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Through interviews with representatives of the ABMS and the ACGME, as well as leaders of many ABMS member Boards and other key informants, the MSAG ...

     American Society of Addiction Medicine

     4601 N. PARK AVENUE ? SUITE 101 ? CHEVY CHASE, MD 20815

    SUMMARY:

    Actions of the Board of Directors

    of the

    American Society of Addiction Medicine

    on Recommendations Presented by the

    Medical Specialty Action Group

    April 25, 2007

    Miami, Florida

     “We can pursue one option or another, but in the end,

    we should do whatever will save the most lives.”

    James W. Smith, M.D., FASAM

    MSAG Hazelden Meeting

    December 1, 2006

    Copyright 2007, American Society of Addiction Medicine.

    All rights reserved.

    Charge from the ASAM Board of Directors

The American Society of Addiction Medicine (ASAM) is a national medical specialty society of more

    than 3,000 physicians. Its mission is to increase access to and improve the quality of addiction treatment;

    to educate physicians, other health care providers and the public; to support research and prevention; to

    promote the appropriate role of the physician in the care of patients with addictive disorders; and to

    establish Addiction Medicine as a primary specialty recognized by professional organizations,

    governments, physicians, purchasers and consumers of health care services, and the general public.

    ASAM was founded in 1954, and has had a seat in the American Medical Association House of Delegates

    since 1988.

The leadership of ASAM is committed to the formal recognition and designation of specialty status for

    the field of Addiction Medicine by the American Board of Medical Specialties. This commitment was

    codified in ASAM’s Mission Statement and Strategic Plan, most recently revised in 2006. Concurrently,

    ASAM President Elizabeth F. Howell, M.D., FASAM, created a Medical Specialty Action Group (MSAG)

    to “develop a knowledge base and recommend actions to the ASAM Board regarding the recognition of

    Addiction Medicine as a Board-certified medical specialty by the American Board of Medical

    Specialties.”

In October 2006, the ASAM Board of Directors, based on its understanding at the time and after review

    of multiple options, directed the MSAG to gather data on two options for ABMS recognition, which it

    described as follows:

    Option 1. Establish an independent American Board of Addiction Medicine (ABAM) now, to

    become an ABMS primary specialty Board, or

    Option 2. Establish an independent ABAM now, create Addiction Medicine as a subspecialty of

    several ABMS-recognized specialties, and later seek to establish Addiction Medicine as an

    ABMS primary specialty Board.

The MSAG was charged with gathering relevant information, analyzing the advantages and disadvantages of

    each option, making a recommendation as to which option ASAM ought to pursue, and explaining the rationale

    for and implications of the recommended course of action. The MSAG was asked to report on its work to the

    ASAM Board of Directors during the Society’s annual meeting in April 2007.

This charge was met through a presentation of the MSAG’s report and recommendations to the ASAM Board

    on April 24, 2007, which were acted on by the Board the next day, when it voted to accept the report and

    approve the recommendations (see page 9). The following is a synopsis of the MSAG’s report and the actions

    taken by the ASAM Board of Directors.

    Research Methods

To assure that the MSAG would have broad representation from the ASAM membership, the MSAG

    Steering Committee publicized the initiative widely and invited members to participate. To assure that the

    many medical specialties that comprise ASAM would be represented, the Steering Committee developed

    a document titled the MSAG Structure and Guidelines for Selecting Members.

Through this process, 30 members agreed to serve on one of four committees of the MSAG: the Process

    and Structure Committee, the Training Committee, the Finance Committee, and the Steering Committee.

    The Steering Committee was composed of the MSAG co-chairs, the chairs and co-chairs of each of the

    ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 2

    other committees, the ASAM Executive Vice President, the MSAG Consultants, and the ASAM Director of Credentialing.

    The members extracted information, key documents and reference materials from Internet sources, existing Boards, medical specialty societies, and related organizations. Members of the MSAG studied the experience of recent and prospective applicants to the ABMS to learn how applicants have successfully navigated the process of attaining ABMS recognition.

