There is no denying that maintenance of certification (MOC) by medical boards is under attack. EPM’s Dr. Judith Tintinalli caught up with Dr. Terry Kowalenko, president of the American Board of Emergency Medicine (ABEM), to discuss the board’s $33 million in assets and recent legislative action critical of ABEM certification.
EPM: Terry, thank you for talking to EPM about the recent report in the Journal of the American Medical Association about certification fees (Drolet BC, Tandon VJ. Fees for Certification and Finances of Medical Specialty Boards. JAMA 2017;318:477-9). What was your first reaction when you read the report?
Dr. Terry Kowalenko: I think there are three big take-aways for your readers. First, ABEM has the lowest application and written exam fees for initial certification. We also had the lowest fees for specialties that have an oral examination, which is a majority of boards. Second, ABEM’s MOC fees are right at the mean for all of the boards. And third, our financial positions make sense in the context of ABEM being a mid-sized board with over 35,000 diplomates. In addition, we’ve leveraged our financial holdings to be able to fix our fees.
EPM: How do you react to the claim that the certifying boards have too much money?
Dr. Kowalenko: When I saw that all of the boards combined had over $600 million in holdings, I wasn’t terribly surprised. After all, there are over 850,000 physicians certified by the boards belonging to the American Board of Medical Specialties (ABMS). ABEM has about $33 million in assets, most of which came from the growth of our assets since the stock market began its recovery in 2008. Just as others have personally benefited from the market performance over the past ten years, so did ABEM.
What’s often excluded from this type of conversation is the financial benefit to being ABEM-certified. The last ACEP/Stern salary survey that was conducted showed that, on average, an emergency physician receives around $7,000 more in total annual compensation for being board certified than a non–board certified EP. When you multiple that by ABEM’s 35,000 diplomates, that’s easily over $200 million in additional compensation every year
EPM: OK, so what has ABEM done with the money it has?
Dr. Kowalenko: I think the biggest benefit to physicians has been that we’ve kept our fees fixed. ABEM treated this money like an endowment to offset growing costs. For example, ABEM started using the format in 2015, which uses a custom-designed computer platform for test administration. Using this technology resulted in higher costs; in fact, the exam now is two-and-a-half times as much to administer as paper exams, but none of the additional cost has been passed on to candidates. Let me stress that point: None of the additional costs have been passed on to physicians who are just starting their careers. This is one of the reasons why we have such low initial certification fees compared to the other boards.
Because we’ve been keeping our fees fixed, our operating margins are declining, which led to an operating loss two years ago. Last year, even with the fixed fees, we had a positive operating margin of about three percent. But that was due to an increase in the number of physicians taking the ConCert Examination. This is an important thing to talk about. Because ABEM has such a permissive policy about taking the ConCert early, there have been a record number of test takers during the past few years. This year, over 40 percent of physicians taking the ConCert are taking it early. But even though this has resulted in a short-term increase in revenue, there will be a future correction that will have a very significant negative impact on our operating margin. I think the bottom line is that because ABEM benefited from being well-positioned financially, we have been able to leverage that benefit into something positive for ABEM-certified physicians.
EPM: How do see the recent legislative activity affecting ABEM certification?
Dr. Kowalenko: We think the recent legislative activity has been misdirected and mischaracterized. ABEM has always had a quasi-regulatory function, and we recognize that physicians are being burdened from all sides. This creates an environment in which ABEM and the other boards have become a target for physician frustration. The irony is that in the past seven years, ABEM has actually streamlined our MOC requirements. We’ve tried to increase relevance, we’ve added CME options, and we’ve made reporting requirements easier.
Our biggest concern about the anti-MOC bills is the resulting loss of professional self-regulation. The public expects our profession to create and enforce standards. If we keep up our end of this social contract, we can self-regulate without government interference. Organized medicine has an abysmal track record for self-regulation, and every time we put our self-interests first, we get burned. Medicine has lost the battles for cost control as a result of federal legislation. We’ve lost the right to control quality with PQRS and now MIPS. Controlling access to care has been deeply affected by EMTALA. One of the last places where physicians have control is professional self-regulation through certification and maintenance of certification. That’s where we, physicians, can set our own standards. We can determine who is qualified to work with us in our emergency departments. I worry that those of us who continue to maintain our certification may lose our jobs to those who have lower standards. The anti-MOC bills are threatening our ability to control our choices—they’re handing that over to state governments.
EPM: How do you interpret the legislative results so far?
Dr. Kowalenko: It’s been mixed. The way it’s been reported, quite honestly, has been extremely inconsistent and confusing. For example, last year in Oklahoma, an anti-MOC bill passed that was not really enforceable. When it went to the legislature this year, it was defeated 77-21, but it is often reported as an anti-MOC victory. The Texas bill, which restricts the use of MOC and ongoing certification for hospital credentialing and payment, was amended substantially from the original version, but I think it would be counted as a loss for the certifying boards and those physicians who value board certification as a distinguishing standard of their skills and knowledge. In several other states, bills have been modified or referred and there is no definitive outcome or impact. In Michigan, we are hearing a general attitude from the legislature that state government should not be interfering with professional self-regulation. So, despite what feels like a whirlwind of activity, there isn’t clear pattern, and there may be serious unintended consequences.
EPM: Where do you think this will take our specialty?
Dr. Kowalenko: I think there is a growing awareness that anti-MOC bills might have unfortunate long-term consequences. As emergency physicians, we are acutely aware that our patients can’t choose who they see. This puts an extra importance on board certification and maintenance of certification for emergency physicians and the standards that certification embodies. Of course, as the ABEM President I’m biased, but the more rigorous the certification process is, the stronger certification is as a credential. We need to think about how strong we want ABEM certification to be. There is a balance that ABEM is trying reach by being rigorous without being onerous, with having value without being overly expensive. Another thing we all need to be sensitive to is what the public might hear. We don’t want them to think that as physicians we are in any way being self-serving. Every profession and/or industry that took that path ended up with greater external scrutiny and regulation. ABEM, every outstanding EM organization, and every emergency physician has worked tirelessly to improve the lives of people when they are most vulnerable. We need to make certain that the public supports our continued interest in maintaining profession self-regulation.