Paul S . Te irs te in

Chief of Card io logy

Direc to r, In te rventiona l Card io logy

Scripps Clin ic

Within the pas t 12 months , I or my s pous e/partner have had a financ ialin te res t/a rrangement or affilia tion with the organization(s ) lis ted below.

Affilia tion/Financial Relations hip Company

Pres iden t (unpaid) National Board of Phys ic ians and Surgeons(NBP AS.org)

Cours e Direc tor/s peaker Num erous CME confe rences

Grandfa ther: Interna l Medic ine , Card io logy

Not grandfathered: Interventional cardio logy (recertified once)

In itia l ABMS Member Board Certifica tion vs MOC

•I fu lly s upport in itia l ABMS member boa rd ce rtifica tion

•The NBPAS, require s it!

•I am proud of my in itia l ABIM board certifica tions in 3 s pec ia ltie s

•Provid ing in itia l board ce rtifica tion is huge contribu tion .

•The ABMS and its member boards s hould be proud of it…but a ls o beconten t with it.

Curtis s“ Sparky”Stin is

There is s till no evidence MOC, rece rtifica tion , ortake home computer modules improves pa tien toutcomes

The propos ed new tes ts (s ecure or take -home) s tillcan not be ta ilo red to individua l phys ic ian prac tice s

The work of MOC lacks meaning = bus y work

Appearance of a financ ia l motiva tion underlying theMOC requiremen ts

Des p ite a ll the apologies , ema ils and dis cus s ionabout modern izing MOC and recertifica tion :

Be aware tha t many phys ic ians making dec is ions abou tMOC are grandfa the rs and have neve r had to do MOC!

6.4%if remove s͞lightly agree͟

The pos te r ch ild for conflic ts of in te res t

Profes s ionalis m is no t:

1) E Blas ting on ly the s e lec tedtria ls tha t s upport youro rganiza tion

2) Not d is c los ing tha t 6/7 tria lsquoted were au thored by ah igh ly pa id ABIM employees

3) Blu rring the lines be tween tria lsexamining in itia l certifica tionand MOC

10-6-2016

In J anuary,2015, 10 daysa fte rlaunch ing theNBPAS,

ABIMapologizes toits 200,000dip lomats

The lesserof two evils

NOTSOFAST!!!The end of the 10 year recertifyingexam! Should wecelebrate?

• The revis ed ABIM MOC program replaces one la rge was te of time every 10 yearswith 5 s malle r was tes of time every 2 years .

• There is no evidence the new MOC program will improve pa tien t ca re . Ie , it will s tillbe a was te o f time and money.

• The cos t of MOC is s till $200-300 per d ip lomate per year yie ld ing $40-60M in revenueeach year for ABIM.

• By requiring biannua l ac tivitie s to fu lfill MOC, ABIM is able to pres e rve its la rgeannua l revenue s tream.

The end of the 10 year rece rtifica tion exam…time to ce lebra te? ? ?

>200,000 ABIM diplomates x $250 = >$50M

ABMSbelieves in p͞rofessionalism a͟nd the p͞rivilege of self-regulation ͟

Professionalism includesmanaging conflictsof interest

ABMSis reinventing MOCbut should ABMSmemberboardsbe allowed to self-regulate?

Aren’t they too conflicted?

Is this s͞elf-regulation͟or regulation by theABMSmember boards?

Is th is new plan rea lly going to he lp our pa tien ts ?

Or, is th is new plan jus t “ checking the box” to quie t the c ritic s ?

Does the propos ed plan crea te an MOC pa thway tha t is a little le s stime cons uming for the doc to rs (s o they s top compla in ing) while s tillp rovid ing the ABMS member board an annual fee?

As you eva lua te a lte rna tive propos a ls for MOC, as k yours e lf:

•Medicare does NOT require board certifica tion or MOC

•But many priva te payers require ABMS member board certifica tion and MOC intheir contrac ts with providers

•There fore , the major academic hos pita ls tha t employ phys ic ians us ually requireMOC for hos p ita l privileges

•Why would the payers even care about MOC? ? ?

