Research & Commentary: Indiana Should Continue to Pursue Maintenance of Certification Reform

Published April 26, 2018

States are increasingly imposing “maintenance of certification” programs (MOC), which require doctors complete a host of new tests and programs to retain certain medical certifications. Increasing certification mandates for doctors has become a profitable industry for state medical organizations administering the certifications. Because of this disturbing trend, several states are considering reforms that would limit the influence of MOCs. During the 2017–18 legislative session, the Indiana General Assembly considered a proposal that would have prohibited a hospital from denying hospital staff or admitting privileges to a physician or podiatrist based solely on the decision of the physician to participate in maintenance of certification.

The Indiana proposal would ban the use of MOCs in determining a board certification to practice in a specialty medical area and would prohibit an accident and sickness insurer from denying reimbursement based on MOC. Lastly, it would block health maintenance organizations from denying contracts or reimbursement based on MOCs. The bill passed the Senate in February 2018.

MOC advocates argue hospitals should be allowed to require MOCs if they so choose and that preventing them from doing so would be an unnecessary mandate. In a statement to Health Care News in 2017, Michigan physician Dr. Chad Savage disagreed with this argument, contending the groups administering the MOCs are not a representative body of a medical specialty. “They are a private corporation that has appointed itself a monopolistic authority over physician board certification,” Savage stated.

Dr. Meg Edison, a private practitioner in Grand Rapids, Michigan, argues MOCs are now predominantly a money-raising scheme. Many older physicians have even chosen early retirement over the expensive MOCs, Edison reports. “Realizing they’d make more money if doctors had to maintain certification, some boards introduced the MOC program, which grandfathered certain age classes of doctors and required the younger doctors to keep taking tests, paying more money, and completing research projects,” Edison said. “For those of us who are not grandfathered, if we do not participate in any portion of MOC, we are completely stripped of all board certification, regardless of how many times we have passed the exams, and we are erased from their websites.”

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 three found a negative association,” wrote Teirstein. The National Board of Physicians and Surgeons has emerged as a result of the American Board of Internal Medicine’s excessive MOC requirements.

If properly designed, MOC certifications would simply ensure physicians are educated on the latest health care research and methods. Unfortunately, MOCs have become barriers to entry for the medical field and profit centers for greedy medical board organizations. Commonsensical certification programs are necessary for certain professions, such as doctors, lawyers, and teachers. However, physicians should not be required to pass a maze of time-consuming tests and complete costly programs just to retain their licenses. Indiana lawmakers should not overlook this much-needed reform and immediately eliminate the dubious MOC scheme in the Hoosier State.

The following documents examine maintenance of certification in greater detail.

More States Consider Outlawing Forced Maintenance of Certification
Michael Hamilton writes in Health Care News about the growing trend in many states to prohibit maintenance of certification from being used as a condition of medical licensure or hospital-admitting privileges.

Oklahoma Frees Physicians from Forced Maintenance of Certification
Jenni White writes in Health Care News about Oklahoma’s recent passage of legislation limiting the power of maintenance of certification, how medical boards can use them, and how several states are considering similar protections. “Oklahoma will become the first state to protect physicians without maintenance of certification (MOC) from losing their licenses, reimbursement, employment, or hospital-admitting privileges,” wrote White.

First State Goes MOC-Free, Others May Follow
Robert Lowes, reporting for Medscape Medical News, discusses the new anti-MOC laws being considered in several states and how the debate has progressed over time.

It’s Time for Change! Conversations About Maintenance of Certification
In this issue of Michigan Medicine, the authors talk to three physicians about their frustrations with MOC and how this bureaucratic requirement is affecting their practice and patients.

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
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.”

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?–important-and-to-whom?source=policybot
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 healthcare, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes.'”

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, The Heartland Institute’s website, and PolicyBot, Heartland’s free online research database. 

If you have any questions about this issue or The Heartland Institute’s website, contact Lindsey Stroud, The Heartland Institute’s state government relations manager, at [email protected] or 312/377-4000.