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Taking Physician Practice Performance Into Account In Recertification: A Reply To Muney And Orszag

October 25th, 2013

In their thoughtful Health Affairs Blog posting, Alan Muney and Peter Orszag emphasize the importance of practice assessment in providing “a sustainable method for a continuous infusion of quality and affordability into our health care system.” However, they are mistaken in stating that “no medical specialty board certification process reviews how a physician actually practices in the office.” The American Board of Medical Specialties (ABMS) Program for Maintenance of Certification (MOC) addresses this need, through the Programs for MOC developed and implemented by the 24 medical specialty member boards that comprise ABMS.

For example, Part II of the MOC process addresses lifelong learning and self-assessment, and some of the activities must be based on identified specialty and/or practice gaps. Part IV directly addresses practice performance assessment and improvement with the goal of improving patient care based on performance data. Many ABMS Member Boards are using self-assessment modules and performance in practice modules (PIMS) as part of their Part II and Part IV activities.

Physician participation in these MOC activities is linked to enhanced clinical performance and improved patient care. Studies have cited improvement in clinical care areas ranging from cardiology to pediatrics and covering chronic conditions including asthma, diabetes and depression. Additionally, physicians who participate in such activities have improved their ability to identify gaps in knowledge and/or care. ABMS provides access to annotations of research studies and articles that reflect these types of findings.

Although many MOC Part IV requirements focus on the individual provider, more are beginning to address quality improvement at the practice and/or organization level. For example, hospital-based PIMs developed by the American Board of Internal Medicine address multiple conditions using performance data collected by the institution for reporting to the Centers for Medicare & Medicaid Services. As part of the MOC Portfolio Program, physicians participate in multi-disciplinary quality improvement activities, which directly relate to their clinical practice or a process that affects clinical outcomes. They are required to describe the change and its effect on the delivery of care and, at the same time, work with care team members to conduct the actual activity. Organizations involved in the MOC Portfolio Program have demonstrated past success in improving quality of care.

Like Muney and Orzag, ABMS believes that Board Certification should be based, in part, on how physicians actually practice medicine and not solely on their “book knowledge”. The Program for MOC evaluates both.

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4 Responses to “Taking Physician Practice Performance Into Account In Recertification: A Reply To Muney And Orszag”

  1. Michael Millenson Says:

    Mr. Tocci, my response specifically says that individual clinicians are free to override guidelines at the best institutions as long as reasons are documented. Simply “trusting” doctors and patients to do the right thing turns out not to be a very good approach to get consistently good care unless that trust is accompanied by some guidance both can use. It’s how we operate in every other aspect of our lives, and the key is the appropriate balance between autonomy and accountability.

  2. leetocchi Says:

    Mr Millenson, Ok now reconcile your 3 possibilities with the most recent blog by Dr. Parekh PROVIDING OPPERTUNITIES FOR POPULATION HEALTH IMPROVMENT. I will trust individual physicians and patients decisions on variation over mandated treatments which will boil down to cost decisions made for the good of the collective.

  3. Michael Millenson Says:

    Variation is only the “engine of innovation” when done within a framework designed to specifically to find out what works best. So, for instance, there are only 3 possibilities that can apply to a guideline: it doesn’t fit the patient clinically; the physician’s variation from the guideline produces better care; or the guideline fits and should be followed.

    All the leading institutions in quality improvement allow and encourage clinicians to override guidelines when they feel it is appropriate and to document the reason. It is the idiosyncratic belief by individual doctors that they are smarter and they get better results than their peers, without being willing to be part of evidence-based testing of that hypothesis, that has brought government regulation upon the profession.

    Or to put it differently: since John Wennberg first published about unsubstantiated practice variation in 1973, exactly how many decades more do you think we should wait for the profession to solve the problem itself? When you don’t regulate yourself successfully after 40 years, a bit of distrust might set in on the part of others.

  4. leetocchi Says:

    Lois, Thanks for the formal rebuttal. I think you were kind with the “In their thoughtful blog post” comment, and now informing them of the MOC process adopted by most of the specialty boards. That process is designed to do ongoing clinical practice evaluation. My opinion is that many in government like Mr. Muney and Mr. Orszag don’t trust the doctor to do the right thing and think they can somehow data mine the answer to variation in medical practice. Variation is the bane of economists, but the engine of innovation in medicine. The other posted opinions go over the cost and questions of why be so rigorous in the certification of some providers at the same time when we are having an expolsion of midlevel practioners.

    My concern now involves the degree which CMS has taken the role of quality arbiter. It doesn’t pass the smell test when a major payor of health care is the inspecting and certifying agent of healthcare. CMS can have its quality metrics, but they should not be involved in the certification of clinical competience of providers.

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