Two recent studies in the Journal of the American Medical Association are sparking fresh controversy over the effectiveness of, and need for, the maintenance of certification (MOC) requirements mandated by the American Board of Internal Medcine (ABIM.)
The studies in JAMA’s December 10 issue both look at MOC’s impact on the costs and quality of patient care, although in different ways. The first study, led by ABIM’s Bradley Gray, Ph.D., compared costs and outcomes for two groups of Medicare beneficiaries during the years 1999-2005: one group treated by internists who received board certification in 1991, and were thus required to recertify in 2001, and a second group treated by internists who certified in 1989, and were thus grandfathered out of ABIM’s recertification requirements.
The study used a quality measure the annual incidence of ambulatory care-sensitive hospitalizations (ACSH) per 1000 beneficiaries. (The authors define ACSH as “hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care.”)
The study found no statistically significant association in ACSH growth between the MOC-required and MOC-grandfathered physicians, but did find a 2% slower growth in the cost of care provided by the physicians who had to recertify compared with the grandfathered cohort.
The second study, led by John Hayes, MD, of the Zablocki VA Medical Center in Milwaukee, Wisconsin, compared performance data of 71 MOC-required and 34 MOC-grandfathered physicians at four VA medical centers, including Zablocki, for 12 months starting in October, 2012. The ten performance measurements ranged from colorectal screening to blood pressure control to post-myocardial infarction use of aspirin. It found “there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification om 10 primary care performance measures.”
While the study results might appear to provide ammunition to MOC opponents, an accompanying editorial by Thomas Lee, MD, MSc, chief medical officer for Press Ganey and a practicing internist, notes that “another assessment might be that the effect of MOC is unknown at best and that changes to its structure must be undertaken with caution and sensitivity to their effect on physicians’ professional lives.”
Lee points out that ACSH, the outcome measure used in the Gray-led study, “was designed to assess access to primary care in populations, not the quality of care delivered by individual physicians” and applied only to about 80 patients in each participating physician’s panel. Moreover, “the 2% reduction in spending is as large or larger than the savings recorded by Medicare accountable care organizations in their first two years, so further study to determine if this finding is real and reproducible is critical.”
(Gray and his co-authors note in their study that even small per-patient savings, when extrapolated over Medicare’s nearly 50 million beneficiaries, would far exceed the costs of administering the MOC program.)
The most significant finding of the Hayes study, Lee says, is that all the performance measurements were significantly better than those of the general population, regardless of whether the patient received care from a MOC-required or MOC-grandfathered physicians, and thus “provide a reminder that healthcare today has become team-based.”
In mid-December JAMA convened a webcast to discuss the studies’ findings and answer questions. Judging by tweets accompanying the events, MOC’s critics remain unconvinced of the value of ongoing recertification.