's no evidence that it helps anybody, and it takes a ton of time." Teirstein also takes issue with the 2.5% reduction in costs which he points out was a reduction in the growth differences in cost, which is much smaller than the 2.5% lower cost the ABIM claims. That same study also shows an increase in emergency room use for patients treated by MOC-required physicians, he added. The second study concluded no “… consistent association between ICARD certification and the outcomes of PCI procedures.” (6).

References

1. Baron RJ, Braddock CH III. Perspective: knowing what we don’t know — improving maintenance of certification. New Engl J Med. November 30, 2016 Nov 30 [Epub ahead of print] [CrossRef]
2. Lowes R. ABIM suspends controversial MOC requirements through 2018. Medscape Medical News December 16, 2015. Available at: http://www.medscape.com/viewarticle/856076 (accessed 12/1/16).
3. Cook DA, Blachman MJ, West CP, Wittich CM. Physician Attitudes About Maintenance of Certification: A Cross-Specialty National Survey. Mayo Clin Proc. 2016 Oct;91(10):1336-45. [CrossRef] [PubMed]
4. https://nbpas.org/ (accessed 12/1/16).
5. Gray BM, Vandergrift JL, Johnston MM, et al. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. [CrossRef] [PubMed]
6. Fiorilli PN, Minges KE, Herrin J, et al. Association of physician certification in interventional cardiology with in-hospital outcomes of percutaneous coronary intervention. Circulation. 2015 Nov 10;132(19):1816-24. [CrossRef] [PubMed]
7. ABIM leaders say they are revamping MOC requirements. Medscape Medical News. December 1, 2016. Available at: http://www.medscape.com/viewarticle/872593?nlid=110968_2863&src=wnl_dne_161201_mscpedit&uac=9273DT&impID=1244926&faf=1 (accessed 12/1/16).

Cite as: Robbins RA. ABIM overhaulding MOC. Southwest J Pulm Crit Care. 2016:13(6):276-7. doi: https://doi.org/10.13175/swjpcc128-16 PDF

Hospital Employment of Physicians Does Not Improve Quality

The Annals of Internal Medicine posted a manuscript on-line today reporting that the growing trend of physician employment by hospitals does not improve quality (1). In 2003, approximately 29% of hospitals employed members of their physician workforce, a number that rose to 42% by 2012. The authors conducted a retrospective cohort study of U.S. acute care hospitals between 2003 and 2012 and examined mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions for 803 hospitals that switched to the employment model compared with 2085 control hospitals that did not switch. Switching hospitals were more likely to be large (11.6% vs. 7.1%) or major teaching hospitals (7.5% vs. 4.5%) and less likely to be for-profit institutions (8.8% vs. 19.9%) (all p values <0.001).

The authors used Medicare Provider Analysis and Review File (MedPAR) from 2002 to 2013 to calculate hospital-level risk-adjusted performance on mortality, readmissions, and length of stay for acute myocardial infarction, congestive heart failure, and pneumonia. Hospital Compare data from 2007 to 2013 was used to assess overall patient satisfaction. After conversion to a physician employed model, no difference was found in any of 4 primary composite quality metrics with the single exception of readmission rates for pneumonia. That decline was modest (19.3% vs. 19.1% readmissions) and judged not likely to be clinically significant by the authors.

Recently, Baker and colleagues found that hospital employment of  physicians is associated with higher spending and prices (2). This data combined with the data from the present study suggest that the trend is for higher healthcare costs without an improvement in quality. Commenting in Medscape Richard Gunderman, a well-known healthcare delivery researcher from the University of Indiana, said that those who think quality comes from increasingly larger organizations with more advanced information technology and greater standardization across the system will see these results as surprising and disappointing (3). Pointing to high levels of burnout and widespread complaints of lack of time with patients, Gunderman said less physician control over individual patient care has taken a toll. "There's no doubt that a demoralized workforce will tend to drive quality down," he said. "Many hospitals and health systems around the country are grappling with poor and, in some cases, dismal engagement scores. I think that's an indication that a lot of physicians feel that the changes taking place across healthcare are problematic."

