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Background

Concern with the idea of indefinite certification began as early as the 1940s, when it became clear that the rapid advance of medical knowledge made the concept of lifetime certification unrealistic. However, the first time-limited board certifications were not adopted until 1970 by the American Board of Family Practice (now the American Board of Family Medicine). Pediatric surgery became the first surgical specialty to institute 10-year, time-limited certificates in 1973, and by 1976, all American Board of Surgery certificates became time-limited [1].

In 1989, the ABA acknowledged the benefit of establishing a formalized process whereby diplomates could demonstrate continued proficiency in their field. It established the continued demonstration of qualifications (CDQ) program for this purpose [2]. Initially, participation in this predecessor to MOCA was voluntary. In 1995, the ABA approved a proposal to begin issuing time-limited certifications as of January 1, 2000. With this decision, diplomates wishing to maintain certification beyond 10 years would be required to participate in the ABA’s CDQ program, which was subsequently renamed recertification. This program included a voluntary recertification examination, the last of which was administered in 2009, when the official transition from recertification to MOCA was completed [2].

In 2000, the 24 Boards compromising the American Board of Medical Specialties (ABMS)—of which the ABA is one—agreed upon a relatively radical restructuring of the recertification process, designed to emphasis not only cognitive proficiency but also the concept of lifelong learning, self-assessment, and performance improvement. From this discussion, came the four-part MOCA program that exists today. The complete MOCA program became available to diplomates in 2004 [2].

Components of MOCA

MOCA consists of four components, each of which must be satisfactorily completed within the 10-year MOCA cycle in order to ensure maintenance of certification: (1) Part I: Professional standing assessment; (2) Part II: Lifelong Learning and Self-Assessment; (3) Part III: Cognitive Expertise Assessment; and (4) Part IV: Practice Performance Assessment and Improvement.

Part I: Professional Standing Assessment

All diplomates must hold an active, unrestricted medical license in at least one jurisdiction of the United States or Canada. Licensure restrictions are administered by the Medical Board of each state and vary somewhat by region. Examples of actions which typically lead to licensure restrictions include failure to practice within the scope of a licensee’s education and training, willful neglect of a patient’s health or safety, felony or criminal conviction, sexual misconduct, and presigning of blank prescription forms. If a restriction is placed on a diplomate’s medical license, it must be reported to the ABA within 60 days [2].

Part II: Lifelong Learning and Self-Assessment

ABA diplomates are expected to engage in continuing medical education (CME) opportunities throughout the duration of the MOCA cycle, which the ABA calls Lifelong Learning and Self-Assessment (LLSA). The exact number of CME credits required varies based on year in which initial certification was earned (Table 9.1). In 2013, the ABA reduced the number of required CME credits for diplomates certified on or after January 1, 2004 from 350 to 250 to be more consistent with the ABMS average of 25 CME credits per calendar year. Therefore, diplomates certified on or after January 1, 2004, must now complete at least 250 CME credits over the 10-year MOCA cycle, all of which must be Category 1 American Council for Continuing Medical Education (ACCME)-accredited activities. Examples of such activities include attendance at meetings sponsored by medical societies such as the American Society of Anesthesiologists (ASA) and completion of educational programs offered in peer-reviewed medical journals [2].

Table 9.1 Continuing medical education requirements by year certified
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The intent of the LLSA program is to encourage lifelong learning; therefore, in 2006, the ABA established a cap on the number of CME credits it would award per calendar year to encourage diplomates to earn CME credits throughout the MOCA cycle [2]. Until 2012, this cap was 70 credits per calendar year. Effective in 2013, the ceiling was lowered to 60 credits per calendar year [2]. Furthermore, diplomates must participate in CME activities in at least 5 of the 10 years of each MOCA cycle [2]. Many hospitals and some states require documentation of annual or biannual CME activity, which is consistent with the ABA’s goal to have diplomates regularly participating in CME programs.

The ABA itself does not offer CME activities; however, all healthcare organizations interested in providing CME programs suitable for MOCA must be approved by the ABA [2]. In addition, the ABA has become more proscriptive in its CME requirements. For example, diplomates who entered the MOCA program between January 1, 2008 and December 31, 2009 are required to complete 60 credits of the ASA’s Self-Education and Evaluation (SEE) program and/or the ASA Continuing Education (ACE) program or another ABA-approved self-assessment CME program at least once during their MOCA cycle (Table 9.2) [2]. Diplomates certified on or after January 1, 2010 and those carrying non-time-limited certificates who voluntarily enter the MOCA program are required to complete 90 credits of the ASA’s SEE or ACE program or other ABA-approved CME program at least once during their MOCA cycle [2]. In addition, all MOCA participants who entered the program after January 1, 2008 must fulfill at least 20 credits of Patient Safety CME offered through the ASA or the ABMS [2].

