Maintenance of Certification Does NOT Equal Maintenance of Quality
The good folks at The Health Care Blog kindly pointed out a post on MOC that they asked me to comment on. MOC, for those blissfully ignorant of this recent regulatory development, stands for Maintenance of Certification. In Anesthesia it’s called MOCA for obvious reasons. Dr. Lois Margaret Nora, head of the American Board of Medical Specialties, invited constructive feedback on this process, which is mandatory for everyone certified after 2000, at least in Anesthesia. What happens to the old guys certified before 2000? I guess their skills never decline and their knowledge is forever renewing automatically through a chip implanted in their elderly brains.
MOC is actually a good idea. You might be surprised to hear this coming from me. It is. Skills and knowledge decline over time. That’s what CME’s (Continuing Medical Education) credits used to be for. Let’s put off for the moment consideration of the considerable time, effort and money each physician must expend on this 10 year process every 10 years. Let’s look at what’s really required. Here’s what the ABA (American Board of Anesthesiology) website says:
“Each MOCA cycle is a 10-year period that includes continuing assessment of Professional Standing (medical licensure), ongoing Lifelong Learning and Self-Assessment, a decennial assessment of Cognitive Expertise, and periodic assessments of Practice Performance. MOCA is an opportunity for physicians to improve their skills in six general competencies: Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Professionalism; Interpersonal and Communication Skills; and Systems-Based Practice.”
There are four parts to MOCA: 1. Maintenance of Licensure (MOL), which has it’s set of requirements separate from MOC. 2. Lifelong Learning and Self-Assessment, translated = CME’s! But you cannot apply more than 60 credits a year and over the 10 years 90 must be “self-assessment” and 20 must be “patient safety” credits. 3. Cognitive Examination = a very long multiple choice test that costs, get this, $2,100. Yep. Two thousand big ones. 4. Practice Performance Assessment and Improvement, which you can do with an online module. Very effective. But wait! Look what else you can do!
“We are pleased to announce that participating in MOCA in 2013 can qualify ABA diplomates for a bonus incentive payment if they also participate in the Physician Quality Reporting System (PQRS). MOCA participants will receive an additional 0.5% incentive payment (MOC:PQRS incentive) based on their estimated Medicare Part B Physician Fee Schedule allowed payments for Centers for Medicare and Medicaid Services (CMS). This bonus is in addition to the 0.5% incentive payment allowed for participation in PQRS only. CMS will be offering the MOC:PQRS incentive in 2013 and 2014 as defined by the Affordable Care Act. The MOC:PQRS incentive is not currently defined beyond 2014.”
Ah. Now we get down to it. I don’t even know what most of that means but two things catch the eye: CMS and PQRS. CMS is of course the Centers for Medicare and Medicaid Services, and PQRS is the Patient Quality Reporting System. Government regulatory agencies. The federal government has figured out a way to make doctor’s requirements for MOC translate into data points for itself. This is no surprise. Not only will CMS want data, it will use that data to generate data about whether or not MOC increases quality of care. And how will it define quality? The same way it does now. Meaningful Use. Criteria that are easily measured and have little to do with actual quality of the care given to any one patient.
Want to improve quality of care and maintenance of the skill set and knowledge needed to be a good anesthesiologist?
1. Provide doctors with more time with patients and less time on MOC paperwork
2. Develop an open-access and curated central location for all significant recent clinical research
3. Provide time for “professional development” like my pre-schooler’s teachers do. And no, I don’t mean the grand rounds where the guy researching natriuretic peptide puts of slides of the Krebs cycle for an hour.
4. Provide MEANINGFUL ways doctors can improve their skills. Why not provide “mini residencies”? If a doctor needs practice on fiberoptic intubations, give him a month- or week-long intensive airway “rotation” where he gets to intubate everything hard and spends time with the ENT guys who do this in the office every day. Or schedule the ORs in such a way that the poor slob who does cataracts and knee scopes all day every day gets a chance to do some thoracic cases and practice lines and double-lumen tubes.
If all this is too technical, that’s because it is for us anesthesiologists too. Skills can be lost in the slotting of doctors into specialty groups. No amount of simulation or on-line courses or grand-round CME’s will be as effective as these measures in making sure everyone knows what they are doing for the best interests of every patient every time.