New Quality Indicator: MOC promotes better care, ABOto director says

BOSTON—With greater scrutiny of doctors and easier access to information about doctors’ education, the American Board of Otolaryngology’s Maintenance of Certification (MOC) program is more important than ever, said Robert Miller, MD, executive director of the American Board of Otolaryngology (ABOto).

“Health care quality is a major issue,” Dr. Miller, who’s also physician editor of ENT Today, said in a presentation at the 2010 Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, held here Sept. 26-29. “I think more and more doctors are recognizing this. And the important point is, if we don’t do something to address physician quality, somebody else will. And I don’t think any of us would like that.”

Dr. Miller says MOC will improve quality of care

The MOC program, started 10 years ago, is overseen by the American Board of Medical Specialties (ABMS) and is a process for life-long learning and improving the quality of a doctor’s practice. It includes four parts: professional standing, continuing education and self-assessment, a cognitive exam, and performance in practice.

The performance in practice assessment, involving a review of a doctor in his working environment, is still being developed. But when it is complete, it will be the most important part of MOC, Dr. Miller said.

“Frankly, if we could develop a really accurate, well-done, easily done Part IV, probably Parts I, II, and III go away,” he said. “But we’re far from that. It’s clearly the most difficult to develop.”

MOC should not be confused with recertification, he stressed. “Some people get maintenance of certification and recertification confused,” Dr. Miller said. “Recertification is basically retaking of an exam every so often, usually every 10 years. Maintenance of certification does include such an exam, but it includes a lot of other activities that make it a more continuous process.”

The essence of MOC is to improve the care of patients, which is the ABOto’s mission, he said.

“The fiduciary responsibility of the board is to the public,” he said. “We don’t act in a vacuum of what effect this is going to have on our diplomates. But when push comes to shove, the board has a very easy decision-making process because we’re always concerned about what’s good for the patient.”

Diplomates certified in 2002 and later are exempt from MOC requirements, but Dr. Miller encouraged everyone to participate regardless.

Other Benefits

Aside from promoting quality care, there are other, practical reasons to do so, he said. Patients going to the ABOto website or calling the ABOto are told about doctors’ certification and whether they’ve participated in MOC. ABMS requires release of that information, he said.

“I think you can see the more educated patients may wonder about a doctor that doesn’t participate in MOC,” he said.

Hospital privileges may eventually require MOC, he added. “I don’t know of any that currently require MOC but I think this is something coming down the line,” he said.

Also, state licensing boards are requiring doctors to do “something similar to MOC” to meet state licensing requirements, he said.

Mark Wax, MD, professor of otolaryngology-head and neck surgery at Oregon Health and Science University, who was part of the same session, said that doctors who are not grandfathered still need to take MOC seriously, even though that may not have been his view at first.

“I thought, ‘Great, I won’t ever have to do this, it won’t affect me,’” Dr. Wax said. “I think we’re all wrong in that. I think the states are going to mandate that we’re going to have to do something to keep our license through them.”

To underline his point on the importance of MOC, Dr. Miller showed a curve of physician quality as it exists today, with a thin tail on the left for “bad” doctors and a thin tail on the right for “excellent” doctors, and the crest of the curve at the “good” line in the middle.

“The purpose of MOC is to shift the curve to the right,” he said. “Most otolaryngologists practice good medicine on most patients most of the time. Why not all of the patients all of the time?”

Maintenance of Certification: Its Four Parts

Part I: Professional Standing

• Must have certificate from the American Board of Otolaryngology
• Must have an unrestricted medical license
• Must maintain privileges at hospital/ambulatory surgery center

Part II: Continuing Education and Self-Assessment

• Part of a lifelong learning program
• 25 CME units per year
• Completion of self-assessment program that is clinically oriented, is specialty-specific and is aided by online modules
• It is a non-punitive assessment

Part III: Cognitive Examination

• Secure, closed-book exam administered at testing centers around the country
• Totally clinical, no basic science
• 80 questions: 12 on fundamentals, and the other 68 on a selected practice area
• Focuses on specific practice, with clinical fundamentals and one specialty module
• Cannot be used to imply subcertification, except for neurotology and sleep medicine

Part IV: Performance in Practice (Still being developed)

• Possibly the most important part of MOC but the most difficult to develop
• Based on a quality improvement approach
• Will look at doctor-patient interaction and outcomes
• Has to be meaningful but minimally intrusive
• Has resulted in reduced malpractice rates
• ’Enhanced’ Part IV being developed that will meet Physician Quality Reporting Initiative requirement