Table 9.2 Practice performance assessment and improvement requirements by year in MOCA cycle
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Diplomates who complete a 12-month ACGME-accredited subspecialty fellowship or a 12-month anesthesiology subspecialty fellowship in an ACGME-accredited anesthesiology program are entitled to 50 Category 1 CME credits so long as the fellowship is completed in the year of or after primary certification in Anesthesiology is awarded [2]. The ABA does not grant CME credit for fellowships or subspecialty certifications finished prior to primary certification in Anesthesiology.

It is the responsibility of diplomates to report CME activities to the ABA via the ABA portal, which is accessible at the ABA website (www.theABA.org). Furthermore, a minimum number of LLSA credits must be submitted to the ABA by the delegate at least 5 months prior to the examination date for recertification [2].

Part III: Cognitive Examination

Between years 7 and 10 of the MOCA cycle, all diplomates are required to demonstrate core knowledge in anesthesiology by passing an ABA examination for recertification. The examination is a 4-h computer-based test consisting of 200 multiple-choice questions with one best answer [2]. One hundred and fifty of the questions (75 %) are in topics in general anesthesia; the remaining 50 questions (25 %) are divided among pediatric anesthesia, cardiothoracic anesthesia, neuroanesthesia, critical care medicine, obstetrical/gynecologic anesthesia, and pain medicine [2]. Until 2010, the examinee was allowed to answer only 150 of the 200 questions, and leave unanswered 50 questions of the examinee’s choice; but currently, all 200 questions must be answered [3]. There is no predetermined passing score on the MOCA Cognitive Exam. However, the ABA reports that since the first MOCA exam was administered in 2005, the pass rate has been greater than 90 % [4].

Prior to taking the examination, diplomates must demonstrate the following three prerequisites: (1) satisfactory professional standing (a.k.a. active, unrestricted license to practice medicine in the United States or Canada); (2) successful completion of half their required CME credits; (3) and one satisfactory Practice Performance Assessment and Improvement Activity (see below) [2].

The MOCA Cognitive Examination is administered twice a year in the winter and summer, and there is no limit to the number of times a diplomate may take the exam. Furthermore, there is no penalty for taking the MOCA Cognitive Examination in years 7–10; in other words, the clock will not restart until after year 10 of the MOCA cycle [2].

Part IV: Practice Performance Assessment and Improvement

The Practice Performance Assessment and Improvement (PPAI) requirement consists of three parts: (1) simulation course; (2) case evaluation; and (3) attestation. Requirements for completion of these activities vary based on year certified (Table 9.3) [2]. Diplomates certified in year 2008 or later are required to complete an ASA-endorsed simulation education course during the 10-year MOCA cycle. Participation in simulation education is optional for diplomates certified in years 2003–2007. The purpose of simulation training is to provide a context in which to improve skills in areas such as teamwork and communication, crisis management, and clinical emergencies such as the difficult airway, anaphylaxis, and cardiac arrest. Currently, there are 35 ABA-endorsed simulation centers offering courses that meet the MOCA Part IV requirement (see http://www.asahq.org/For-Members/Education-and-Events/Simulation-Education/Endorsed-Simulation-Centers.aspx).

Table 9.3 Practice performance assessment and improvement requirements by year in MOCA cycle
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Diplomates certified in years 2004 or later are also required to complete a case evaluation [2]. This is a four-step process intended to allow diplomates to analyze their practice then develop and implement a practice improvement program. This process may be conducted individually or as a group effort, for example among several diplomates who work at the same facility. The improvement initiative is expected to be evidence based and to take one of four forms: a (1) clinical pathway; (2) clinical reminder; (3) personal reminder; or (4) change in system or practice. For example, an anesthesiologist who perceives that patients on beta blockers neglect to take their prescribed dose on the morning of surgery, despite being told to do so in the Preanesthesia Clinic, thinks that a phone call reminding patients to do so would improve compliance. Before any intervention, the anesthesiologist collects data on how many patients on beta blockers actually take their medication on the day of surgery over a 2-week period. Next, a system is implemented in which, while nurses are calling patients to tell them when to arrive for surgery, they also review which medications patients should take that morning. Data is collected over another 2-week period after the intervention. The results demonstrate a 20 % increase in beta blocker use on the morning of surgery in patients on chronic beta blockers, suggesting the intervention helped improve medication compliance. As a result of its success, the change in practice becomes a permanent practice change. Additional examples of case evaluations are available on the ABA website (www.theABA.org).

