Cost of physician board recertification fuels questions about how best to achieve better outcomes for patients

In their study, published online on July 27 in the Annals of Internal Medicine, the researchers found that most costs of the latest maintenance-of-certification (MOC) requirements implemented for medical specialties by the American Board of Internal Medicine (ABIM) arise due to the time required for physicians to fulfill requirements, such as completing online modules, rather than the fees payable to ABIM.

The researchers said that the high costs of the program highlight the need for higher-quality evidence that it actually will lead to improved clinical outcomes for patients.

"This is a first attempt to gauge the costs of implementing the revised recertification programs, so that researchers can begin to better evaluate costs and benefits of this large investment in physician education in comparison with alternative strategies for improving healthcare quality," said senior author Dhruv Kazi, MD, MSc, assistant professor in the Department of Medicine, Department of Epidemiology and Biostatistics, and the Center for Healthcare Value at UCSF. "Ultimately, we want to know whether these requirements offer a good return on investment for society."

The researchers developed a mathematical simulation model of the entire ABIM-certified workforce of internists, hospitalists and internal medicine subspecialists in the United States and estimated total societal costs over 10 years -- including ABIM fees and the monetary value of physician time spent on fulfilling MOC requirements. They calculated that costs to individual physicians would average $23,607 over 10 years, with costs in some subspecialties exceeding $40,000. Subspecialists face higher costs than general internists in the program, primarily because they take additional certification examinations that generate more fees and a greater time outlay.

"We found that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," said Alexander Sandhu, MD, the lead author of the study and the Veterans Affairs Health Services Research and Development fellow at the Center for Health Policy/Center for Primary Care and Outcomes Research at Stanford University, and a clinical instructor for the Department of Medicine. "We estimate that ABIM MOC will cost 33.7 million physician-hours over 10 years. Efforts to reform MOC and lower its costs should focus on making the most efficient use of physician time."

Kazi said, "The time required to complete testing modules might in some cases otherwise be dedicated to patient care, or to participating in grand rounds or other activities intended to keep physicians attuned to best practices where they work."

Study co-author R. Adams Dudley, MD, MBA, director of the Center for Healthcare Value at the Philip R. Lee Institute for Health Policy Studies at UCSF, said a comprehensive evaluation of the policy should consider both costs and benefits.

"Downstream improvements in the quality or efficiency of care resulting from participating in MOC may offset some of these upfront costs," Dudley said. "However, we found no high-quality studies examining the effect of the increased requirements on clinical or economic outcomes, so we were unable to model potential benefits."

The ABIM was created early in the last century to develop uniform standards, and rigorous board certification exams have long been the norm, but it was only in 1990 that the ABIM began requiring recertification for new physicians. Physicians who were board-certified earlier were grandfathered in and have not been required to meet any newer requirements.

With medical advances accelerating, the ABIM decided a few years ago to further bolster requirements intended to keep physicians up-to-date, changing its once-every-10-years MOC program to a more continuous one and gradually increasing the amount of testing required. In 2014, the ABIM again increased the requirements and fees. Faced with mounting criticism from physicians and specialty societies, the ABIM temporarily suspended some of the new requirements in February 2015 but retained the increased fees and number of modules. It's these latest requirements that the researchers evaluated in the new Annals study.

The ABIM also announced in February that it was going to work closely with physicians and professional societies to reform MOC.

"Our hope is that our estimates of the costs of MOC and, critically, the drivers of these costs, will help inform these upcoming consultations about MOC reform," Kazi said.