    Through interviews with representatives of the ABMS and the ACGME, as well as leaders of many ABMS member Boards and other key informants, the MSAG members compiled and collated the criteria and procedures for attaining ABMS member Board status as a specialty or subspecialty, and for creating and maintaining ACGME-accredited training programs. In addition, the MSAG’s research resulted in a

    unique historic and dynamic review of the evolution and current operation of ABMS specialties and subspecialties approved over the past 30 years.

    Background

    Addiction is a major public health problem in America. Addiction Medicine is a specialized area of medical practice that is recognized by the American Medical Association, by government agencies, health insurers, other private-sector organizations, most health care professionals, and many laypersons. However, Addiction Medicine is not yet a medical specialty recognized by the ABMS.

    As a leader in this specialty, ASAM has developed educational programs and other processes to increase, to document, and to recognize the knowledge base in Addiction Medicine. Since 1986, ASAM has offered a process through which physicians who wish to demonstrate their expertise can become certified in Addiction Medicine. The heart of the certification process is an examination developed for ASAM by the National Board of Medical Examiners an examination that is similar in scope and rigor to the

    examinations employed by many ABMS-recognized medical specialties and subspecialties.

    Through the ASAM examination, more than 4000 physicians have been certified in Addiction Medicine. However, these physicians are not, and cannot describe themselves as, Board-certified because there is no specialty Board representing Addiction Medicine, either ABMS-recognized or self-designated.

    In the absence of an ABMS-recognized specialty of Addiction Medicine, patients and their families, and even medical colleagues, do not always know how to find a physician who has expert knowledge and skills in the evaluation and management of addictive disorders. Hospital medical staffs and academic medical centers do not have official departments of Addiction Medicine. Managed care panels often do not include such specialists to care for members who have addictive disorders, do not reimburse for such care at rates comparable to those for other specialized care, and do not involve Addiction Medicine physicians in their utilization review panels.

    This imbalance is even more striking when one considers recent Federal data showing that one in four hospital admissions in the U.S. is related to an alcohol, tobacco or drug use disorder, and that millions of Americans are affected by such disorders in a family member.

    The members of the MSAG were motivated by a conviction that accreditation of Addiction Medicine training by ACGME and recognition of Addiction Medicine by ABMS would support the highest standards in training and certification for Addiction Medicine physicians, to the benefit of the patients and families who receive care from them.

ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 3

    Findings

A number of recent developments suggest that the addiction field may be at a “tipping point” in history –

    a time at which many vectors are aligned to pave the way for a fully recognized medical specialty or

    subspecialty of Addiction Medicine. Certainly, the extraordinary level of cooperation and guidance the

    MSAG received from the leaders of other medical Boards and specialty societies, as well as from officials

    of the ABMS and ACGME, was most encouraging.

A UNIQUE BODY OF KNOWLEDGE MUST BE DEFINED

    An applicant to the ABMS or ACGME must be able to demonstrate that its body of knowledge and

    training programs are distinct from those of an already-approved ABMS Board. Specifically, the

    application must document that the new medical specialty meets the definition of “an area of medical practice which connotes special knowledge and ability resulting from specialized effort and training in the

    specialty field.” Given that the subspecialty of Addiction Psychiatry already exists within the ABMS

    structure, an application for Addiction Medicine must distinguish between the two fields. As an

    exploratory step, the MSAG Training Committee initiated the task of outlining three key documents that

    define Addiction Medicine (including those elements that distinguish it from Addiction Psychiatry): core

    content, core competencies, and scope of practice.

AN INDEPENDENT BOARD OF ADDICTION MEDICINE IS NECESSARY

    The MSAG also investigated whether it is necessary to create an independently incorporated American

    Board of Addiction Medicine (ABAM) as an initial step in the process of seeking ABMS recognition for

    Addiction Medicine, either as an ABMS specialty Board or as a subspecialty of one or more ABMS-

    recognized specialty Boards. The MSAG members learned that this is indeed an essential step.

The ABMS Bylaws stipulate that “a medical specialty Board must be a separately incorporated,

    financially independent body.…” Several sources confirmed that Addiction Medicine’s certifying Board must be separately incorporated as an independent Board, with no overlap between the governance of the

    specialty society (ASAM) and the certifying Board (ABAM).