At least once in each MOCA cycle, the ABA solicits three references submitted by the diplomate and intended to attest to the diplomate’s clinical work and participation in practice improvement activities [2]. The diplomate submits the names of the references to the ABA via the ABA portal. The attestation process is due in year 9 of the MOCA cycle.

Voluntary MOCA for Non-Time-Limited Certificate Holders

Diplomates who hold non-time-limited certificates and voluntarily participate in MOCA have the option to complete the program on an expedited basis [2]. The diplomate is asked to report CME from the 10 years prior to MOCA enrollment, and MOCA requirements are adjusted based on the number of years elected to complete the program (minimum of 2 years). If the MOCA program is completed in 5 years or less, only two Part IV activities are required: the attestation and either a case evaluation or simulation course.

It should be noted that although there is no ABA obligation for diplomates with non-time-limited certificates to participate in MOCA, some hospitals require MOCA participation as a condition for granting hospital privileges. In addition, some liability insurers offer a discount to physicians who participate in MOCA components, such as a simulation course [5, 6]. In addition, effective in 2013, participation in MOCA can qualify ABA diplomates for an incentive payment from the Centers for Medicare and Medicaid Services.

MOCA for Subspecialties

The ABA offers subspecialty certification in five disciplines: (1) critical care medicine; (2) pain medicine; (3) hospice and palliative medicine; (4) sleep medicine; and (5) pediatric anesthesiology. Like primary certification in anesthesiology, all subspecialty certifications are now issued on a 10-year time-limited basis. Until 2010, the recertification process involved only a cognitive examination. In January 1, 2010, the ABA began transitioning from subspecialty recertification to the Maintenance of Certification in Anesthesiology for Subspecialties (MOCA-SUBS) program [2]. The last subspecialty recertification examinations will be given in 2016 and the first MOCA-SUBS Examinations will be administered in 2017.

Many of the MOCA and MOCA-SUBS program requirements overlap and may therefore be shared, facilitating the maintenance of both certifications. These requirements include: Part I: Professional standing; Part II: Lifelong Learning and Self-Assessment; and Part IV: Practice Performance Assessment and Improvement [2]. Diplomates who hold one subspecialty certification are required to complete a case evaluation in a subspeciality-related discipline. In addition, a portion of the diplomate’s CME must be related to the subspecialty. Separate Part III Cognitive Examinations are required for each certificate being maintained [2].

Diplomates holding time-limited primary and subspecialty certifications are encouraged but not required to maintain both certifications.

Reciprocity for Diplomates with Certifications in Other Specialties

Diplomates who are certified in another specialty recognized by the ABMS are allowed to complete one of the Part IV MOCA activities through their other certifying Board in substitution for the Part IV: case evaluation requirement [2].

Diplomates Who Are Not Clinically Active

Diplomates who hold time-limited certificates in anesthesiology or a subspecialty but are not clinically active can maintain their certification(s) by participating in the MOCA program [2]. These diplomates are excluded from the Part IV MOCA requirement but must complete all other components of the MOCA program. Diplomates who successfully meet these requirements are designated “Certified—Not Clinically Active.” [2].

Diplomates Whose Primary Anesthesiology Certification Has Been Deferred

After passing Parts 1 (written) and 2 (oral) of the initial certification examination, some diplomates may elect to defer primary certification. If certification is deferred for less than 5 years, CME credit earned during the period from completing the oral examination until certification is awarded can be credited toward the Part II: LLSA MOCA requirement. The remainder of the MOCA requirements must be completed within the 10-year time frame [2].

If certification is deferred for more than 5 but less than 10 years, candidates may submit up to 5 years worth of their most current CME credit earned within the years from passing the oral examination until certification is awarded. They have 5 years to complete the remaining MOCA requirements [2].

MOCA Reporting

Although all diplomates are automatically enrolled in the MOCA program upon initial certification, it is the responsibility of diplomates to maintain accurate and up-to-date personal information to the ABA portal.

Furthermore, although some CME sponsors, such as the ASA, the American Society of Regional Anesthesia (ASRA), and the New York State Society of Anesthesiologists (NYSSA) submit CME activities and credit information directly to the ABA on behalf of diplomates, the majority of CME sponsors do not. Therefore, it is the responsibility of diplomates to self-report CME activities and credits to the ABA electronically through the ABA portal. Whereas provider-reported CME activities are not subject to ABA audit, self-reported CME is; therefore, diplomates are expected to keep documentation of self-reported CME activity for at least 3 years after submission [2].

