Maintenance of Certification and Texas SB 1148: A Threat to Professional Self-regulation

During the 2017 legislative session Texas lawmakers voted to approve Senate bill (SB) 1148 entitled “Relating to Maintenance of Certification by a Physician or an Applicant for a License to Practice Medicine in This State.”¹ SB 1148 was intended to restrict the use of maintenance of certification (MOC) as a credential for hospital privileging, to wit: “a hospital, institution, or program that is licensed by this state, is operated by this state or a political subdivision of this state, or directly or indirectly receives state financial assistance may not differentiate between physicians based solely on a physician's maintenance of certification.”¹ The original bill was also written to prevent managed care plans from “differentiating between physicians based solely on a physician's maintenance of certification in regard to: (1) paying the physician; (2) reimbursing the physician; or (3) directly or indirectly contracting with the physician to provide services to enrollees.” SB 1148 was introduced by 2 physician-legislators, received support of the Texas Medical Association (ostensibly reflecting the temperament of its members), was vigorously debated and opposed by some academic and community physicians, and was signed into law by the governor on June 15, 2017.

A major impetus for the introduction of SB 1148 came from physician dissatisfaction with the MOC programs developed by the member boards of the American Board of Medical Specialties (ABMS). MOC critics argue the programs are excessively costly, are time consuming, are irrelevant to practicing physicians, and, most importantly, fail to improve patient care.² Although criticism of recertification programs and MOC is not unprecedented,³ seeking legislative reprieve from state governments represents a significant departure from prior efforts to limit implementation of these programs, a course of action that may have unintended consequences.

Society cedes to the medical profession the privilege of self-regulation based on 3 assumptions: the assumption of expertise, altruism, and self-scrutiny. Among other responsibilities, self-regulation requires the profession to establish the means of setting and maintaining standards of education and training, entry into practice, and practice. Integral to effective self-regulation is the responsibility and obligation to ensure that these standards are met.⁴ Specialty boards were created to develop the standards that define individual specialties. The standards are established by physicians for physicians. Initially many (but not all) boards granted lifetime certification based primarily on a single examination. However, over time it became increasingly clear that lifetime certification could not guarantee competence for the entirety of a physician’s career.⁵ For this reason, ABMS and its member boards embraced the concept of recertification to improve the quality of patient care, set standards for clinical competence, and foster the continuing scholarship required for professional excellence over a lifetime of practice. Details of MOC programs were left to the discretion of member boards. In the past few years these programs have been subjected to intense scrutiny and criticism.² In response, individual specialty boards have begun to transition from a strictly authoritative model to a more-collaborative model working in partnership with physicians and professional societies to ensure MOC programs remain meaningful and relevant.⁶

Although critics often assert that there is no evidence that certification or MOC makes any difference in clinical care, some peer-reviewed literature refutes that claim. Board certification and recertification are associated with improved patient care, greater adherence to practice guidelines, fewer state board disciplinary actions, and, importantly in this era of rising health care costs, less-costly care.⁷ Moreover, patients seem to prefer board-certified physicians.⁸ They also expect their physicians to undergo periodic recertification.⁸ But even if there are doubts about the validity of claims of improved patient care, participation in MOC can instill a sense of professional responsibility and a measure of confidence that physicians are doing the hard work necessary to maintain and enhance knowledge and competence in their specialty.

Although the passage of SB 1148 may be viewed as a victory by those who stand opposed to the concept of MOC, it is a pyrrhic one. Beyond establishing criteria used for board certification, self-regulation also entails setting standards for admission to medical school, determining the content of medical school curriculum, establishing criteria for awarding medical degrees, determining standards for medical licensure, generating voluntary guidelines for acceptable clinical practice, and determining the criteria by which hospital privileges are granted to individual physicians.⁹ Although directed at MOC specifically, SB 1148 has potential consequences for all of these privileges and weakens the claim to self-regulation by establishing a precedent for additional governmental intervention into the practice of medicine that proponents of SB 1148 may find less agreeable.

Nearly 40 years ago, Relman commented on the controversy then surrounding recertification: “The development of an acceptable method of recertification ought to be an achievable goal for any specialty board that commits itself to the task; it is simply a question of will. The boards need to be pragmatic and flexible in their approach to this problem, but for a profession that takes such pride in its self-imposed discipline, total abandonment of the recertification idea would be a mistake. A retreat on this issue would not be well received by a public that has already begun to wonder whether medicine is more interested in defending its privileges than in maintaining its standards.”³ Relman was right on both accounts. Specialty boards must continue to work with their diplomates to ensure recertification programs maintain their relevance and rigor while minimizing redundancy.^5,6 At the same time, efforts to limit or eradicate recertification programs through legislative action or other means may be seen by the public as nothing more than veiled attempts to lower professional standards.

Corresponding Author: David H. Johnson, MD, Department of Internal Medicine, University of Texas Southwestern School of Medicine, 5323 Harry Hines Blvd, Room G5.210A, Dallas, TX 75390-9030 (david.johnson@utsouthwestern.edu).

Published Online: August 7, 2017. doi:10.1001/jama.2017.10127

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Johnson reports serving as a member of the American Board of Internal Medicine board of directors from 2007 until 2015 and being board chair from 2013 until 2015.