What Is Maintenance of Licensure (MOL)?

The Federation of State Medical Boards (FSMB) represents the 70 state medical and osteopathic boards of the United States and its territories.In 2004, the FSMB’s House of Delegates adopted a policy stating: “State medical boards have a responsibility to the public to ensure the ongoing competence of physicians seeking licensure.” In 2010, the FSMB’s House of Delegates adopted a three-part model for MOL and recommended that physicians satisfying the requirements of Maintenance of Certification (MOC)/Osteopathic Continuous Certification (OCC) should be recognized as having substantially fulfilled the requirements of MOL. However, it is important to understand that the FSMB has no regulatory authority. That authority rests with the state/territory boards, and requirements differ widely. For example, documentation of continuing medical education (CME) currently is required in 62 of 69 jurisdictions, and topic-specific CME is required in 15 states. While MOL is still several years away from being adopted by any state medical board, the FSMB is currently working to develop and implement various pilot projects in nine states to prepare for MOL and to determine best practices.

What Are the Core Components of MOL?

The framework for MOL recommends that state medical boards require physicians to periodically demonstrate involvement in three components of lifelong learning:

1. Reflective Self-Assessment (What improvements can I make?): Physicians must participate in ongoing self-evaluation, self-assessment, and practice assessment, with subsequent completion of educational or improvement activities.
2. Assessment of Knowledge and Skills (What do I need to know and be able to do?): Physicians must demonstrate the knowledge, skills, and abilities to provide safe, effective patient care within the framework of the six Accreditation Council for Graduate Medical Education competencies: medical knowledge, patient care, interpersonal and communication skills, practice-based learning, professionalism, and systems-based practice.
3. Performance in Practice (How am I doing?): Physicians must demonstrate accountability for performance in their practice using methods that incorporate reference data to assess performance in practice and guide improvement.

What Is the Rationale for MOL?

According to the FSMB, MOL is the state medical boards’ answer to increasing demands from public and health policy makers for greater accountability and transparency, as it:

• Satisfies the lifelong learning and skills maintenance required of physicians facing rapidly evolving medical practice
• Is part of a movement to improve health care quality, decrease medical errors, and improve patient safety
• Provides consumers/patients greater accountability and transparency within the health care system

Isn’t MOL the Same as MOC/OCC?

Certification by a specialty board represents mastery of a medical or surgical specialty. Certifications are time-limited and require documentation of continuous professional development. The American Board of Medical Specialties (ABMS) and the American Osteopathic Association Bureau of Osteopathic Specialists (AOA-BOS) develop professional standards for medical specialty boards. MOC/OCC requirements include four components*:

• Part I: Professional standing (ie, physician must hold a valid license in the U.S.)
• Part II: Lifelong learning and self-assessment (CME or equivalent)
• Part III: Cognitive expertise (ie, a certification examination)
• Part IV: Practice performance assessment (ie, performance improvement activity)

* OCC includes an additional requirement for continuous membership in the AOA.

What Is the Relationship Between MOL and MOC/OCC?

MOL, MOC, and OCC all value the concept of lifelong learning and continued professional development. MOL is a product of the FSMB, while MOC/OCC is a product of the ABMS/AOA-BOS. State medical boards do not require specialty certification or recertification (and therefore do not require MOC/OCC) for licensure or licensure renewal, and that is not expected to change. Though MOC/OCC is not required by state medical boards for licensure, the FSMB’s proposed MOL system recommends that state medical boards recognize physicians actively engaged in MOC/OCC in their area of practice as being in substantial compliance with MOL. In addition, ABMS has developed a tool kit to advance the state medical boards’ adoption of the FSMB’s policy, encouraging the state medical boards to accept MOC participation as meeting a state’s requirements for license renewal. For physicians who were never specialty certified, or who are not participating in MOC/OCC, the FSMB will help state medical boards identify activities that physicians already engage in, such as accredited CME that could help meet the requirements of MOL.

What Are Physician Organizations Saying About MOC and MOL?

The American Medical Association (AMA) House of Delegates voiced its disapproval of the current state of MOC and MOL programs at its June 2013 meeting, and it commissioned a study to evaluate the impact of MOC and MOL requirements on physicians (including the impact on physician workforce, practice costs, patient outcomes, patient safety, and patient access). A completed report is due at the 2015 annual meeting. It also adopted these resolutions:

• Opposing mandatory specialty board recertification and discrimination by hospitals and other entities against physicians who don’t recertify
• Supporting of lifelong CME and lifelong specialty board certification
• Calling for increased transparency by the ABMS and its component specialty boards through published reports on revenue, expenses, and compensation of board members and senior staff
• Requesting the AMA work with ABMS and component boards to integrate existing data-reporting programs with certain recertification programs

The Association of American Physicians and Surgeons (AAPS) argues that recertification demands take physicians away from their patients and result in hospitals denying patients access to their physicians. It filed suit in federal court against the ABMS for restraining trade and causing a reduction in access for patients to their physicians, stating that the “ABMS has entered into agreements with 24 other corporations to impose enormous recertification burdens on physicians, which are not justified by any significant improvements in patient care.” The AAPS suit “seeks declaratory and injunctive relief to enjoin ABMS’s continuing violations of antitrust law and misrepresentations about the medical skills of physicians who decline to purchase and spend time on its program.” It also seeks “a refund of fees paid by its members to ABMS and its 24 other corporations as a result of ABMS’s conduct.” The suit cites that ABMS has a proprietary trademarked program of recertification that brings in tens of millions of dollars in revenue to seemingly nonprofit corporations that pay salaries to their executives, often in excess of $700,000 per year.

Dr. Casaletto is an emergency physician at Carolinas Medical Center in Charlotte, North Carolina. She is the immediate past chair of ACEP’s Academic Affairs Committee and ACEP’s Young Physician’s Section, as well as Councillor for NCCEP.