Are you CERTIFIED?

by Veronica Olvera

Maintaining your board certification is about to become a more taxing process. The American Board of Family Practice is rolling out its new Maintenance of Certification program to comply with a decision by the American Board of Medical Specialties to enhance certification requirements. The ABMS hopes this will head off possible future efforts by the federal government, third-party payers, state licensing boards and others to put onerous and burdensome regulations on the practice of medicine.

But many family physicians are worried about the burdens of the maintenance program. In addition to the examination board-certified family physicians take every six or seven years, diplomates will be required to complete clinical self-assessment modules each year and they will need to participate in an expanded version of the ABFP’s current record review process. ABFP is also developing patient satisfaction and peer review instruments to measure professionalism. These should be available in the next couple of years.

The new Maintenance of Certification process will begin in Jan. 2004 for those certifying or recertifying in 2003. From that point on, each class of physicians needing to certify or recertify will begin the program.

 “Our major reason for MOC is to proactively facilitate the improvement of care delivered to the public by certified specialists. If we are able to do so, it will relieve the likelihood of potential cumbersome impositions by third parties,” says James Puffer, M.D., executive director of ABFP.

MOC is intended to prove every board certified physician’s competency through a four-part system designed to evaluate six areas of medical expertise. The four sections are evidence of professionalism, evidence of self-assessment and lifelong learning, evidence of cognitive expertise and evidence of assessment of performance in practice.

Under evidence of professionalism, doctors are measured by the maintenance of their licensure. ABFP will implement an ABMS-designed peer/patient satisfaction aspect to the test by 2004 or 2005. To evaluate self-assessment and lifelong learning, doctors will complete one Web-based clinical module each year that tests their knowledge about a given disease. The first two modules available will cover diabetes and hypertension, but in subsequent years, ABFP plans to launch modules on a variety of disease states.

“The Institute of Medicine published a series of articles outlining 20 specific areas in which they felt attention should be directed. So, we have used that list as a guidepost,” Puffer says. Each ABFP self-assessment module will include two parts. One will assess the breadth of knowledge and the other will test the ability to apply that knowledge.

The third part, cognitive expertise, consists of the current board examination. This process will continue, but with the added convenience of more available test sites and frequent testing schedules. The test can be taken at one of the 200 computer-based testing centers in the United States. According to ABFP, 80 percent of diplomates will be within a one-hour drive of one of these testing centers.

The assessment of performance in practice will begin in 2004. At some point during the seven-year cycle, most physicians will be required to submit 10 patient charts for review. Physicians will be able to select which charts will be reviewed and assessors will determine whether certain quality indicators are being met. Based on their performance, doctors will go through a personally tailored quality improvement program after which they may be asked to complete a second chart audit.

Not all doctors will need to provide charts, however. The performance evaluation for administrative physicians who do not regularly see patients will have some alternate requirements. “If they are medical directors, or actively involved with quality improvement plans, then they can submit that to file for part four,” Puffer says.

MOC will be in full swing by Jan. 1, 2004, but for some the testing has already started. Doctors can expect to receive a thin envelope with red letters insisting the contents are “important.” Enclosed is an explanatory letter with two pamphlets about the MOC program. Puffer says reactions have been mixed since releasing information about certification, but that the new program is not that much different from the original certification process. The original model was only modified to meet the new requirements established by the ABMS. In 2005, the examination will completely computer-based. “Family physicians will find it will take them no longer to certify than it did under the old paradigm,” Puffer says.

On a larger scale, ABFP’s changes in the certification process reflect the public call for quality assurance in health care. Since the Institute of Medicine released its controversial report in 1999 that estimated 98,000 people die annually from medical mistakes, there has been a wave of public scrutiny on doctors. The Institute’s original number was taken from a projection based on New York’s 13.6 percent patient death rate due to doctors’ mistakes. The Leapfrog Group, an organization of private and public employers who purchase health care benefits for their employees, states on their Web site that “medical errors are a leading cause of death in America -- there are more deaths in hospitals each year from preventable medical mistakes than there are from vehicle accidents, breast cancer, or AIDS.”

Catherine Eikel of The Leapfrog Group, says the matter at hand is not about physician discipline, but quality care. “As Leapfrog is focused on mobilizing consumers and using market reinforcements, we are working toward a health care system in which physician discipline occurs when purchasers and consumers vote with their feet by actively not choosing providers that do not provide high quality care,” she says. “So unlike a certification body, Leapfrog does not explicitly accredit or certify providers. Instead, we bring information on provider quality to purchasers and consumers as a way to help them make informed health care decisions.”