Most hospitals surveyed do not initially require board certification of pediatricians

February 21, 2006

A survey of 200 hospitals found that nearly 80 percent do not require board certification of pediatricians at the time of initial granting of hospital privileges, although most hospitals do require board certification at some point in the pediatrician's tenure, according to a study in the February 22 issue of JAMA.

At hospitals, privileging involves the granting of permission for physicians to perform specific activities under the hospital's jurisdiction. Medical specialties evaluate and recognize competence among physicians through the creation of specialty boards and testing for board certification, according to background information in the article. It is unknown how or if hospitals use board certification as a proxy measure of professional competence in their privileging decisions.

Gary L. Freed, M.D., M.P.H., of the University of Michigan, Ann Arbor, Mich., and colleagues conducted a national survey to determine hospital policies and practices related to the recognition and use of board certification and recertification of pediatricians. The study consisted of a telephone survey, between Jan. 1 and June 30, 2005, of 200 nonspecialty hospitals stratified by teaching status, children's vs. general hospitals, freestanding children's hospital vs. part of hospital system, and urban vs. rural location.

The response rate to the survey was 82 percent (159 eligible hospitals). Overall, survey results showed that 124 hospitals (78 percent) did not require general pediatricians to be board certified at the time of initial privileging; however, 111 hospitals (70 percent) did require pediatricians to be board certified at some point during their tenure. Of the 124 hospitals that did not require board certification, 60 (48 percent) did report having some time frame in which certification must be achieved, typically 4 to 6 years.

"However, many of these hospitals [42 percent] do not have a specific time limit in which certification must be achieved. Thus, it is possible that the stated requirement for board certification is never actually enforced," the authors write.

The researchers add that 43 percent of 113 hospitals required pediatric subspecialists to achieve subspecialty certification within a specific time frame.

"The ability of credentialing committees to discern the competence of physicians in the privileging process is difficult and complex, with the role of board certification varying among hospitals. Expectations of the public regarding the qualifications (including board certification) used by hospitals in these efforts also must be considered by those individuals who determine privileging requirements. The establishment of Maintenance of Certification (MOC) and the institution of recertification by the American Board of Pediatrics (ABP) have created new and potentially useful tools for hospitals to aid in the assessment of physicians. At the same time, efforts must be undertaken by the ABP to assess the impact of recertification and the MOC program on physician quality so that these efforts will provide the maximum utility to hospitals and the patients they serve," the authors conclude.
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(JAMA. 2006;295:905-912. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: This study was supported by the American Board of Pediatrics Foundation.

Most Health Plans Do Not Require Pediatricians to be Board Certified

In a related article in this issue of JAMA, Gary L. Freed, M.D., M.P.H., of the University of Michigan, Ann Arbor, Mich., and colleagues conducted a study to determine the credentialing policies regarding the use of board certification and recertification of general pediatricians and pediatric subspecialists among health plans.

Health plans conduct a credentialing process to select and retain qualified clinicians who will provide care to their subscribers. The credentialing process is designed to aid health plans in choosing competent clinicians from among all physicians who apply to care for their patients, according to background information in the article. Plans typically establish a set of minimum criteria that must be met by a physician to be granted privileges. One of the tools available to health plans to help ensure physician competence is assessment of board certification status.

Freed and colleagues conducted a telephone survey of credentialing personnel from 244 U.S. health plans, from February through July 2005. The plans were stratified by enrollment size, Medicaid proportion, and for-profit or not-for-profit status. The response rate was 79 percent (193 health plans).

Overall, 174 (90 percent) of the 193 health plans do not require general pediatricians to be board certified at the time of initial credentialing. Of the 161 health plans that require a pediatric residency, 98 (61 percent) have no time frame in which board certification must be achieved. A total of 80 (41 percent) of the 193 health plans require a general pediatrician to be certified at some point in their association with the health plan. Similarly, only 40 percent ever require subspecialists to become board certified in their subspecialty. Although 41 percent of plans report requiring recertification of general pediatricians, almost half do not have a time frame in which recertification must occur. Seventy-seven percent of plans allow physicians to bill as subspecialists with expired certificates.

"The finding that so few health plans require board certification for a pediatrician to bill as a subspecialist raises questions as to the ability of the plans to ensure the initial or continued competence of these physicians. Such actions also may be self-defeating to plans' quality improvement efforts, as they negate an incentive for these physicians to become certified," the authors write.

"These findings, although specific to pediatrics, very likely apply to the credentialing processes for other primary care disciplines if not more widely to all who undergo plan credentialing. Although there has been variation among specialties in the initiation of time-limited certificates, the ABP has required recertification for almost 20 years. We believe it unlikely that our finding represents a time lag by health plans in incorporating pediatric recertification into their credentialing processes. Many health plans currently do not use board certification in their credentialing processes. Likely, increasing pressure from the public regarding preferences for demonstrable efforts in patient safety will result in a greater emphasis on quality assessments in physician credentialing. As such, the new Maintenance of Certification program will provide health plans with a useful tool in this process," the researchers conclude.

(JAMA. 2006;295:913-918. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: This study was supported by the American Board of Pediatrics Foundation.

Editorial: Credentialing and Public Accountability - A Central Role for Board Certification

In an accompanying editorial, Christine K. Cassel, M.D., and Eric S. Holmboe, M.D., of the American Board of Internal Medicine, Philadelphia, discuss the findings of the articles on the use of board certification by hospitals and health plans.

"Two limitations of the studies by Freed et al create clear directions for future research: both studies examine only one medical specialty, and both are conducted during a time in which dramatic changes in physician self-regulation and, in particular, the drive for accountability and quality are occurring. The windows of opportunity glimpsed through the resulting snapshot are important. It would be valuable to have this study reproduced in several other major specialties or perhaps across physician groups involved in hospitals or health plans."

"It is difficult to imagine that health plans would have different standards for how they monitor board certification in pediatrics than they would in internal medicine or family practice. However, within the last 5 years, major changes have occurred in the process and criteria for Maintenance of Certification; over the next 5 years, additional dramatic changes undoubtedly will occur. Health plans and hospitals need to recognize this change, and studies like those of Freed et al performed a few years from now might show a more rigorous approach to monitoring certification status as well as a more robust data exchange that would allow certification to be even more effective in its ability to identify competence and facilitate quality improvement and excellence in physicians."

(JAMA. 2006;295:939-940. Available pre-embargo to the media at www.jamamedia.org)

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