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A Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification ProgramCost Analysis of the ABIM Maintenance-of-Certification Program

Alexander T. Sandhu, MD; R. Adams Dudley, MD, MBA; and Dhruv S. Kazi, MD, MSc, MS
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 28 July 2015.


From the University of California, San Francisco, and San Francisco General Hospital, San Francisco; Veterans Affairs Palo Alto Health Care System, Palo Alto; and Stanford University, Stanford, California.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs.

Acknowledgment: The authors thank Ann F. Bolger, MD; James G. Kahn, MD, MPH; and Rashmee U. Shah, MD, MS, for their thoughtful comments on the draft manuscript and Meghann Williams, Elizabeth Thew, and LaCretia King for their administrative support.

Financial Support: This study was funded in part by the University of California, San Francisco (Dr. Kazi), and the U.S. Department of Veterans Affairs (Dr. Sandhu).

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1011.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Kazi (e-mail, kazi@ucsf.edu). Data set: No additional data are available.

Requests for Single Reprints: Dhruv S. Kazi, MD, MSc, MS, Division of Cardiology, San Francisco General Hospital, 1001 Potrero Avenue, Room 5G1, San Francisco, CA 94110; e-mail, kazi@ucsf.edu; Twitter, @kardiologykazi.

Current Author Addresses:Dr. Sandhu: Stanford University Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305.

Dr. Dudley: Center for Healthcare Value, Philip R. Lee Institute of Health Policy Studies, 3333 California Street, San Francisco, CA 94118.

Dr. Kazi: Division of Cardiology, San Francisco General Hospital, 1001 Potrero Avenue, Room 5G1, San Francisco, CA 94110.

Author Contributions: Conception and design: A.T. Sandhu, R.A. Dudley, D.S. Kazi.

Analysis and interpretation of the data: A.T. Sandhu, R.A. Dudley, D.S. Kazi.

Drafting of the article: A.T. Sandhu, D.S. Kazi.

Critical revision of the article for important intellectual content: A.T. Sandhu, R.A. Dudley, D.S. Kazi.

Final approval of the article: A.T. Sandhu, R.A. Dudley, D.S. Kazi.

Provision of study materials or patients: D.S. Kazi.

Statistical expertise: A.T. Sandhu, D.S. Kazi.

Obtaining of funding: A.T. Sandhu, D.S. Kazi.

Administrative, technical, or logistic support: R.A. Dudley, D.S. Kazi.

Collection and assembly of data: A.T. Sandhu, D.S. Kazi.


Ann Intern Med. 2015;163(6):401-408. doi:10.7326/M15-1011
Text Size: A A A

Background: In 2014, the American Board of Internal Medicine (ABIM) substantially increased the requirements and fees for its maintenance-of-certification (MOC) program. Faced with mounting criticism, the ABIM suspended certain content requirements in February 2015 but retained the increased fees and number of modules. An objective appraisal of the cost of MOC would help inform upcoming consultations about MOC reform.

Objective: To estimate the total cost of the 2015 version of the MOC program ("2015 MOC") and the incremental cost relative to the 2013 version ("2013 MOC").

Design: Decision analytic model.

Data Sources: Published literature.

Target Population: All ABIM-certified U.S. physicians.

Time Horizon: 10 years (2015 to 2024).

Perspective: Societal.

Intervention: 2015 MOC.

Outcome Measures: Testing costs (ABIM fees) and time costs (monetary value of physician time).

Results of Base-Case Analysis: Internists will incur an average of $23 607 (95% CI, $5380 to $66 383) in MOC costs over 10 years, ranging from $16 725 for general internists to $40 495 for hematologists-oncologists. Time costs account for 90% of MOC costs. Cumulatively, 2015 MOC will cost $5.7 billion over 10 years, $1.2 billion more than 2013 MOC. This includes $5.1 billion in time costs (resulting from 32.7 million physician-hours spent on MOC) and $561 million in testing costs.

Results of Sensitivity Analysis: Costs are sensitive to time spent on MOC and MOC credits obtainable from current continuing education activities.

Limitation: Precise estimates of time required for MOC are not available.