Multiple sources also confirmed the ACGME requirement that an applicant seeking to accredit training

    programs must first apply to the ABMS for approval. Thus, a separately incorporated Board is necessary

    even to apply to the ACGME. (The ACGME does not require that such a Board actually obtain ABMS

    approval, but it does require that an application for approval be made to the ABMS before it will accept

    an application to the ACGME.)

Finally, the MSAG members learned that a Board is fundamentally different from a medical specialty

    society, and that the two organizations have distinct missions and governance processes. As one

    interviewee told us, “We’re a business. We have a business plan. Our business is to certify diplomates

    [and to assure they maintain their certification status].”

    TRAINING PROGRAMS ARE KEY Availability of ACGME-accredited training programs is the key element in approval of a new ABMS

    specialty Board or a new subspecialty. Indeed, the most difficult challenge to be met in achieving ABMS

    recognition of Addiction Medicine is to establish, financially support, and continually fill Addiction

    Medicine training programs.

Addiction Medicine training programs would first be accredited by ABAM, using criteria that reflect

    those of the ACGME. In a second phase, ABAM would apply to the ACGME to establish a new

    accreditation process for training in Addiction Medicine. Before applying to the ACGME for

    accreditation of training programs, an applicant Board must have applied to the Liaison Committee on

    ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 4

Specialty Boards (LCSB) for recognition as a new examining Board or for subspecialty certification by

    one or more ABMS member Boards. (ASAM as an organization would officially support the application

    to the LCSB.)

Regardless of the decision by the LCSB, the applicant Board may then submit an application to the

    ACGME, which determines the recognition of a new medical discipline and its associated review

    committee. Prior to the ACGME review, an ad hoc committee (including members nominated by the applicant organization) reviews each petition. The applicant must provide information similar to that

    required by the ABMS for recognition of a new examining Board or new subspecialty certificate.

    Following its review of the petition, the ad hoc committee makes one of three recommendations to the ACGME:

    1. Preliminary approval for development of the new specialty. If this recommendation is accepted

    by the ACGME Board of Directors, the petitioners are authorized to develop Program

    Requirements appropriate to the new specialty. The ad hoc committee will recommend the

    structure and function of an appropriate Residency Review Committee with no more than three

    appointing organizations; or

    2. Refer the application to an existing Residency Review Committee to be considered for inclusion

    in the current specialty or for consideration as a new subspecialty of the existing general specialty;

    or

    3. Deny the application.

In the case of a proposed subspecialty certificate, the ACGME requires documentation that there has been

    appropriate communication between the proposed Residency Review Committee and the relevant ABMS

    Board(s) concerning the proposed subspecialty area, and (1) that the Board(s) awards a certificate in the

    subspecialty and supports accreditation in that area; or (2) that the Board(s) does not intend to award a

    certificate at this time, but is not opposed to the Review Committee’s beginning to accredit training

    programs in the subspecialty; or (3) that the Board(s) opposes accreditation of training programs in the

    proposed subspecialty.

The cost of establishing training programs appears to vary widely because the process differs from one

    facility or program to the next. For example, some institutions reported direct costs of programs in the

    range of $50,000 per trainee per year, while other institutions added indirect costs and faculty expenses,

    bringing the total to $200,000 per trainee per year.

    ABMS RECOGNITION IS ESSENTIAL In the course of the MSAG’s research, the importance of ABMS Board recognition was underscored by

    many of the leaders consulted. None stated the argument more clearly than one Board executive, who at

    the end of the interview was asked, “Do you have further advice to give us?” He replied: “Yes. ABMS

    Board certification is what it is all about. It’s not about CME and brochures. Your members’ future and

    improved patient care lies in receiving ABMS certification. If this is not achieved, then you can predict

    that there will be no future for your specialty.”

    SPECIALTY VERSUS SUBSPECIALTY STATUS As described in the ABMS Bylaws, a primary specialty board is a separately incorporated, financially

    independent body, which determines its own requirements and policies for certification, elects its

    members in accordance with the procedures stipulated in its own bylaws, accepts its candidates for

    certification from persons who fulfill its stated requirements, administers examinations, and issues

    certificates to those who voluntarily take and pass such examinations.

ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 5

A conjoint Board is an ABMS-recognized member Board that is separately incorporated and has similar

    responsibility for determination of requirements for certification, accepting candidates for certification,

    administering examinations, and issuing certificates” as a primary specialty Board. A conjoint Board is

    established under the joint sponsorship of not less than two primary specialty Boards. Medical specialty

    organizations such as ASAM also may be included as sponsors.

    Subspecialty certification is conferred by one or more ABMS member Boards to designate special competence in a component of a specialty. Subspecialty certification is conferred only on physicians who

    are certified in a primary medical specialty by one or more ABMS member Boards in an area of general

    certification.

In evaluating the various options, the MSAG Steering Committee gave particular attention to: (1) scope

    of practice, (2) training, (3) funding, and (4) feasibility and (5) flexibility.

    1. Scope of Practice. A major difference between a primary Board and a conjoint Board is that a

    primary Board’s members are physicians from within a single specialty, whereas the members of

    a conjoint Board are drawn from multiple primary specialties. This is much more closely aligned

    with the composition of Addiction Medicine.

    Like a subspecialty, a candidate for certification in Addiction Medicine by a conjoint Board

    already would be credentialed by a sponsoring primary Board. Thus, no other Board need be

    concerned that Addiction Medicine is drawing away its candidates or otherwise encroaching on

    its scope of practice.

    2. Training. An attractive feature of both a conjoint Board and a subspecialty is that, under the

    customary model, candidates for Board certification would be required to take only a one- or two-

    year Addiction Medicine fellowship after completing their residency training, rather than taking a

    full three- or four-year residency in Addiction Medicine, as would be the case with a primary

    specialty.

    Another model of training under a conjoint Board might involve a one-year post-residency

    training program. For example, the American Board of Emergency Medicine currently offers a

    five-year program to be double-Boarded in Emergency Medicine and Internal Medicine or

    Emergency Medicine and Pediatrics (a similar program with Family Medicine is in development).

    3. Funding. Creation of either a subspecialty or a conjoint Board would sharply reduce or eliminate

    the problem of funding training, because Addiction Medicine would not have to support the

    development of entirely new residency programs. Instead, a much more modest expense could be

    incurred by adapting existing programs to include the essential competencies in Addiction

    Medicine.

    4. Feasibility. Establishment of either a subspecialty or a conjoint Board may be attractive to

    Psychiatry, Internal Medicine, Family Medicine, Pediatrics, and other ABMS primary Boards

    whose patients are significantly affected by addictive disorders because neither option requires

    them to accommodate a new specialty. Moreover, the addition of Addiction Medicine may be

    helpful in attracting candidates to fill currently vacant training slots.

    5. Flexibility. Flexibility also is a desirable feature of a conjoint Board. For example, the experience

    of the American Board of Emergency Medicine demonstrates that ABMS acceptance of a

    conjoint Board does not preclude subsequent recognition as a primary specialty. (On the other

    hand, it appears that ABMS recognition of Addiction Medicine as a subspecialty would foreclose

    the possibility of later recognition as a primary specialty.)

    ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 6

    The original description of Option 2 by the ASAM Board of Directors was based on the

    assumption that, at some point after subspecialty status was attained, an application could be

    made for primary specialty status. That assumption appears to be incorrect.

    A reservation related to the pursuit of a conjoint Board derives from the fact that, although

    requirements for conjoint Boards exist within the ABMS Bylaws and several conjoint Boards

    have been approved (with one currently active), no new conjoint Board has been approved for

    several decades.

After evaluating the multiple factors associated with each of these options, the MSAG members identified

    certain key differences. For example, if a decision is made to pursue recognition of Addiction Medicine as

    a specialty through either a primary or a conjoint Board, ABAM would remain in existence in perpetuity,

    and ASAM would continue as the membership organization of choice. On the other hand, if a decision is

    made to pursue subspecialty status, ABAM will be dissolved whenever its role is subsumed by an existing

    primary Board or Boards.

