Research & Commentary: Are Maintenance of Certification Programs a Money Grab?

Published April 22, 2016

Certification and licensing can have a significant effect on the growth of any market, especially in the health care industry, where doctors face myriad licensing, certification, and education requirements to maintain their licenses and continue practicing. Providing certification for doctors has become a profitable industry for the medical boards administering the certifications. Many have begun to question the new certification requirements. They argue certifications have become excessive, overpriced, and have become mandatory when they are supposed to be voluntary.

Certification has changed significantly since the early 1990s. For decades, doctors were required to take one exam, generally administered immediately after completing their training and education, to prove they were knowledgeable to treat patients. Doctors choosing a specialty field were required to follow this test with another in their chosen field. Physicians maintained their certification by participating in classes and seminars, known as continuing medical education, which provided doctors with up-to-date information on any new developments in their chosen field.

This system worked well for years, and there are few who argue against the idea doctors should be required to stay current on all the latest medical developments. However, problems began to emerge when medical boards began requiring additional testing and programs, now known as “maintenance of certification” (MOC).

Critics of MOCs argue the new requirements are excessive, costly, time-consuming, and unnecessary. Groups administering MOC programs say they improve health care outcomes, but Dr. Paul S. Teirstein argues in an article published in The New England Journal of Medicine these results are far from clear.

“In fact, close examination of the reports cited by the American Board of Internal Medicine reveals that the data are ambiguous at best: in a meta-analysis of 33 studies, 16 described a significant association between certification status and positive clinical outcomes, 14 found no association, and 3 found a negative association,” wrote Teirstein. “Moreover, the authors of the meta-analysis concluded that the research methods of most published studies on this topic are inadequate. Almost all published studies evaluate initial board certification, not recertification or MOC, and the rigorous requirements for initial certification should not be equated with the busywork required for the MOC every 2 years.”

As a result of these and other, similar concerns, several states are now considering legislation to limit or end the use of MOCs. In April, Oklahoma passed a bill that forbids the requirement of a MOC as a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in the state.

In an article on Oklahoma’s efforts, the Docs4PatientCare Foundation argues the bill reaffirms what board certification should be: voluntary. “The funny thing is, this law shouldn’t be revolutionary,” said Docs4PatientCare. “It simply legislates exactly what American Board of Medical Specialties (ABMS) says about board certification: that it is voluntary. ABMS has long claimed ‘board certification is a voluntary process, and one that is very different from medical licensure.’  But for those of us on the ground, it’s very clear that it is NOT voluntary. We can quickly lose our jobs, our hospital privileges, and our insurance participation if we choose not to participate in any portion of MOC.”

MOCs present a growing challenge for doctors because they have been integrated into sweeping health care policies and regulations, such as the Affordable Care Act (ACA). Docs4PatientCare says language in the ACA directs the secretary of the Department of Health and Human Services to require physicians to participate in MOCs in order to work in the Medicare and Medicaid programs.

These certifications were intended to ensure physicians are educated on the latest health research and methods, not to act as a profit center for medical board organizations. While a certain degree of certification will always be necessary, physicians should not be required to pass through a quagmire of costly and expensive tests that may be unnecessary. Oklahoma provides a model other states can follow to end MOCs completely.

The following documents examine maintenance of certification in greater detail.

The Physician’s Prescription for Health Care Reform
The Docs4PatientCare Foundation outlines several basic principles for health care reform: “Lack of transparency, market distortion, limits on patient choice, and pressure to alter medical ethics have led to escalating prices and reduced patient access. These tragic consequences were predictable and unnecessary.” 

Oklahoma Bans Forced MOC, Becomes the First “Right to Care” State
Docs4PatientCare examines a recently passed bill in Oklahoma that ends the forced use of MOCs, a policy they call “Right to Care.”  “In a time when gridlock is a given, MOC is something that unites us all,” wrote authors for Docs4PatientCare. “The funny thing is, this law shouldn’t be revolutionary. It simply legislates exactly what ABMS says about board certification: that it is voluntary.” 

Boarded to Death: Why Maintenance of Certification Is Bad for Doctors and Patients – t=article
Paul S. Teirstein argues in an article published in The New England Journal of Medicine against the expansion of MOCs. Teirstein explains how these unnecessary requirements negatively harm the health care industry. “More broadly, many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice. Perhaps it’s time for practicing physicians to take back the leadership of medicine.” 

Medical Specialty Certification in the United States: A False Idol?
Westby G. Fisher and Edward J. Schloss write in the Journal of Interventional Cardiac Electrophysiology about the recent changes made to medical specialty certification: “We review the history of board certification and the changes made to the process. As part of this review, we examine both literature and public record to examine the motives behind the changes made. We then review the legal challenges and changes under way to modify the current ABMS board re-certification process.” 

The Ugly Civil War in American Medicine
Kurt Eichenwald writes in Newsweek about the ongoing “war” between the medical boards administrating certification standards and the thousands of doctors questioning the increasing time and cost involved. “This spat is hardly academic, though. Some doctors are leaving medicine because they believe the ABIM is abusing its monopoly for money, forcing physicians to unnecessarily sacrifice time with their patients and time for their personal lives.” 

Negative Secular Trends in Medicine: The ABIM Maintenance of Certification and Over-Reaching Bureaucracy
Robert M. Doroghazi writes in the American Journal of Medicine about the negative effect of bureaucracy in the medical field. Doroghazi focuses on the many issues created by MOCs: “But I think there is no better example of this trend of ever-expanding, over-reaching, and arbitrary bureaucracy than the recently proposed changes in the Maintenance of Certification (MOC) requirements by the American Board of Internal Medicine (ABIM).” 

Maintenance of Certification: Important and to Whom?
Paul M. Kempen writes in the Journal of Community Hospital Internal Medicine Perspectives about MOCs, how and why they emerge, and who they truly benefit. “Certification is at best a slight, or possibly false, promise, recently openly admitted by the ABMS: ‘FACT: ABMS recognizes that regardless of the profession – whether it is health care, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes.'” 

Medical Licensing: An Obstacle to Affordable, Quality Care
Shirley Svorny, an adjunct scholar for the Cato Institute, argues many licensure requirements make health care more expensive and less accessible by raising barriers. Svorny says only institutional oversight and a complex network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today.  

The Medical Monopoly: Protecting Consumers or Limiting Competition?
Sue A. Blevins of the Cato Institute examines the effect of government health care policies on the health care market. Blevins finds licensure laws appear to limit the supply of health care providers and restrict competition to physicians from non-physician practitioners. The primary result is an increase in physician fees and income, driving up health care costs.  


Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this subject, visit Health Care News at, The Heartland Institute’s website at, and PolicyBot, Heartland’s free online research database, at  

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