As a measure of physician competence, recertification receiving mixed response
From the November ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
Two years ago, after recertification became mandatory for internists with time-limited certificates, UPMC Health Plan in Pittsburgh reached a decision. Because internal medicine leaders were still negotiating over what recertification should look like, the health plan—with 3,000 participating physicians—decided to waive its recertification requirement for internists for two years.
Those two years are almost up, and when the health plan's credentials committee meets later this fall, it faces another big choice. Given the ongoing dialogue over how recertification should be configured, should the plan extend its two-year grace period?
"On one hand, we have no idea how many internists have let their certificates lapse or whether we'd move to disenroll them," said Ralph Schmeltz, FACP, Governor for the College's Pennsylvania Western Chapter and chair of the health plan's credentials committee. "On the other hand, it's not fair to other specialists who recertify—like family physicians and obstetricians—to continue to give internists this dispensation."
Three years into mandatory recertification, the issue remains in flux. While many internists and internal medicine subspecialists with time-limited certificates have entered the recertification cycle, others have decided to forgo a process they say is too cumbersome and expensive.
Predictions of mass hospital and health plan disenrollments in the wake of mandatory recertification haven't materialized, and a snapshot of recertification policies from health plans and hospitals reveals a mixed bag. Even some insurers and provider groups that require internists to recertify say they haven't begun to enforce those policies yet.
Confounding the issue is the attitude of many internists themselves. Despite complaints about the current process, internists interviewed for this article overwhelmingly supported the idea of recertification. Even internists who aren't required to recertify claim they are committed to maintaining certification, saying it's an important indicator of professional stature, a key defense in malpractice suits, a necessary item on their resume in a mobile workforce and a good bargaining chip in a volatile market.
While many stakeholders are still at a crossroads when it comes to recertification, they say it's an important proxy at a time when there are few verifiable measures of physician quality and competence. But they add that the fact that different specialty boards have very different routes to recertification makes it an uneven standard. And as a growing number of purchasers push for national performance measures, analysts claim that the value of recertification as a national quality standard may change.
This year, the American Board of Internal Medicine (ABIM) released some statistics on the number of internists entering the recertification process. Among general internists who had no subspecialty training and whose time-limited certificates expired in 2000 and 2001, 73% had entered the Continuing Professional Development (CPD) recertification process as of this spring, according to the ABIM's spring/ summer 2002 CPD News.
(The total percentage of physicians with internal medicine certificates expiring in 2000 and 2001 who have entered the CPD process is 65%. That number includes diplomates who also certified in subspecialties or added qualifications, according to ABIM statistics released this fall. See the fall 2002 ABIM Perspective newsletter online.)
While 27% of general internists with time-limited certificates that expired in 2000 and 2001 have let their certificates lapse, they were joined by internists in 11 subspecialties with time-limited certificates who also decided to not "re-up" in their subspecialty. About 10% of gastroenterologists, for example, have not entered the CPD process in gastroenterology, while 21% of infectious diseases specialists and 34% of hematologists whose subspecialty certificates lapsed in 2000 or 2001 have also not begun the recertification process in their subspecialty. (See "A look at who is recertifying.")
When ABIM surveyed general internists who didn't recertify, it received some intriguing responses. Just over half of the internists who responded—54%—had entered other specialties, were pursuing nonclinical careers or had left medicine, according to the ABIM.
More than 40% of the others, however, replied that the benefits of recertifying were not worth the time or effort, while 35% cited time constraints and 20% noted that CPD was not important to their patients. When asked if their decision to not recertify had affected them, 14% of generalists reported "some impact," with one diplomate claiming to have lost hospital privileges and another seeing a drop in salary.
Among responding general internists, however, 70% said they'd suffered no negative professional fallout from their decision. Among subspecialists who responded, that figure was 79%.
