December 24, 2010

Freda Bush MD, Chair

Humayun Chaudhry DO, President and CEO
Federation of State Medical Boards

Dear Drs. Bush and Chaudhry,

The Council of Medical Specialty Societies (CMSS), with 37 Member Organizations representing more than 650,000 practicing physicians in the US, is pleased to comment on the draft document “Maintenance of Licensure Implementation Group: A MOL Proposal Template”, revised by the MOL Implementation Group September 10, 2010. We commend the Implementation Group for its excellent work on this draft, and the Federation on its vision for MOL.

Overall Goal:

First Recommendation, line 131, page 5:

“Recommendation: The entire MOL program should be implemented as expeditiously as possible with SMBs moving forward together. For practical reasons, some SMBs may institute MOL in a phased implementation in which each phase should take no longer than three years. Regardless of the implementation approach, all SMBs should complete the implementation process within a 10 year period.”

CMSS supports the above recommendation.
CMSS particularly appreciates the overall goal of MOL that “all licensed physicians be engaged in a culture of continuous quality improvement and lifelong learning….” This goal is consistent with CMSS’ strategic priority that “CMSS and its member specialty societies will facilitate a Culture of Performance Improvement in medical practice.” We also appreciate and support the goal that MOL should reflect a reasonable expectation of physicians that “enables them to demonstrate their commitment to continual improvement without being overly burdensome or creating barriers to patient care or physician practice.”

Lifelong Professional Improvement: Three Components

MOL Component One: Reflective Self Assessment

Second Recommendation, line 144, page 5:

“MOL Component One: Reflective Self‐Assessment

Recommendation: State medical and osteopathic boards should require each licensee to complete accredited Continuing Medical Education (CME), a substantial portion of which is practice‐relevant and supports performance improvement.”

CMSS supports the above recommendation.
CMSS strongly supports the recommendation that “Component One begins with the established CME system.” CMSS operates under a definition of Medical Professionalism that has three components: Altruism (ensuring that the needs of patients come first), Self‐regulation, and Transparency (to peers, patients and the public). The system of Continuing Medical Education in the US has been created, and has evolved to fulfill this vision of Professionalism. SMB’s should accept CME credits from multiple stakeholders, including both Knowledge‐based and Performance‐improvement CME. There should be a clear firewall between the provider of continuing medical education (i.e. specialty societies and other accredited CME providers) and the evaluator of physicians (i.e. certifying boards).

MOL Component Two: Assessment of Knowledge and Skills

Third Recommendation, line 152, page 5

“MOL Component Two: Assessment of Knowledge and Skills

Recommendation: State medical and osteopathic boards should require licensees to undertake objective knowledge and skills assessments to identify learning opportunities and guide improvement activities. Component Two activities should meet all of the following criteria:

1) be developed by an objective third party (could include SMBs);
2) be a structured, validated and consistently reproducible tool/activity;
3) be credible with the public and profession;
4) provide meaningful assessment feedback to the physician licensee appropriate to the scope of the activity to guide subsequent education; and
5) provide formal documentation that describes both nature of the activity (i.e., content and areas assessed) and attainment of a prospectively defined standard or benchmark.”

CMSS supports the above recommendation, with clarification.
CMSS appreciates the flexibility afforded by this recommendation. While CMSS also agrees that successful participation in ABMS MOC would suffice for MOL, other comparable activities besides ABMS MOC should also qualify a physician for re‐licensure under MOL.

It is not clear whether MOL Component Two is intended to reference ABMS MOC Part III (secure exam) or Part II (Self‐assessment). In the fifth recommendation below, it is recommended that this component be accomplished every five years. However, ABMS MOC Part III is generally accomplished every ten years, and is unlikely to occur more frequently. Clarification of this discrepancy would be important as MOL moves toward implementation.

MOL Component Three: Performance in Practice

Fourth recommendation, line 157, page 6.

“MOL Component Three: Performance in Practice

Recommendation: State medical and osteopathic boards should require licensees to assess the quality of care they provide compared to peers and national benchmarks and then apply best evidence or consensus recommendations to improve and subsequently reassess their care.”

CMSS supports the above recommendation.
CMSS appreciates the flexibility of this recommendation to include ABMS MOC Part IV, Performance‐improvement CME and other quality improvement programs of specialty societies, and comparable programs of other groups, such as participation in the Improving Performance in Practice (IPIP) program, and others.

Periodicity requirements:

Fifth recommendation, line 166, page 6.

“Recommendation: State medical and osteopathic boards should require each licensee to complete a minimum Component One activity on an annualized basis, as defined by the SMBs, that includes a specific portion devoted to practice‐relevant and performance improvement CME activity, and to complete both one Component 2 and one Component 3 activity every five years.”

CMSS supports the above recommendation.
CMSS appreciates the recommendation for a time interval of ten years, consistent with that of most ABMS MOC cycles, thus reducing burden on physicians. As stated in our comments to the third recommendation above, ABMS Part III is generally accomplished every ten years, and is unlikely to occur more frequently. In this recommendation, MOL Components Two and Three are recommended to be accomplished every five years. To the degree that MOL Component Two is intended to reflect ABMS MOC Part III, there would thereby be a discrepancy in the interval (5 versus 10 years). Clarification of this discrepancy would be important as MOL moves toward implementation.

Board certification in the Context of MOL:

Sixth recommendation, line 176, page 6.

