Credentialing and Public Accountability: Title and subTitle BreakA Central Role for Board Certification

As the health care world looks more closely at ways to measure and improve quality of care, the role of board certification has been emerging as one important method to ensure physician-level competence and accountability. The practices and standards used in identifying physicians for health plan panels and for hospital privileges have been less visible but currently are the only easily available and widely trusted initial screens of physicians that are available to patients. As public interest in physician competence increases, it is important to examine these basic standards for specialists.

The health plan credentialing and hospital privileging processes are a major way that the health care system can assist consumers in identifying physicians who are up-to-date and competent and who maintain certain standards of professionalism. A major issue is whether the current techniques that health plans and hospitals use in profiling physicians provide such assistance.

Board certification is one of the few tools that is widely applicable to most physician specialties, and it can potentially provide assurance to hospitals and health plans that the physicians they identify meet specific criteria. The remarkable aspect is that certification is an evaluation conducted and endorsed by the profession itself. No other health profession has a self-generated measure as robust as this, and in other countries the medical profession has not developed independent bodies to set standards for specialists that are in any way comparable to certifying boards in the United States. Of note, the National Health Service in the United Kingdom currently is working to engage physicians in ongoing evaluation of their competence.

In this issue of JAMA, Freed and colleagues¹ describe the use of board certification in the privileging of pediatricians by various types of hospitals. Overall, 78% of the hospitals do not require their general pediatricians to be certified, but 70% require board certification of their pediatricians at some time during their tenure. Only 44% of hospitals require subspecialist pediatricians to achieve certification within a specific time frame.

In another study in this issue, Freed and colleagues² report on the use of board certification and recertification by health plans to credential pediatricians. They report that 90% of plans do not require pediatricians to be board certified at initial credentialing and that only 41% require board certification at any time. In addition, only 40% of health plans ever require subspecialists to be board certified in their subspecialty, and 77% allow them to bill as subspecialists even though their certificates have expired.

The studies by Freed et al^{1 - 2} only include pediatricians, raising questions about whether these findings can be generalized, but nonetheless certainly portray a changing landscape. Pediatrics is a specialty that essentially does not involve Medicare and that occupies a relatively small place in most commercial health plans because, fortunately, children do not use high-cost health services to the same degree as do older adults. In addition, pediatricians do not have high stakes in hospital credentialing processes, because relatively few are engaged in high-risk specialty procedures or surgical interventions. Therefore, it is possible that greater scrutiny is applied to the other specialties. Hospitals have often used board certification as an absolute requirement for surgeons joining a hospital staff, precisely because it is a peer-generated practice as well as a knowledge-based evaluative process. For the most part, hospital privileging decisions are made by medical staff committees and are approved by members of the board of trustees, who hold ultimate accountability. It is very difficult to know the actual level of clinical skills of the individual physicians who are credentialed. Surgical boards often require some degree of supervised practice before initial certification, to ensure exactly those skills.

Until 2002, each of the 24 member boards of the American Board of Medical Specialties (ABMS) had its own, different standards. Some had time-limited certification; others did not. Some required practice assessment as part of certification; many did not. Since 2002, all have agreed to comparable standards of Maintenance of Certification (the ABMS program designed to document the competence of specialists); although these standards are to be implemented over variable timelines, all boards are required to be in compliance by 2010. The 2 most important features are that all boards' certificates are now time-limited and require performance assessment.

Physicians must maintain their certification by meeting a series of requirements over a cycle varying from 6 to 10 years. Freed et al^{1 - 2} note this among the questions they ask of health plans and hospitals, suggesting that some health plan managers are aware of this requirement and others are not. This has important implications for the veracity of information provided to consumers if board certification is listed as an attribute of the physician. If that certification lapses, the information presented is no longer correct. More work will be required of credentialing and privileging units within organizations, as they will need to verify the duration of certification and whether physicians have renewed their certification. However, such ongoing monitoring of certification will provide the public with real-time information about whether a physician is keeping up with the standards set by his or her specialty. Not only does the scrutiny of Maintenance of Certification have implications for the validity of the information to the public, but it also has potential for more impact on quality of care because in addition to the cycle length, and the requirement for ongoing Maintenance of Certification, ABMS boards have agreed to include a component of practice assessment as part of Maintenance of Certification.

Since the beginning of board certification in the early part of the 20th century, knowledge examinations have been an important factor, and they will continue to be as medical information continues to expand and change. Knowledge is an important foundation for clinical judgment and decision making in complex situations. Modern health services research has shown that knowledge is essential but not sufficient.³ Physicians may know the correct answer on an examination, but in practice the proper treatment (eg, aspirin or β-blockers after acute myocardial infarction) may not be provided to the patient. Modern health care occurs in complex, interdisciplinary teams with multiple professionals involved in the care of the patient and with systems of information that often are not optimal. The ABMS boards agree with the Accreditation Council for Graduate Medical Education that systems-based practice and practice-based learning and improvement are core competencies of every specialist. Therefore, to maintain certification requires some ability to examine the outcomes of patient care in a physician's practice. For many boards, these reports are in the early stages of being used to help physicians assess their performance and learn improvement strategies. But it is not difficult to imagine that standards will be set by the boards and by increasingly knowledgeable consumers (eg, hospitals, health plans) for the levels of performance that are acceptable and desirable.

Hospitals and health plans can be partners with the medical profession to improve quality by providing the clinical data that physicians need to maintain their certification. This in turn will help to improve the credibility and value of the credentialing process. Many physicians still do not have electronic medical records or participate in disease registries. They, therefore, may have difficulty assessing quality measures because of inability to collect data about their practice. Health plans and hospitals have some of those data. As we become more data rich, hospitals and health plans should consider ways they can provide physicians with relevant clinical outcomes of the patients for whom they provide care. Those data might then be used by the physician in Internet-based analyses of the practice that could be sent to the specialty boards to maintain board certification. This model, currently being used in internal medicine, pediatrics, family medicine, and a number of the surgical boards, could potentially be used in every specialty. In addition, when payment and other recognition are based on clinical quality of care (so-called “pay-for-performance,” tiering, etc), data collected by the boards for certification could be transferred with the physician's permission to health plans and hospitals for this purpose. Thus, the ultimate goal, as emphasized in a recent Institute of Medicine report on quality measurement,⁴ is to reduce the redundancy of measures and to allow physicians to practice and to collect data and have those data applied in numerous ways but with consistent measures.

These developments will be more familiar to many younger physicians and perhaps less familiar to older physicians who have not been in the habit of collecting patient-outcome data or in renewing their certification. The goal for the profession should be to have every physician actively engaged in Maintenance of Certification or similar activities, which provide more information for communities in understanding quality of care and areas that need special attention for improvement.

Two limitations of the studies by Freed et al^{1 - 2} create clear directions for future research: both studies examine only one medical specialty, and both are conducted during a time in which dramatic changes in physician self-regulation and, in particular, the drive for accountability and quality are occurring. The windows of opportunity glimpsed through the resulting snapshot are important. It would be valuable to have this study reproduced in several other major specialties or perhaps across physician groups involved in hospitals or health plans. It is difficult to imagine that health plans would have different standards for how they monitor board certification in pediatrics than they would in internal medicine or family practice. However, within the last 5 years, major changes have occurred in the process and criteria for Maintenance of Certification; over the next 5 years, additional dramatic changes undoubtedly will occur. Health plans and hospitals need to recognize this change, and studies like those of Freed et al performed a few years from now might show a more rigorous approach to monitoring certification status as well as a more robust data exchange that would allow certification to be even more effective in its ability to identify competence and facilitate quality improvement and excellence in physicians.