Insurers, health plans and hospitals
Many of the internists surveyed noted that they don't have to recertify to maintain their current position, a requirement that varies among organizations and markets. Interviews with different health care stakeholders across the country revealed a wide range of recertification requirements.
Liability insurers. Among liability insurers, ProAssurance Corporation (the nation's third largest), for example, is definitely tracking recertification. The company asks physicians about their certification status on their renewal forms, and claims that a lapsed certificate could "definitely" lead to higher premiums or even a nonrenewal, according to a company spokesperson.
Other insurers such as Copic Insurance Company in Colorado are just now starting to track recertification. This year for the first time, Copic began entering physicians' recertification status into its database.
But other companies say that recertification isn't even on their radar screens. Midwest Medical Insurance Company, for instance, which insures more than 10,000 physicians in several Midwestern states, considers physicians who have passed their boards once to be board certified indefinitely. Midwest doesn't ask physicians whether they've recertified, and it doesn't intend to.
"With so many factors now affecting the medical malpractice market," said a Midwest spokesperson, "there are just too many other considerations."
Health plans. Among health plans, recertification policies run the gamut from carved-in-stone requirement to non-issue. Humana Inc., for example, does not require initial certification from its physician panel (except in one market, among 18 states), so it does not track recertification.
United HealthCare also does not mandate board certification for its physicians, nor does Blue Cross of California. But Blue Cross Blue Shield United of Wisconsin does, and it expects its 6,000 network physicians to maintain active certification.
"If their certificates lapse, they don't participate," said chief medical officer James E. Hartert, FACP, who pointed out that some physicians—although not internists, yet—have been bounced out of the network for failing to maintain an active certificate.
Blue Cross Blue Shield of Michigan has the same requirement. That policy has been in effect since 1998, said Suzanne Keister, RN, manager of network management for the plan's PPO programs. She noted that employers increasingly demand active certification for providers.
"The trend in the industry is definitely toward equating quality of care with board certification rates," Ms. Keister explained. But she acknowledged that access issues, as well as the size of a physician's practice, would be important factors in deciding whether to disenroll a physician with lapsed certification.
Thomas Ruane, MD, the PPO plan's medical director, admitted that enforcing a strict recertification policy for a physician who was already board certified when he began participating in the plan could be "dicey." The plan might have a hard time "requiring somebody who voluntarily met a higher standard when they joined the network to maintain that standard," he said. And the fact that so many internists are "grandfathered" with lifetime certificates makes enforcement a problem, he added.
Hospitals. Hospital bylaws fall into a similar broad range. Many community hospitals don't require initial certification for staff privileges, pointed out Lawrence L. Faltz, FACP, Governor for the College's New York Hudson Valley Chapter and medical director for Phelps Memorial Hospital Center in Sleepy Hollow, N.Y.
'Given the current situation where every admission is precious, a hospital running at 50% occupancy won't turn physicians away unless they're a danger to patients.' —Lawrence L. Faltz, FACP
In part, that's because some states—including New York—prohibit hospitals from using certification as the only criterion when appointing or reappointing physician staff. And "given the current situation where every admission is precious," Dr. Faltz said, "a hospital running at 50% occupancy won't turn physicians away unless they're a danger to patients."
Academic centers around the country face a different dilemma: How can they require staff physicians with time-limited certificates to recertify when some of their own department heads were never certified at all? And several hospital systems, such as St. Joseph Healthcare in Albuquerque, N.M., and St. Barnabas Health Care System in Toms River, N.J., take a different approach: They require physicians to be initially certified, but don't require them to recertify.
"Once physicians have been on staff, our own quality programs are able to gauge their current competence," said Fred M. Jacobs, FACP, JD, executive vice president for medical affairs at St. Barnabas. "Passing or failing an external exam is not that big of a factor when we're able to closely track a physician's actual performance."
Recertification as a quality measure
That view raises bigger questions about the value—and future—of board certification. Some health plans and hospitals that require active certification argue that it is one of very few objective measures of physician quality and competence.