Funding for the study was provided by the Agency for Healthcare Research and Quality. Limitations of the study was that the patients were primarily Medicare beneficiaries aged 65 years and older. Therefore, the applicability of the findings to a younger population is unknown, however, the authors doubted that after switching to an employment model, hospitals would improve care for one group and not another.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Scott KW, Orav EJ, Cutler KM, Jha AK. Changes in hospital–physician affiliations in U.S. hospitals and their effect on quality of care. Ann Intern Med. 2016. Available at: http://annals.org/article.aspx?articleid=2552987 (accessed 9/20/16). [CrossRef]
2. Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
3. Frellick M. Physician employment by hospitals does not improve quality Medscape. September 19, 2016. Available at: http://www.medscape.com/viewarticle/868978?nlid=109338_2863&src=wnl_dne_160920_mscpedit&uac=9273DT&impID=1200121&faf=1#vp_2 (accessed 9/20/16). 

Cite as: Robbins RA. Hospital employment of physicians does not improve quality. Southwest J Pulm Crit Care. 2016;13(3):133-4. doi: http://dx.doi.org/10.13175/swjpcc099-16 PDF

Smoking Rates Low in Southwest

The Gallup survey confirms that smoking rates in the US are declining and that smoking rates are lower in the Southwest than the US as a whole (1). Nationally, the smoking rate fell to 19.7% in 2013 from 21.1% in 2008. Among the Southwest states California ranked second (15.0%), Colorado ninth (17.4%), and Arizona tenth (17.5%). Only New Mexico was above the Nation's average at 20.0%. Utah remains the state with the lowest percentage of smokers, 12.2 percent, and Kentucky the highest, 30.2 percent.

Nine of the 10 states with the lowest smoking rates have outright bans on smoking in private worksites, restaurants, and bars, with California allowing for ventilated rooms. Bans are significantly less common in the 10 states with the highest smoking rates. Kentucky, West Virginia, and Mississippi -- the states with the three highest smoking rates -- do not have statewide smoking bans. In addition, these three states have some of the lowest average cost of a pack of cigarettes (2).

The Campaign for Tobacco-Free Kids has identified access to tobacco as a major factor in youth smoking (3). However, tobacco products still remain readily accessible. Recently, CVS, the National chain of pharmacies, announced that it will no longer sell cigarettes (4). A recent New York Times op-ed called for Walgreen’s to do the same (5).

Richard A. Robbins, MD

Editor

References

1. McCarthy J. In U.S., Smoking Rate Lowest in Utah, Highest in Kentucky. Available at: http://www.gallup.com/poll/167771/smoking-rate-lowest-utah-highest-kentucky.aspx?utm_source=rss&utm_medium=rss&utm_campaign=in-u-s-smoking-rate-lowest-in-utah-highest-in-kentucky-smoking-rate-in-alaska-has-dropped-the-most-since-2008 (accessed 4/12/14).
2. Boonn A. Campaign for tobacco-free kids. Available at: https://www.tobaccofreekids.org/research/factsheets/pdf/0202.pdf (accessed 4/12/14).
3. Campaign for tobacco-free kids. Enforcing laws prohibiting cigarette sales to kids reduces youth smoking. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0049.pdf (accessed 4/12/14).
4. CVS quits for good. Available at: http://info.cvscaremark.com/cvs-insights/cvs-quits (accessed 4/12/14).
5. Bach PS. The tobacco ties that bind. New York Times. 4/10/14. Available at: http://www.nytimes.com/2014/04/11/opinion/the-tobacco-ties-that-bind.html?_r=0 (accessed 4/12/14).

Reference as: Robbins RA. Smoking rates low in southwest. Southwest J Pulm Crit Care. 2014;8(4):233. doi: http://dx.doi.org/10.13175/swjpcc051-14 PDF