In 2010, the ABA began publicly reporting the MOCA enrollment status of diplomates through the ABA Diplomate and Candidate Directory and ABA portal. Diplomates are now designated as “meeting MOCA requirements” or “not meeting MOCA requirements.” Diplomates are meeting MOCA requirements if their professional standing is satisfactory, and by the end of their fifth MOCA year, they have completed at least half of their CME credits and one Part IV PPAI activity; and by the end of their tenth MOCA year, they have completed all CME credits and two PPAI activities [2]. The Directory also indicates diplomates who are not required to participate in MOCA because they hold non-time-limited certificates [2].

Physicians who have applied for the ABA examination are considered candidates for the ABA examination. The ABA no longer recognizes the term “Board Eligible” as a physician status [2].

Failure to Fulfill MOCA Requirements

For diplomates who hold time-limited certifications, failure to fulfill MOCA requirements at the end of the 10-year cycle results in expiration of ABA certification. The ABA will grant a grace period of up to 3 years in order for a diplomate to regain “Active” status [2]. For each additional year past expiration needed to complete the MOCA requirements, the ABA moves the MOCA cycle forward 1 year, and any activities completed in the original Year 1 of the diplomate’s MOCA cycle are erased and must be redone. In addition, any outstanding MOCA activities from the 10-year cycle must be successfully completed [2]. Failure to fulfill MOCA requirements within 3 years of expiration of primary certification requires the diplomate to reestablish qualifications for admission for primary certification, including successful completion of the written and oral ABA Board Examinations. During the grace period, diplomates are not designated as Board certified.

Cost of MOCA

There is a single fee for each 10-year MOCA cycle, due upon registration for the Cognitive Examination. In 2013, the registration fee for the MOCA Cognitive Examination was $2,100; the reexamination fee was $800 [2]. However, this is just a fraction of the complete costs associated with fulfillment of MOCA criteria. The cost of currently accredited simulation courses is approximately $1,500–$1,800. Although opportunities for free CME credits exist (e.g., Medscape CME), the majority must be purchased. The cost per credit varies widely. For example, for ASA members, the ACE and SEE programs offer CME credit at a rate of $5 per credit. However, the ASA Patient Safety modules run approximately $11 per credit. Factoring in the annual ASA membership due of $625, the relative cost per credit is even higher.

Benefits of MOCA

There is a general perception that having a maintenance of certification (MOC) program helps to ensure the quality of physician care. Indeed, in a 2003 Gallup Poll conducted by the American Board of Internal Medicine, nearly 75 % of respondents agreed with the idea that physicians should be periodically reevaluated on their qualifications, and more than half said they would be inclined to find a new doctor if their current doctor’s board certification expired [7]. However, despite its widespread acceptance, that participation in MOC activities actually improves patient outcomes or has a sustained effect on physician decision-making has yet to be demonstrated [8].

Furthermore, there is some evidence to suggest that the physicians who might benefit the most from participation in an MOC program are the very ones who have been given the opportunity to opt out of it altogether. Examining the likelihood of physicians passing a recertification examination in internal medicine, Ramsey and colleagues found a significant inverse relationship between exam scores and number of years since primary certification [9]. Several studies have demonstrated a lower adherence to practice guidelines among older physicians compared to younger colleagues [10–12]. Therefore, the ABA’s choice to absolve from MOCA responsibilities diplomates certified prior to 2000 may be considered a missed opportunity.

The ABA’s decision to include a simulation course as a MOCA requirement is also controversial. The ABA’s support of simulation mirrors that of the Council on Graduate Medical Education and the ABMS, both of which believe that simulation training is an important component of improving patient safety [13]. There is some evidence to support the benefits of simulation relative to traditional learning methods in promoting teamwork and improving performance in critical event management [14, 15]. However, other studies suggest that the same results may be achieved through case-based learning, foregoing the significant expense of a mechanical simulator, which can cost from $6,000 to $250,000 [6, 16]. Although simulation shows promise as an education tool, important questions still remain, including its relative success in changing provider behavior compared to traditional forms of CME, such as classroom learning or workshops [17]. In addition, a link between simulation education and absolute reduction in medical errors or benefit in patient outcomes has yet to be established [18]. While other specialties offer simulation courses, mostly in the form of computerized case-based scenarios, anesthesiology is the only specialty whose MOC program requires diplomates to participate in a hands-on simulation class.

Continual Evolution of MOCA

The MOCA program is a concept in evolution and its requirements are subject to change in response to internal process audits and external governances. It is incumbent on the ABA diplomate to remain vigilant to these changes.