    Conclusions and Recommendations

In weekly conference calls and in daily email exchanges, the MSAG Steering Committee discussed the

    reports and findings of the other three committees of the MSAG. However, Steering Committee members

    withheld any decisions or conclusions as to the best option until they could meet face-to-face in

    Philadelphia at the end of March 2007.

    CONCLUSIONS During that meeting, the MSAG Steering Committee concluded that ABMS recognition of Addiction

    Medicine as a primary specialty is not attainable in the coming decades because it is not feasible to

    develop primary residencies in Addiction Medicine in sufficient numbers to produce a critical mass of

    diplomates for a primary Board. Without such training programs and trainees, a certification process

    could not be established.

The Steering Committee also determined that either a conjoint Board or subspecialty certification in

    Addiction Medicine do appear possible. Choosing between these two options clearly requires additional

    research and extensive consultation with the leaders of ABMS, ACGME, and other specialty Boards,

    many of whom have been extraordinarily helpful as the MSAG committees pursued their preliminary

    research.

Therefore, the MSAG Steering Committee, having been presented with Options 1 and 2 in October 2006,

    came to favor what it called “Option 3,” which it defined as “Take action, while deferring a final

    decision.”

Because the ABMS and ACGME requirements are similar (albeit not identical) for recognition of a

    specialty Board or subspecialty certification, the Steering Committee determined that it is possible to

    create an American Board of Addiction Medicine, which then would take the next steps in building the

    required infrastructure and preparing an application to ABMS and ACGME. This could be done while

    deferring the actual decision as to whether to pursue recognition of Addiction Medicine as a conjoint

    specialty or as a subspecialty. Option 3 thus would allow the process to move forward, even as it affords

    time for essential dialogue and consultations with the leaders of potential sponsoring Boards and other

    medical organizations.

ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 7

Under Option 3, ASAM would create ABAM and give it the responsibility for physician credentialing

    through administration of the Certification/Recertification Examination. ABAM also would assume

    responsibility for creating a process to certify training programs and to continue a dialogue about

    specialty versus subspecialty recognition with a variety of stakeholders.

The very act of setting up ABAM would send a clear message to ASAM’s members and the larger

    medical community that Addiction Medicine is moving forward. Other advantages of Option 3 are that it

    would allow time to fully vet the core content, core competencies, and scope of practice of Addiction

    Medicine, both within ASAM and with other Boards and specialty organizations. It also would afford

    sufficient time to develop guidelines for accreditation of fellowship training (either by ASAM or ABAM)

    that are aligned with ACGME’s accreditation guidelines, in preparation for full ACGME recognition of

    training in Addiction Medicine.

RECOMMENDATIONS

    ASAM’s Board of Directors had multiple priorities to consider. One is the future of Addiction Medicine;

    another is the future of ASAM. The mission of ASAM, as articulated in the Society’s 2006 Strategic Plan,

    is “To improve the care and treatment of persons with the disease of addiction and advance the practice of

    Addiction Medicine.” The members of the MSAG are convinced that, once Addiction Medicine has

    achieved membership in ABMS, patients and their families will benefit greatly and the health status of

    Americans will be improved.

To empower the Society to take the steps necessary to the success of this initiative, the MSAG Steering

    Committee recommended and the ASAM Board approved Option 3, with benchmarks for essential

    activities.

By approving Option 3, ASAM’s Board took definitive action to create an American Board of Addiction

    Medicine, while deferring a decision as to which path to take to achieve accreditation of training

    programs by the Accreditation Council on Graduate Medical Education and the recognition of Addiction

    Medicine by the American Board of Medical Specialties.

The path forward will not be easy. The obstacles are political and attitudinal, as well as structural and

    procedural. Specifically, success in attaining recognition as a conjoint Board or subspecialty will require a

    full understanding and careful response to the requirements of ACGME and ABMS, as well as the time

    and effort required to consult with existing specialty Boards and other medical specialty societies.

    Next Steps

The MSAG Steering Committee understood that it was undertaking a task for which many ASAM

    members had worked for decades. The Committee also understood that achievement of ABMS

    certification is a long-term project that will be accomplished in three phases.