•Payers a re certified jus t like phys ic ians

•The certifica tion body for 90% of the payers is the NCQA

•NCQA…requires payers contrac t with phys ic ians who are board certified and doMOC.

Ins urance Companies and MOC

Like Fiddle r on the Roof…It takes a Village

•Payers ---BCBS/Anthem etcRequire MOC becaus e

•NCQA – HEDISRequires MOC becaus e

•ABMSRequires MOC

•Founder and CEO of NCQA is a board member of ABMS

•What holds th is cozy village of fidd lers togetherIs it Tradition? No its …

Tuition! ie MONEY

•Who are they fiddling with?

•Phys ic ians !The upda ted mus ica l

“ Medical Indus tria l Complex”

Califo rn ia ACC

Nationa l ACC

American College of Phys ic ians (ACP)

Was h ington Sta te Medica l As s oc ia tion

Georg ia chapter of AMA

Other phys ic ian s oc ie tie s :

• ie The American Association of Clinical Endocrinologists

(AACE), California Neurology Society, etc

AMA

Oklahoma legis la ture

Othe rs (a t leas t 19 s pec ia lty organ iza tions )

Critic is m of MOC has now gone mains tream

Numerous organiza tions a re now publica lly c ritica l o f MOC

2016AMA annual meeting (June) in Chicago goesAnti-MOC

• AMA House of Delegates approved resolution 309 stating:

" RESOLVED, That our American Medical Association call forthe immediateend of any mandatory, secured recertifyingexamination by theAmerican Board of Medical Specialties(ABMS) or other certifying organizationsas part of therecertification process for all thosespecialties that still require asecure, high-stakes recertification examination.”

History For SB 1148

Action Journal Page Date Chamber

First Reading 94 02/01/2016 S

Approved by Governor 04/11/2016 731 04/12/2016 S

•How do we ge t California to adopt laws s imila rto Oklahoma?

•The bes t method of overcoming the ins urancecompany and other cha llenges is through s ta temedica l as s oc ia tions

•The CMA takes on enormous importance for th isis s ue .

The CMA and other s ta te medica l as s oc ia tions a rekey organiza tions in th is d is cus s ion

To advertis e “ Board Certified ” in Ca liforn ia andTexas requires ABMS or equiva len t ce rtifica tion

•Many hos p ita l a tto rneys view dis c los ing board certifica tion on the hos p ita l webs iteas "advertis ing" and the refo re require MOC to main ta in hos pita l privileges .

• The Califo rn ia law regard ing phys ic ian advertis ing was well in tended bu t waspas s ed when board certifica tion was life -long .

•This law needs to be updated to require in itia l ABMS certification , no t MOC or re -certifica tion .

Making a Diffe rence…we all a re lucky to be doctors

•Reporte r’s que ry: Has n ’t th is an ti-MOC ac tivity taken a lo t o f yourtime? Wouldn ’t it have taken les s time jus t to do your MOC?

•Docto rs , in gene ra l a re not lazy…we tend to be workaholics .

•But we wan t to do meaningfu l work

•We believe MOC is meaningles s make work

•We are here to work, but le ts do meaningfu l work and \ make adiffe rence .

•Do s ometh ing meaningfu l now and pas s a s trong an ti-MOC res olu tion

The ABMS publis hed oppos ition to AMA callfor end to recertifying exams - paraphras ed

• Cons umers , pa tien ts , hos pita ls expect phys icians to be up to date : True , bu tthere is ne ither evidence nor general cons ens us that MOC is a valid method ofins p iring or as s es s ing a phys ic ians competence .

• CME by its elf is no t s ufficien t to verify tha t a phys ic ian is up to date: Perhaps ,bu t ne ither are MOC activities and MOC compared to CME is onerous andcos tly. CME is the method us ed by s ta te licens ing boards and mos t be lieve itis the bes t method we have .

