Oscar Wilde famously described a cynic as someone who knows the price of everything, and the value of nothing. We may perhaps be forgiven for allowing some cynicism to creep into our discussions about MOC, given the wide gap that had developed between its cost and its perceived worth. But as we proclaim to members the ACC's remarkable achievements in restoring value to ongoing certification, we should recall that we physicians ourselves created MOC, which we always expected to have some cost, in response to a genuine challenge to our autonomy.

In the late 1980s, as the unsustainable growth of medical spending became apparent, physician competence became an early focus of the nascent sea change we have now come to call "value for volume." Payers, hospitals and patients rightly began to question the prudence of paying doctors who had obtained board certification for life based upon a single high stakes examination, taken just out of training, with no need to demonstrate ongoing engagement with life-long learning. Had physicians not responded to that concern, other bodies of varying competence and intent – federal, state, private or all three – likely would have. We needed to police ourselves or be policed.

The physician-run ABIM responded by doing what they already knew best how to do; they gave tests. Initially the disconnect between that summative approach to assessment and a more formative approach to learning raised few objections, but with time, the ABIM's approach to maintaining security and keeping up with the growing science of standardized testing became increasingly costly and dehumanizing. We all know what happened next; as Richard A. Chazal, MD, MACC, so aptly put it, while the ACC developed into an organization designed to teach you, the ABIM devolved into an organization designed to test you.

To its great credit, after initially obtaining a suspension of MOC Part IV and helping end "double jeopardy" for dual boarded cardiac subspecialists, the College has now negotiated choices that definitively restore value to the continuous demonstration of competence. The details of options now open to members are outlined in the bullet points below, and more thoroughly here.

Much has been made of the cost of the Collaborative Maintenance Pathway (CMP) with respect to MOC. Recall that physicians need to meaningfully demonstrate competence, that failing to do so puts quality patient care and our autonomy at risk, and that the CMP is not mandatory. Then consider this: a tall latte from Starbucks costs $2.95, which taken daily, comes to a yearly cost of $1076.75. The cost of CMP, including membership in the ACC, the fee to ACC for the CMP modules, and the fee to the ABIM to maintain MOC, (and excluding the savings from board review, CME, travel, and lost work time) comes to $963.00, excluding section memberships, per year. Meaning that you can now review your knowledge of your specialty on a continuing basis with the world's experts in your field, identify knowledge gaps, correct them, and then demonstrate competence and maintain certification — all for a fraction of the daily cost of a cup of coffee.

The most embittered world-weary cynic should see some value in that.

SUMMARY OF OPTIONS FOR MEMBERS:

1. For those who prefer it, the 10-year secure ABIM examination still exists.
• Diplomates who pass the exam and maintain 100 MOC II points per five years will remain certified for the next 10 years.
• Those preferring to switch to another pathway like CMP DO NOT need to enroll until the year their 10-year certificate expires, provided they maintain their MOC part II points in the interim.
• There is no obligation to obtain any of those MOC points through ACC.
• For many, preparing for the high-stake exam means lost time from work to attend a board review course, which attaches a significant "hidden cost"
• The exam must be taken at a secure site, taking time from work, and it includes the entire discipline.
• The annualized cost of this option, excluding board review courses, and associated lost work time for review, is about $128 per year.
2. ABIM's two-year "knowledge check in" provides an alternative to the 10-year secure examination.
• These exams are NOT modular; the entire specialty curriculum is fair game for questions on each two-year exam
• There is no formative component to the knowledge check-in; candidates prepare on their own.
• While the exam does not require travel to a secure site, those taking it at home are subject to camera-based confirmation of the candidate's identity during the exam; ABIM will spot check those taking the exam by web cam.
• There is no requirement to buy anything from ACC to participate in this pathway.
• Subspecialists in EP or interventional cardiology whose certificates expire in 2019 will still need to take the 10-year secure exam in their disciplines, as this option will not be available for them until 2020.
• The annualized cost of this option, excluding board review courses and associated lost work time for review, is about $128.00 per year.
3. The CMP provides an ongoing, formative assessment of competence administered by the ACC, with a summative option to maintain MOC from the ABIM.
• The SAPs (ACCSAP, EPSAP, CathSAP, etc.) are the formative portion of the program, and are designed to identify and correct gaps in knowledge. The fee to ACC for the formative component of CMP is $300.00 per year. SAPs have never been offered to members for free, and the current price represents a 25 percent per year decrease in the in the yearly cost of the previous ACCSAP product.
• CMP is modular, with one rotating area of focus each year. Every five years, the complete curriculum of the specialty is reviewed.
• CMP provides enough CME to meet most states' yearly educational requirements, so no fees to other sources for CME, and gives a meaningful updated review every five years.
• The CMP also offers enough Part-II MOC credits to easily meet the 100 points per five years requirement.
• To obtain MOC from the ABIM, participants in CMP need to show "meaningful" engagement with the formative component of each module (based upon clocked screen time – no camera), and then pass a summative exam on the material from the same module.
• Both the formative and summative components can be taken from home. There is a fee amounting to $128.00 per year to the ABIM to maintain MOC by this approach.
• CMP keeps the physician in practice, rather than travelling to board reviews and secure test centers, all saving expense.
• CMP arguably demonstrates engagement and competence more completely, because participants continually review up to date material, identify and correct gaps in knowledge, and demonstrate proficiency by frequent limited reexamination.
• Subspecialists in EP or interventional cardiology whose certificates expire in 2019 will still need to take the 10-year secure exam in their disciplines, as this option will not be available for them until 2020.
• CMP cannot be used to recertify after a lapse in maintenance of certification; the knowledge check in or 10-year exam are the only options once a certificate has lapsed. This also applies to re-obtaining certification in Cardiovascular Diseases for a subspecialist in EP or interventions who has let his Cardiovascular Diseases certificate lapse.
• The annualized cost for CMP without ABIM MOC certification for an ACC member is: $300.00 per year
• The annualized cost for CMP and ABIM MOC certification for an ACC member is: $428 per year
• The annualized cost for CMP without ABIM MOC certification for a non-ACC member is: $380 per year
• The annualized cost for CMP and ABIM MOC certification for a non-ACC member is: $508 per year
4. For those who do not wish to participate in MOC or in the ACC's educational programs, alternate certification with the National Board of Physicians and Surgeons (NBPAS) or other bodies remain an option.
• NO ONE is obliged to participate in the ACC's educational offerings; they are a resource offered as an alternative.
• Choices will likely depend upon local acceptance of alternate certifications by state medical boards, hospitals and insurance carriers.
• Because the ACGME recognizes only ABMS certification, academics cannot use this option, and will need to pursue one of options 1 through 3 listed above
• Candidates pursuing this alternative who also participate in one of ACC's SAP programs will be issued a certificate of participation by the College. ACC cannot warrant that its certificate will be accepted by licensing boards, hospital credentialing committees or insurance panels in place of board certification.

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This article was authored by Daniel Philbin, MD, FACC, BOG chair-elect and governor of ACC's New Hampshire Chapter

Keywords: Insurance Carriers, Certification, Licensure, Patient Care, Curriculum, Self-Evaluation Programs

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