Studies examine effect on patient care and costs of requirements for maintaining board certification

Two studies in the December 10 issue of JAMA, a theme issue on medical education, evaluate the effect of the requirement of maintaining board certification on hospitalizations, health care costs and quality of patient care.

One of the largest changes in physician accreditation policy was the initiation of a 10-year Maintenance of Certification (MOC) requirement in 1990 by the American Board of Internal Medicine (ABIM). This change was also adopted by 24 certifying boards of the American Board of Medical Specialties, affecting 85 percent of all U.S. physicians. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes.

In one study, Bradley M. Gray, Ph.D., of the American Board of Internal Medicine, Philadelphia, and colleagues examined outcomes of care for Medicare beneficiaries treated in 2001 by two groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84,215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69,830 similar beneficiaries in the sample. The primary outcome measured was ambulatory care-sensitive hospitalizations (ACSHs), which are hospitalizations triggered by conditions (such as diabetes and asthma) thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars).

Annual incidence of ACSHs (per 1,000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both groups, as did annual per-beneficiary health care costs (pre-MOC period, $5,157 for MOC-required beneficiaries vs $5,133 for MOC-grandfathered beneficiaries; post-MOC period, $7,633 for MOC-required beneficiaries vs $7,793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with group differences in the growth of the annual ACSH rate.

The researchers found that the MOC requirement was associated with a decreased growth in costs related to laboratory tests, imaging, and specialty visits.

"Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries," the authors write.

The authors note that this research should be replicated for the current MOC program using more robust measures of care quality, across other patient populations as well as across internal medicine subspecialties, and for other certification boards' MOC requirements.

In an another study in the December 10 issue of JAMA, John Hayes, M.D., of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisc., and colleagues examined whether there are differences in the quality of primary care provided between internists with time-limited board certification and those with time-unlimited certification. Before 1990, board certification was time-unlimited. Since 1990, to maintain certification internists must pass an examination every 10 years.

American Board of Internal Medicine initiatives encourage internists with time-unlimited certificates to recertify. However, there are limited data evaluating differences in performance between internists with time-limited or time-unlimited board certification, according to background information in the article.

The study consisted of an analysis of data for 10 primary care performance measures (such as blood pressure control, colorectal cancer screening) from 1 year (2012-2013) at four Veterans Affairs (VA) medical centers. Participants were internists with time-limited (n = 71) or time-unlimited (n = 34) ABIM certification providing primary care to 68,213 patients.

After adjustment for various factors, the researchers found no significant differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any of the performance measures. "To whatever extent a goal of MOC is to improve the quality of patient care, these findings raise a question of whether that goal is being achieved, at least among internists at these VA hospitals."

"Additional research to examine the difference in patient outcomes among holders of time-unlimited and time-limited certificates in VA and nonacademic settings and the association with other ABIM goals may help clarify the potential benefit of MOC participation," the authors conclude.

Editorial: Certifying the Good Physician - A Work in Progress

Physicians should work constructively to help MOC improve, much as physicians should work continuously to improve how they collaborate with colleagues and with patients, writes Thomas H. Lee, M.D., M.Sc., of Press Ganey, Brigham and Women's Hospital, Harvard Medical School, Boston, in an editorial in this issue of JAMA.

"In addition, physicians must make the commitment to lifelong, meaningful learning to ensure that their knowledge and skills remain current and relevant. Patients would be disappointed by anything less. The medical profession may never fully understand the effect of MOC, but that does not mean that physicians should give up or stop trying to make it better. The MOC program is a work in progress, as are all good physicians."