“Recommendation: State medical and osteopathic boards should consider physicians who provide evidence of successful ongoing participation in either an ABMS Maintenance of Certification (MOC) or AOA Osteopathic Continuous Certification (OCC) program to have satisfied the participation in all three components of MOL.”

CMSS supports the above recommendation.
CMSS appreciates that physicians meeting these two named programs of maintenance of certification will qualify for MOL, thus reducing the professional self‐regulatory burden on physicians. That said, it is important that in addition to MOC, comparable programs sponsored by specialty societies and other groups also be accepted for MOL.

Need for More Information About Physician Practices:

Seventh recommendation, line 184, page 7.

Recommendation: State medical and osteopathic boards should regularly collect data from individual licensees about the extent of their engagement in active clinical practice and the nature of their daily professional work.”

CMSS supports the above recommendation.
CMSS recognizes, as does FSMB, that a minority of physicians are in unique situations, particularly those who are no longer clinically active. Since this challenge crosses all specialties, it appears wise of FSMB to recommend gathering more information about this problem before jumping to a solution. For example, the definition of “clinical practice” is yet to be generally accepted. Physicians are engaged in a variety of changing clinical activities over their careers, including out‐patient care in a specialty in which the physician used to provide in‐patient care, and supervision and teaching rather than direct patient care. Moreover, it appears problematic to consider “clinically active” to be determined by an arbitrary number of hours per week or month in clinical practice.

Consistency Across Jurisdictions:

Eighth recommendation, line 196, page 7.

“Recommendation: State medical and osteopathic boards should strive for consistency in the creation and execution of MOL programs.”

CMSS supports the above recommendation.
CMSS appreciates the recognition on the part of FSMB that many physicians have licenses in more than one state, and that many physicians move from one state to another. ABMS MOC is consistent across states. Consistent implementation of MOL across states would both reduce the burden on physicians, and would likely assure the public of consistent, rather than arbitrary, or worse political, standards of quality.

Additional Comments:

Line 327, p. 10.

There appears to be an inadvertent and potentially critical inconsistency in lines 326‐7:

“Component One – Require Reflective Self‐Assessment coupled with accredited CME or another type of Continued Professional Development Program”

This is the only time in the document in which descriptions of MOL Component One include the phrase “or another type of Continued Professional Development Program.” We would recommend deletion of this phrase.

As stated before, both in our previous comments, accredited CME is the “coin of the realm” in the US. Indeed, lines 377‐378 on page 12 of this MOL document underscore that “Component One begins with the established CME system.” Accredited CME reflects the profession’s self‐ regulation of lifelong learning to assure that ultimately the needs of patients come first, that continuing education meets the highest standards, is independent of corporate influence, and reflects the evolution of both medical knowledge and practice. It would be monumentally disruptive to professional self‐regulation to undermine the role of accredited CME in the lifelong learning of physicians.

As part of the evolution of “traditional” CME, the profession recently (1‐1‐10) implemented Performance‐improvement CME and On‐line Point of Care CME. Discussions are now underway in the CME community focusing on the continued evolution of CME to incorporate evidence‐based CME, and to examine “value‐based” versus time‐based credit for CME programming. FSMB is an integral party to these evolutionary discussions in the CME community.

We recognize that lines 378‐394 on page 12 go on to address how CME might evolve, which we consider to be an appropriate exercise in future visioning. That said, such speculation about the future should not currently be incorporated into the description of MOL Component One found in lines 377‐378 on page 12.

Line 402, page 12.

The document has named the second and third of the CME credit systems in the US, but has inadvertently left out the first. AAFP has been awarding CME credit since 1948. The AMA PRA credit system was established in 1968 and the AOA credit system in 1972. [Of note, seven organizations of the profession established ACCME 1981 to accredit providers to then offer AMA PRA credit. ACCME is thus an accreditor of CME programs (as are AAFP and AOA) but does not in and of itself operate a credit system.]

Lines 460‐463, page 14.

CMSS supports what we believe to be an important concept found in this recommendation regarding MOL Component Three: Performance in Practice. It has been our experience that facilitating a culture of performance improvement in practice works when physicians are incented to participate in performance improvement, measure themselves against national benchmarks, compare themselves with peers, and document improvement in their patient populations over time. This appears to be the philosophy described in these lines:

“State medical and osteopathic boards should require licensees to assess the quality of care they provide compared to peers and national benchmarks and then apply best evidence or consensus recommendations to improve and subsequently reassess their care.”

We are pleased to see that FSMB has not fallen onto the trap promulgated by many payers and health plans, wherein physicians are required to meet arbitrary performance standards. The setting of a threshold below which no positive feedback is offered results in practices excluding from reporting on those patients whose measures do not meet the thresholds. In contrast, incentives for participation and for documentation of improvement over time, such as in the Improving Performance in Practice (IPIP) program and other programs of specialty societies, have been shown to engage physicians in managing population health.

Summary:

The Council of Medical Specialty Societies applauds the Federation of State Medical Boards in moving toward Maintenance of Licensure. We support, with the constructive suggestions described above (lines 152, 166, 196, 327, 402), the Sept. 10, 2010 draft MOL Proposal template. Moreover, as the member organizations of CMSS represent the majority of the licensed practicing physicians in the US, we offer our participation on an on‐going basis in assisting FSMB in both finalizing plans for MOL, and for its implementation.

Sincerely,

Dr. Kahn Signature

Norman Kahn MD
Executive Vice‐president and CEO