    In Phase I (2003 October 2006) the ASAM membership and the ASAM Board of Directors arrived at a consensus to seek specialty recognition. The consensus was expressed in the Board’s decision to create

    and finance the MSAG.

    In Phase II (October 2006 April 2007), the MSAG developed the knowledge base and the Steering Committee prepared its report and recommendations to the ASAM Board.

The Board’s approval of the MSAG report and recommendations launches Phase III: the establishment

    of the American Board of Addiction Medicine, leading over several years to the development of

    ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 8

accredited training in Addiction Medicine, and ultimately leading to ABMS recognition of Addiction

    Medicine.

The specific steps recommended by the MSAG and approved by the ASAM Board of Directors include

    the following:

    Step 1. ASAM will encourage and assist in the development of an American Board of Addiction Medicine (ABAM), with incorporation of ABAM targeted for the end of 2007.

    Step 2. The ASAM President and Executive Vice President will communicate and engage in dialogue with officials of ABMS member specialty Boards and medical specialty societies regarding the ASAM

    Board’s decision and plans. The dialogue will include leaders of the American Board of Medical

    Specialties, the Accreditation Council for Graduate Medical Education, the American Medical

    Association, and other parties with an interest in formal recognition of the specialty of Addiction

    Medicine by the ABMS.

    Step 3. The Medical Specialty Action Group will continue its work until ABAM has been created. The MSAG will be reconstituted to include ASAM members who are Board-certified in the specialties whose

    Boards and medical societies are prospective sponsors of ABAM. The reconstituted MSAG will be

    responsible for suggesting a governance and staff structure for ABAM, as well as the initial requirements

    for a mission statement, budget and operating plan.

    Step 4. After ASAM’s 2008 certification examination, the process of certifying individual physicians in Addiction Medicine will be transferred from ASAM to ABAM. This will require that the MSAG (a)

    determine the value of the intellectual property ASAM has invested in developing and refining its

    Credentialing Program over the past two decades, and (b) devise a process for transferring ownership of

    the ASAM Credentialing Program to the American Board of Addiction Medicine.

    Step 5. While ABAM will begin certifying individual physicians in 2009, it will not be in a position to submit a credible application to the ABMS via the Liaison Committee on Specialty Boards until there

    exist a sufficient number of ACGME-accredited training programs in Addiction Medicine. The sequential

    steps to achieve that reality include:

    a. The reconstituted MSAG will initiate a plan to conduct and publish the results of a survey of

    existing fellowship programs in Addiction Medicine (this catalog will complement the existing

    catalog of Addiction Psychiatry fellowships prepared by the Center for Medical Fellowships in

    Alcoholism and Drug Abuse at New York University).

    b. ABAM will confer with leaders of multiple medical specialty societies, including ASAM, to

    obtain their input to the documents defining the core content, core competencies, and scope of

    practice of Addiction Medicine

    c. ABAM will develop an accreditation process for training programs in Addiction Medicine,

    modeled after the ACGME guidelines for accreditation of training programs.

    d. After several years of carefully evaluated activity, ABAM will apply to the ACGME for approval

    of its accreditation process for training programs in Addiction Medicine.

    Step 6. With its certification of individual physicians established and the ACGME’s accreditation of its training programs attained, ABAM will submit an application for recognition by the American Board of

    Medical Specialties (ABMS) as a conjoint Board of the ABMS, or for subspecialty certification of

    ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 9

Addiction Medicine by multiple ABMS medical specialty Boards, whichever path best serves the

    interests of patients and the specialty of Addiction Medicine.

Step 7. In order to fund the MSAG’s ongoing activities, the ASAM Board approved an initial budget

    and authorized the use of monies from the Society’s reserve fund and other available sources.

Step 8. The ASAM Board directed that the MSAG submit a progress report at the October 2007 meeting,

    describing the group’s further findings and achievements. The ASAM Board also determined that, after

    its anticipated incorporation in December 2007, the leaders of ABAM should be invited and encouraged

    to report regularly to the ASAM Board of Directors on ABAM’s findings and achievements.

    ASAM BOARD ACTION ON MEDICAL SPECIALTY STATUS 10

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