• Nationa l certifying and recertifying examina tions are a critical component ofour profes s ion ’s commitment to s e lf-regula tion and to the public trus t: a )There is no evidence nor general cons ens us tha t th is s ta tement is true and b)th is is no t “ s e lf-regula tion ,” it is regulation by the ABMS

• ABMS Member Boards and the AMA Council on Medica l Education have beenworking toge ther to modern ize the Boards ’ recertifying proces s es : True, bu t a)there is no evidence nor genera l cons ens us tha t the propos ed changes willimprove patien t care and b) this is s e lf-regulation by the ABMS memberboards which have a powerfu l financial conflic t of in teres t tha t s erious lyimpairs the ir ab ility to s e lf-regulate .

•I s ugges t the fo llowing res o lu tion :

•CMA s upport leg is la tion to prohib it MOC as a mandated requiremen tfor phys ic ian licens ure , c redentia ling , re imburs emen t, ne tworkpa rtic ipa tion , employment, or advertis ing

www.NBPAS.org

• NBPAS provides and alte rna tive formaintenance phas e of certifica tion

• NBPAS believes CME is the mos t meaningfulmethod available for “ keeping up.”

• NBPAS replaces computer knowledgemodules and s ecure exams with accredited ,continuing medica l educa tion (CME).

• Acceptable CME mus t be accredited by theAACME…independent of commerc ia lin te res ts .

NBPAS Fees and Applica tion

• NBPAS is a not for profit 501(c)(3)organiza tion

• Board members a re high profile , thoughtleaders repres enting mos t ABMS s pecia ltie s

• Fees are very low, only cover cos ts

• Phys ic ian management and board membersare unpaid

• Governance : trans paren t, not-for-profit, twoyear board te rms , COI protec tions , nophys ic ian pay

www.NBPAS.org

• In jus t under 2 years of opera tion with on ly word of mouth ands oc ia l media :

Almos t 5,000 phys ic ians have applied for certifica tion by the NBPAS

A growing number of hos pita ls (>40) have changed the ir bylaws toa llow NBPAS as an a lte rna tive certifica tion for ma in ta in ing hos pita lprivileges

Vis it NBPAS.org

• Phys ic ians , go to NBPAS.org and apply for boardcertifica tion .

• Us e the res ources on NBPAS.org– Downloadable PowerPoints and Sample le tters

• Spread the word

• Lobby you s ta te medica l as s oc ia tion …its our mos tpowerfu l too l to crea te change .

• Lobby your hos pita l to accept NBPAS as an a lte rna tiveboard certifica tion

www.NBPAS.org

• Physicians keep up with changes in medicine via CME, what they learn from their patients, andimportantly, what they learn from colleagues.

• Our colleagues are a valuable source of education, especially for solving problems that do not easilyfit into evidence based medicine and clinical guidelines.

• Last year I was approached by software engineers eager to fulfill an unmet need in peer to peerphysician education. There is no central website where physicians in all specialties can post aquestion and receive answers from the medical community.

• Over the past year we have created Curbside.org which currently is in the beta, question seedingphase. It is especially designed for physicians to ask other physicians questions about clinicalproblems that do not easily fit into evidence based medicine and/or clinical guidelines.

• Curbside is a response to those who cr iticize NBPAS for not offer ing any educational content.

Curbside.org helps physicians “ keep up” with the latest medical knowledge by engaging inrelevant discussions about topics that matter. There are many nuances to the site that make itespecially effective.

• We only want MDs and DOs to sign up. From every medical specialty

• There is a legal disclosure that should reassure participants they wont be sued by patientsor physicians based on their answers

• As a member types a question, previously asked questions with similar key words pop upand one can go directly to an earlier conversation

• Questions and answers get voted up or down by the community and each member canearn a reputational score if desired.

• An answer receiving a lot of “ up” votes will bubble to the top of the list, ie crowdsourcing

Curbs ide .org

Curbs ide .org

• Curbside.org offer s AACME accredited CME for asking and answer ing questions (weare star ting out very conservative…15 min of CME for par ticipating in a conversationand no more than 10 hours of CME provided to any one individual per year )

• It is collaboratively built and maintained by the physician community

• It is interdisciplinary. All physicians can par ticipate, regardless of specialty.

• All content is saved forever, and is easily searchable

• It is 100% free