Conclusion: The ABIM MOC program will generate considerable costs, predominantly due to demands on physician time. A rigorous evaluation of its effect on clinical and economic outcomes is warranted to balance potential gains in health care quality and efficiency against the high costs identified in this study.

Primary Funding Source: University of California, San Francisco, and the U.S. Department of Veterans Affairs.

Figures

Grahic Jump Location
Figure 1.

One-way sensitivity analyses.

These analyses—performed by varying 1 input parameter at a time while holding all others constant—suggest that the total cost of MOC is sensitive to the amount of time required to complete MOC modules each year and to prepare for and take the MOC examination in examination years. Increasing the proportion of CME activities that also earn MOC points would decrease demands on physician time and costs. Because time costs are the primary driver of MOC, the valuation of physician time spent on MOC is another source of uncertainty. If physician MOC time were valued 25% lower than clinical time, it would decrease MOC costs to $4.4 billion. ABIM = American Board of Internal Medicine; CME = continuing medical education; MOC = maintenance of certification.

* Base case assumes 12.5 h to complete 20 MOC points.

† Base case assumes 37.5 h per examination.

Grahic Jump Location
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Figure 2.

MOC costs for individual physicians.

Costs vary substantially among physicians on the basis of the number of certificates held (i.e., physicians holding 1 certificate [left] have lower costs than those holding 2 [middle] or 3 [right]), the number of hours spent on MOC each year (costs increase with time spent on MOC), and physician wage (annual compensation based on hourly wage and 2080 work hours per year, not including benefits). A physician holding 2 certificates (e.g., internal medicine and cardiology) with an annual income of $250 000 who spends 20 hours per year would incur approximately $42 000 in MOC-related costs over 10 years (asterisk). All costs are in 2015 U.S. dollars, and future costs are discounted at 3% per year. MOC = maintenance of certification.

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Comments

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Return on Investment
Posted on July 29, 2015
Christopher D. Adams, MD, FACP, FACR
East Alabama Rheumatology Center
Conflict of Interest: None Declared
This article is the first step in what must become a serial evaluation of MOC value in order to determine if the estimated time and expenses, which are substantial for an individual but gargantuan for the entire cadre of board certified physicians, are really justified by the additional benefit or value that they provide to patients. According to my accountant, my personal direct and indirect costs to re-certify for only the subspecialty of Rheumatology in 2012 were much higher than the lowest estimate in this article. It is one thing to estimate the costs of MOC, but a much more important analysis to determine the value of MOC in terms of costs versus outcomes: patient protection, cost-savings from application of best care practices, and better efficiencies in health care delivery. That determination of value must, of necessity, also include an evaluation of the clinical relevance of such items as arcane questions in the MOC evaluations, and the demonstrated relevance of the entire MOC process to the stated goal of advancing quality medicine.
The Cost of Keeping Up
Posted on July 28, 2015
Richard J. Baron, MD, MACP
President and CEO, American Board of Internal Medicine and the ABIM Foundation
Conflict of Interest: I am President and CEO of the American Board of Internal Medicine and the ABIM Foundation
In a recent post on the Transforming ABIM Blog, I discuss the study’s findings, the role of Maintenance of Certification and the challenges of keeping current in knowledge and practice: “The Cost of Keeping Up” http://transforming.abim.org/the-cost-of-keeping-up/
ABIM worthiness.
Posted on October 2, 2015
Lonnie Hanauer, FACP
Retired physician
Conflict of Interest: None Declared
I first took Internal Medicine Boards fifty years ago (actually 48) when the ABIM gave a written exam followed months later by an oral exam for those who passed the written. I "failed to pass" the oral exam and had to wait a year before I could make another attempt. Rumbling was increasing about the lack of validity of the oral exam. A few years later, the Board announced that they would give a select few candidates the written and oral exams the same week. A few months later, without comment, they announced that the oral exam "could be replaced by a more carefully constructed written exam" and it was never given again. Now we have an equally unstudied "Maintenance of Certification" exam with the only known proven property being that it is expensive and time consuming. The ABIM is as much of a pompous fraud now as it was in 1967.
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