Research & Commentary: Tennessee Should Reject Maintenance of Certification

Published March 22, 2017

There are few who argue against the idea doctors should be required to stay current on all the latest medical developments. But problems have emerged as a result of medical boards requiring additional testing and programs for doctors, a process now known as “maintenance of certification” (MOC). Providing certification for doctors has become a profitable industry for the medical boards administering the certifications. Because of these problems, the Tennessee General Assembly is now considering legislation that would limit the influence of MOCs in its state.

Tennessee’s MOC reform proposal would prevent maintenance of certification from being used as the sole criteria for health insurance plan participation or payment, hospital privileges, or state medical licensure. According to The Chattanoogan, the Tennessee Medical Association says maintenance of certification should remain voluntary, with doctors choosing education content that best fits their own practice.

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.

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. The National Board of Physicians and Surgeons has emerged as a result of the American Board of Internal Medicine’s excessive MOC requirements.

Several other states are also considering legislation to limit or end the use of MOCs. For instance, Oklahoma passed a bill in 2016 that forbids requiring MOC as a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in the state.

In an article appearing in Health Care News, 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.”

MOC certifications were designed with the intention of ensuring 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 this unnecessary burden on practicing physicians.

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.

No More MOC: One State Bans the Controversial Credential Requirement—and Others May Follow
Oklahoma legislators recently passed legislation that removes maintenance of certification (MOC) as a requirement for physicians to be hired, get paid, obtain a medical license, or secure hospital admitting privileges. The Advisory Board Company examines the new law and other similar laws being proposed in other states in this briefing.

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.”

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 John Nothdurft, The Heartland Institute’s government relations director, at [email protected] or 312/377-4000.