"Board certification makes it very easy," said Dr. Schmeltz from Pittsburgh's UPMC. "It's out there, it's obtainable and it's verifiable."
Many administrators also claim that the value of recertification will only increase, particularly as health plans loosen up physician panels to give patients more choice. "We have no way to track a particular physician's screening or immunization record," noted Dr. Ruane from Blue Cross Blue Shield of Michigan. "We don't have any reliable indicators of quality that are actionable besides certification."
Purchasing groups and business coalitions, he added, are already experimenting with new networks that would differentiate among physicians based on quality indicators—and vary reimbursement levels according to physicians' performance. Dr. Ruane claimed that physicians without active certification would not even be considered for those potential future networks.
Some analysts, however, point to factors that could dilute recertification's value as a quality indicator. Several subspecialties—including gastroenterology, pulmonology and critical care—are already coping with workforce shortages that are expected to get worse. In the face of ongoing physician shortages, hospitals and health plans may be loath to dismiss subspecialists with good track records because of lapsed certification. (For more on subspecialist recertification, see "Subspecialists with dual recertification: a dying breed?" below.)
"Grandfathering" is another issue: With a substantial number of practicing internists not subjected to the rigors of recertification, actively maintaining certification becomes an objective quality measure for only a portion of the internal medicine population.
And analysts say that variations in recertification pathways across specialties present problems for "selling" recertification as a quality standard. In 1999, the American Board of Medical Specialties (ABMS)—an umbrella group of 24 specialty boards that includes the ABIM—set forth principles of "maintenance of competence" to guide its board members in designing their recertification processes.
While the ABMS has begun to consider ways to standardize those pathways, there is still substantial variability. Family physicians, for instance, are required to present continuing medical education credits in order to recertify—a practice that the ABIM currently does not accept. Critics complain that such variability makes recertification an uneven quality standard across different specialties.
"One doesn't want to educate the public more about a system in which there are enormous variations without obvious external reasons," said medical historian Rosemary A. Stevens, PhD, professor of history and sociology of science at the University of Pennsylvania and a member of the ABMS executive committee. "The best scenario in the next few years is moving toward a well-executed and reasonably standardized assessment system that all the specialty boards buy into."
Emerging technology may also lead health plans and hospitals to rely more heavily on performance measures as quality indicators. Frustrated purchasers are increasingly clamoring for outcomes measurements as a way to gauge quality in both hospitals and physicians, said College Regent William E. Golden, FACP, a member of the board of directors of the National Quality Forum, a purchaser-provider consortium working to create standardized and publicly reported performance measures.
The Centers for Medicare and Medicaid Services may begin applying performance measures to nursing homes this year, Dr. Golden said. Hospitals can expect them within the next two years, while measures for individual physicians may not be far behind. If national performance measures are standardized for physicians, some analysts say that recertification may lose some of its cachet as a quality standard.
Dr. Stevens from the ABMS pointed out that among specialty boards, ABIM has taken a strong lead in trying to incorporate some performance measures—like its patient and peer assessment module—within its continuous professional development program. But Dr. Golden pointed out that specialty boards may be the wrong forum to design performance measures.
"Good performance measures are created through public guidelines in a public fashion," he said. "To roll them into a recertification process where the creation of the measures is basically 'closed' because of the test-taking environment is contradictory to the whole notion of performance measures."
Integrated health systems around the country are already moving toward using their own data to devise performance measures to gauge physicians' performance in managing different diseases—and to eventually tie performance to reimbursement. Partners HealthCare System in Boston is one of them.
"It isn't absolutely clear that recertification is the best way to document doctors' performance," said George E. Thibault, FACP, vice president for clinical affairs at Partners. "In the absence of better quality measures, recertification will be one of the proxies. But as we get better physician data, it may ultimately be less important."
Process vs. principle
There is one other group that's determining the value of recertification: internists themselves. While many criticize the current process as too time-consuming, costly and arcane, most defend the principle of certification as a key factor of professionalism.
Janet Krommes, MD, for example, will take recertification exams this month in general internal medicine and rheumatology, even though her rheumatology certificate doesn't expire until 2003. With offices in southwestern Pennsylvania and New Jersey—both hotbeds of malpractice problems—Dr. Krommes views staying certified as a necessary form of professional protection.
"Your certification status always comes up in malpractice cases," she said. "Keeping your certificate current is a good psychological defense."
General internist Louis A. Orlando, MD, recertified last year—even though he practices in Kansas City, Mo., where neither hospitals nor health plans require initial certification. Furthermore, the independent provider association to which he belongs—Health Midwest—now requires initial board certification and recertification for any new physician who joins. For Dr. Orlando, active certification is a matter of hedging his bets and maintaining professional stature.
"You take pride in your ability to pass the test," he said. And even though recertification is not required in Kansas City right now, he continued, "ultimately I think it will be—and should be."
Cardiologist Robert E. Tanenbaum, FACP, who also practices in Kansas City, echoed those sentiments. Dr. Tanenbaum recertified in both internal medicine and cardiology last year.
"Most insurance companies are looking for reasons not to pay you," he said. "I'm not going to put myself in the position where somebody who doesn't really know much about medicine can interfere with my ability to practice." The more qualifications he has, Dr. Tanenbaum said, the more marketable he'll be and the less vulnerable to changing future mandates.
"It can't hurt you to have it," he said, speaking of recertification, "but not having it can."
At the same time, however, internists are weighing the costs in time and effort that it takes to recertify, and are continuing to call for a more reasonable process. Victor S. Sloan, ACP-ASIM Member, for instance, works in the pharmaceutical industry, but spends one-half day each week giving free rheumatology care at a clinic in New Jersey. To safeguard that part-time practice, Dr. Sloan is sitting for both his internal medicine and rheumatology exams this month.
"I keep reading about alternate pathways for people like me who don't see patients full-time, but I haven't seen anything happen," he said. "The problem with recertification is that it's too much of a moving target."
When hospitals and health plans require internists to recertify, they expect it only in the physicians' specialty. Virtually no organizations require subspecialists to also maintain active internal medicine certificates, unless those physicians are also practicing general internal medicine.
Internists say the issue of dual recertification is an important one for the future of the profession. "Recertification in core internal medicine should not be unduly difficult for subspecialists to maintain," warned Lawrence L. Faltz, FACP, Governor for the College's New York Hudson Valley Chapter. "Otherwise, I fear a split in organized internal medicine nationally and within departments of medicine."
According to the American Board of Internal Medicine (ABIM), 58% of the subspecialists who recertified in 2000 and 2001 also pursued recertification in internal medicine. Some of those who didn't may be waiting until their subspecialty certificate is up to dual-recertify in "one fell swoop," said James Patterson, MD, immediate past chair of the ABIM's recertification committee. But others—particularly those in subspecialties that don't entail much general internal medicine—may simply let their internal medicine certificates lapse.
One of those subspecialties is critical care. "There is the perception that recertification requires people to focus on areas that really don't reflect their practice," said Donald B. Chalfin, ACP-ASIM Member, a critical care physician who is immediate past chair of the internal medicine section of the Society of Critical Care Medicine. "This is an inpatient specialty, so there's a sense of frustration in having to focus on outpatient issues that aren't germane to our practice."
In an effort to make recertification more meaningful to subspecialists, the ABIM plans to give physicians self-assessment credit for completing materials developed by the Society of Critical Care Medicine, the American College of Cardiology and the American College of Chest Physicians, among others. And ABIM officials claim they are still at the drawing board, designing more streamlined recertification pathways for subspecialists.
"We want to have a recertification process that is relevant for different people," said the ABIM's Dr. Patterson. "We're now actively designing programs for hospital-based internists, as well as for those with outpatient practices."
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